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 surgicallessons have been learned in the hard school of war. Some may yet haveto be unlearned, and others have but little bearing on the problemspresented to the civilian surgeon. Save in its broadest principles, thesurgery of warfare is a thing apart from the general surgery of civillife, and the exhaustive literature now available on every aspect of itmakes it unnecessary that it should receive detailed consideration in amanual for students. In preparing this new edition, therefore, we haveendeavoured to incorporate only such additions to our knowledge andresources as our experience leads us to believe will prove of permanentvalue in civil practice. For the rest, the text has been revised, condensed, and in placesrearranged; a number of old illustrations have been discarded, and agreater number of new ones added. Descriptions of operative procedureshave been omitted from the _Manual_, as they are to be found in thecompanion volume on _Operative Surgery_, the third edition of whichappeared some months ago. We have retained the Basle anatomical nomenclature, as extendedexperience has confirmed our preference for it. For the convenience ofreaders who still employ the old terms, these are given in bracketsafter the new. This edition of the _Manual_ appears in three volumes; the first beingdevoted to General Surgery, the other two to Regional Surgery. Thisarrangement has enabled us to deal in a more consecutive manner thanhitherto with the surgery of the Extremities, including Fractures andDislocations. We have once more to express our thanks to colleagues in the EdinburghSchool and to other friends for aiding us in providing newillustrations, and for other valuable help, as well as to our publishersfor 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 BURSÆ 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 Hyperæmia of Hand and Forearm induced by Bier's 37 Bandage 7. Passive Hyperæmia of Finger induced by Klapp's Suction 38 Bell 8. Passive Hyperæmia induced by Klapp's Suction Bell for 39 Inflammation of Inguinal Gland 9. Diagram of various forms of Whitlow 56 10. Charts of Acute Sapræmia 61 11. Chart of Hectic Fever 62 12. Chart of Septicæmia followed by Pyæmia 63 13. Chart of Pyæmia 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 æt.  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. Spirochæte pallida 147 37. Spirochæta 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 æt.  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 Hæmophilic 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 Nævus 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 æt.  11 337 81. Lymphadenoma in a woman æt.  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 æt.  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 æt.  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 Ischæmic 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 Bursæ 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 ultimateobjects of scientific medicine. The two great branches of the healingart--Medicine and Surgery--are so intimately related that it isimpossible to draw a hard-and-fast line between them, but forconvenience Surgery may be defined as "the art of treating lesions andmalformations of the human body by manual operations, mediate andimmediate. " To apply his art intelligently and successfully, it isessential that the surgeon should be conversant not only with the normalanatomy and physiology of the body and with the various pathologicalconditions to which it is liable, but also with the nature of theprocess by which repair of injured or diseased tissues is effected. Without this knowledge he is unable to recognise such deviations fromthe normal as result from mal-development, injury, or disease, orrationally to direct his efforts towards the correction or removal ofthese. PROCESS OF REPAIR The process of repair in living tissue depends upon an inherent powerpossessed by vital cells of reacting to the irritation caused by injuryor disease. The cells of the damaged tissues, under the influence ofthis irritation, undergo certain proliferative changes, which aredesigned to restore the normal structure and configuration of the part. The process by which this restoration is effected is essentially thesame in all tissues, but the extent to which different tissues can carrythe recuperative process varies. Simple structures, such as skin, cartilage, bone, periosteum, and tendon, for example, have a high powerof regeneration, and in them the reparative process may result in almostperfect restitution to the normal. More complex structures, on the otherhand, such as secreting glands, muscle, and the tissues of the centralnervous system, are but imperfectly restored, simple cicatricialconnective tissue taking the place of what has been lost or destroyed. Any given tissue can be replaced only by tissue of a similar kind, andin a damaged part each element takes its share in the reparative processby producing new material which approximates more or less closely to thenormal according to the recuperative capacity of the particular tissue. The normal process of repair may be interfered with by variousextraneous agencies, the most important of which are infection bydisease-producing micro-organisms, the presence of foreign substances, undue movement of the affected part, and improper applications anddressings. The effect of these agencies is to delay repair or to preventthe individual tissues carrying the process to the furthest degree ofwhich they are capable. In the management of wounds and other diseased conditions the mainobject of the surgeon is to promote the natural reparative process bypreventing or eliminating any factor by which it may be disturbed. #Healing by Primary Union. #--The most favourable conditions for theprogress of the reparative process are to be found in a clean-cut woundof the integument, which is uncomplicated by loss of tissue, by thepresence of foreign substances, or by infection with disease-producingmicro-organisms, and its edges are in contact. Such a wound in virtue ofthe absence of infection is said to be _aseptic_, and under theseconditions 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 inall structures is an elementary form of new tissue known as _granulationtissue_, which is produced in the damaged area in response to theirritation caused by injury or disease. The vital reaction induced bysuch irritation results in dilatation of the vessels of the part, emigration of leucocytes, transudation of lymph, and certainproliferative changes in the fixed tissue cells. These changes arecommon to the processes of inflammation and repair; no hard-and-fastline can be drawn between these processes, and the two may go ontogether. It is, however, only when the proliferative changes have cometo predominate that the reparative process is effectively established bythe production of healthy granulation tissue. _Formation of Granulation Tissue. _--When a wound is made in theintegument under aseptic conditions, the passage of the knife throughthe tissues is immediately followed by an oozing of blood, which sooncoagulates on the cut surfaces. In each of the divided vessels a clotforms, and extends as far as the nearest collateral branch; and on thesurface of the wound there is a microscopic layer of bruised anddevitalised tissue. If the wound is closed, the narrow space between itsedges is occupied by blood-clot, which consists of red and whitecorpuscles mixed with a quantity of fibrin, and this forms a temporaryuniting medium between the divided surfaces. During the first twelvehours, the minute vessels in the vicinity of the wound dilate, and fromthem lymph exudes and leucocytes migrate into the tissues. In fromtwenty-four to thirty-six hours, the capillaries of the part adjacent tothe wound begin to throw out minute buds and fine processes, whichbridge the gap and form a firmer, but still temporary, connectionbetween the two sides. Each bud begins in the wall of the capillary as asmall accumulation of granular protoplasm, which gradually elongatesinto a filament containing a nucleus. This filament either joins with aneighbouring capillary or with a similar filament, and in time thesebecome hollow and are filled with blood from the vessels that gave themorigin. In this way a series of young _capillary loops_ is formed. The spaces between these loops are filled by cells of various kinds, themost important being the _fibroblasts_, which are destined to formcicatricial fibrous tissue. These fibroblasts are large irregularnucleated cells derived mainly from the proliferation of the fixedconnective-tissue cells of the part, and to a less extent from thelymphocytes and other mononuclear cells which have migrated from thevessels. Among the fibroblasts, larger multi-nucleated cells--_giantcells_--are sometimes found, particularly when resistant substances, such as silk ligatures or fragments of bone, are embedded in thetissues, and their function seems to be to soften such substancespreliminary 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 functionbeing to remove the red corpuscles and fibrin of the original clot, andthis performed, they either pass back into the circulation in virtue oftheir amœboid movement, or are themselves eaten up by the growingfibroblasts. Beyond this phagocytic action, they do not appear to playany 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 itbegins to be replaced by cicatricial or scar tissue. _Formation of Cicatricial Tissue. _--The transformation of this temporarygranulation tissue into scar tissue is effected by the fibroblasts, which become elongated and spindle-shaped, and produce in and aroundthem a fine fibrillated material which gradually increases in quantitytill it replaces the cell protoplasm. In this way white fibrous tissueis formed, the cells of which are arranged in parallel lines andeventually become grouped in bundles, constituting fully formed whitefibrous tissue. In its growth it gradually obliterates the capillaries, until at the end of two, three, or four weeks both vessels and cellshave almost entirely disappeared, and the original wound is occupied bycicatricial tissue. In course of time this tissue becomes consolidated, and the cicatrix undergoes a certain amount of contraction--_cicatricialcontraction_. _Healing of Epidermis. _--While these changes are taking place in thedeeper parts of the wound, the surface is being covered over by_epidermis_ growing in from the margins. Within twelve hours the cellsof the rete Malpighii close to the cut edge begin to sprout on to thesurface of the wound, and by their proliferation gradually cover thegranulations with a thin pink pellicle. As the epithelium increases inthickness it assumes a bluish hue and eventually the cells becomecornified and the epithelium assumes a greyish-white colour. _Clinical Aspects. _--So long as the process of repair is not complicatedby infection with micro-organisms, there is no interference with thegeneral health of the patient. The temperature remains normal; thecirculatory, gastro-intestinal, nervous, and other functions areundisturbed; locally, the part is cool, of natural colour and free frompain. #Modifications of the Process of Repair. #--The process of repair byprimary union, above described, is to be looked upon as the type of allreparative processes, such modifications as are met with dependingmerely upon incidental differences in the conditions present, such asloss of tissue, infection by micro-organisms, etc. _Repair after Loss or Destruction of Tissue. _--When the edges of a woundcannot be approximated either because tissue has been lost, for examplein excising a tumour or because a drainage tube or gauze packing hasbeen necessary, a greater amount of granulation tissue is required tofill the gap, but the process is essentially the same as in the idealmethod of repair. The raw surface is first covered by a layer of coagulated blood andfibrin. An extensive new formation of capillary loops and fibroblaststakes place towards the free surface, and goes on until the gap isfilled by a fine velvet-like mass of granulation tissue. Thisgranulation 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 studiedclinically in a recent wound which has been packed with gauze. When theplug is introduced, the walls of the cavity consist of raw tissue withnumerous oozing blood vessels. On removing the packing on the fifth orsixth day, the surface is found to be covered with minute, red, papillary granulations, which are beginning to fill up the cavity. Atthe edges the epithelium has proliferated and is covering over the newlyformed granulation tissue. As lymph and leucocytes escape from theexposed surface there is a certain amount of serous or sero-purulentdischarge. On examining the wound at intervals of a few days, it isfound that the granulation tissue gradually increases in amount till thegap is completely filled up, and that coincidently the epitheliumspreads in and covers over its surface. In course of time the epitheliumthickens, and as the granulation tissue is slowly replaced by youngcicatricial tissue, which has a peculiar tendency to contract and so toobliterate the blood vessels in it, the scar that is left becomessmooth, pale, and depressed. This method of healing is sometimes spokenof as "healing by granulation"--although, as we have seen, it is bygranulation that all repair takes place. _Healing by Union of two Granulating Surfaces. _--In gaping wounds unionis sometimes obtained by bringing the two surfaces into apposition aftereach has become covered with healthy granulations. The exudate on thesurfaces causes them to adhere, capillary loops pass from one to theother, and their final fusion takes place by the further development ofgranulation and cicatricial tissue. _Reunion of Parts entirely Separated from the Body. _--Small portions oftissue, such as the end of a finger, the tip of the nose or a portion ofthe external ear, accidentally separated from the body, if accuratelyreplaced and fixed in position, occasionally adhere by primary union. In the course of operations also, portions of skin, fascia, or bone, oreven a complete joint may be transplanted, and unite by primary union. _Healing under a Scab. _--When a small superficial wound is exposed tothe air, the blood and serum exuded on its surface may dry and form ahard crust or _scab_, which serves to protect the surface from externalirritation in the same way as would a dry pad of sterilised gauze. Underthis scab the formation of granulation tissue, its transformation intocicatricial tissue, and the growth of epithelium on the surface, go onuntil 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 inoperating upon bones, the space left between the divided tissues becomesfilled with blood-clot, which acts as a temporary scaffolding in whichgranulation tissue is built up. Capillary loops grow into the coagulum, and migrated leucocytes from the adjacent blood vessels destroy the redcorpuscles, and are in turn disposed of by the developing fibroblasts, which by their growth and proliferation fill up the gap with youngconnective tissue. It will be evident that this process only differsfrom healing by primary union in the _amount_ of blood-clot that ispresent. _Presence of a Foreign Body. _--When an aseptic foreign body is presentin the tissues, _e. G. _ a piece of unabsorbable chromicised catgut, thehealing process may be modified. After primary union has taken place thescar may broaden, become raised above the surface, and assume abluish-brown colour; the epidermis gradually thins and gives way, revealing the softened portion of catgut, which can be pulled out inpieces, after which the wound rapidly heals and resumes a normalappearance. REPAIR IN INDIVIDUAL TISSUES _Skin and Connective Tissue. _--The mode of regeneration of these tissuesunder aseptic conditions has already been described as the type of idealrepair. In highly vascular parts, such as the face, the reparativeprocess goes on with great rapidity, and even extensive wounds may befirmly united in from three to five days. Where the anastomosis is lessfree the process is more prolonged. The more highly organised elementsof the skin, such as the hair follicles, the sweat and sebaceous glands, are imperfectly reproduced; hence the scar remains smooth, dry, andhairless. _Epithelium. _--Epithelium is only reproduced from pre-existingepithelium, and, as a rule, from one of a similar type, althoughmetaplastic transformation of cells of one kind of epithelium intoanother kind can take place. Thus a granulating surface may be coveredentirely by the ingrowing of the cutaneous epithelium from the margins;or islets, originating in surviving cells of sebaceous glands or sweatglands, or of hair follicles, may spring up in the centre of the rawarea. Such islets may also be due to the accidental transference ofloose epithelial cells from the edges. Even the fluid from a blister, invirtue of the isolated cells of the rete Malpighii which it contains, iscapable of starting epithelial growth on a granulating surface. Hairsand nails may be completely regenerated if a sufficient amount of thehair follicles or of the nail matrix has escaped destruction. Theepithelium of a mucous membrane is regenerated in the same way as thaton a cutaneous surface. Epithelial cells have the power of living for some time after beingseparated from their normal surroundings, and of growing again when oncemore placed in favourable circumstances. On this fact the practice ofskin grafting is based (p. 11). _Cartilage. _--When an articular cartilage is divided by incision or bybeing implicated in a fracture involving the articular end of a bone, itis repaired by ordinary cicatricial fibrous tissue derived from theproliferating cells of the perichondrium. Cartilage being a non-vasculartissue, the reparative process goes on slowly, and it may be many weeksbefore it is complete. It is possible for a metaplastic transformation of connective-tissuecells into cartilage cells to take place, the characteristic hyalinematrix being secreted by the new cells. This is sometimes observed as anintermediary stage in the healing of fractures, especially in youngbones. It may also take place in the regeneration of lost portions ofcartilage, provided the new tissue is so situated as to constitute partof a joint and to be subjected to pressure by an opposing cartilaginoussurface. This is illustrated by what takes place after excision ofjoints where it is desired to restore the function of the articulation. By carrying out movements between the constituent parts, the fibroustissue covering the ends of the bones becomes moulded into shape, itscells 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 longersubjected to pressure by an opposing cartilage, it tends to betransformed into fibrous tissue, as may be seen in deformities attendedwith displacement of articular surfaces, such as hallux valgus andclub-foot. After fractures of costal cartilage or of the cartilages of the larynxthe cicatricial tissue may be ultimately replaced by bone. _Tendons. _--When a tendon is divided, for example by subcutaneoustenotomy, 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 afew days this clot becomes permeated by granulation tissue, thefibroblasts of which are derived from the sheath of the tendon, thesurrounding connective tissue, and probably also from the divided endsof the tendon itself. These fibroblasts ultimately develop into typicaltendon cells, and the fibres which they form constitute the new tendonfibres. Under aseptic conditions repair is complete in from two to threeweeks. In the course of the reparative process the tendon and its sheathmay become adherent, which leads to impaired movement and stiffness. Ifthe ends of an accidentally divided tendon are at once brought intoaccurate apposition and secured by sutures, they unite directly with aminimum amount of scar tissue, and function is perfectly restored. _Muscle. _--Unstriped muscle does not seem to be capable of beingregenerated to any but a moderate degree. If the ends of a dividedstriped muscle are at once brought into apposition by stitches, primaryunion takes place with a minimum of intervening fibrous tissue. Thenuclei of the muscle fibres in close proximity to this young cicatricialtissue proliferate, and a few new muscle fibres may be developed, butany gross loss of muscular tissue is replaced by a fibrous cicatrix. Itwould appear that portions of muscle transplanted from animals to fillup gaps in human muscle are similarly replaced by fibrous tissue. When amuscle is paralysed from loss of its nerve supply and undergoes completedegeneration, it is not capable of being regenerated, even should theintegrity of the nerve be restored, and so its function is permanentlylost. _Secretory Glands. _--The regeneration of secretory glands is usuallyincomplete, cicatricial tissue taking the place of the glandularsubstance which has been destroyed. In wounds of the liver, for example, the gap is filled by fibrous tissue, but towards the periphery of thewound the liver cells proliferate and a certain amount of regenerationtakes place. In the kidney also, repair mainly takes place bycicatricial tissue, and although a few collecting tubules may bereformed, no regeneration of secreting tissue takes place. After theoperation of decapsulation of the kidney a new capsule is formed, andduring the process young blood vessels permeate the superficial partsof the kidney and temporarily increase its blood supply, but in theconsolidation of the new fibrous tissue these vessels are ultimatelyobliterated. This does not prove that the operation is useless, as thetemporary improvement of the circulation in the kidney may serve to tidethe patient over a critical period of renal insufficiency. _Stomach and Intestine. _--Provided the peritoneal surfaces areaccurately apposed, wounds of the stomach and intestine heal with greatrapidity. Within a few hours the peritoneal surfaces are glued togetherby a thin layer of fibrin and leucocytes, which is speedily organisedand replaced by fibrous tissue. Fibrous tissue takes the place of themuscular elements, which are not regenerated. The mucous lining isrestored by ingrowth from the margins, and there is evidence that someof the secreting glands may be reproduced. Hollow viscera, like the œsophagus and urinary bladder, in so faras they are not covered by peritoneum, heal less rapidly. _Nerve Tissues. _--There is no trustworthy evidence that regeneration ofthe tissues of the brain or spinal cord in man ever takes place. Anyloss of substance is replaced by cicatricial tissue. The repair of _Bone_, _Blood Vessels_, and _Peripheral Nerves_ is moreconveniently considered in the chapters dealing with these structures. #Rate of Healing. #--While the rate at which wounds heal is remarkablyconstant there are certain factors that influence it in one direction orthe other. Healing is more rapid when the edges are in contact, whenthere is a minimum amount of blood-clot between them, when the patientis in normal health and the vitality of the tissues has not beenimpaired. Wounds heal slightly more quickly in the young than in theold, although the difference is so small that it can only bedemonstrated by the most careful observations. Certain tissues take longer to heal than others: for example, a fractureof one of the larger long bones takes about six weeks to unite, anddivided nerve trunks take much longer--about a year. Wounds of certain parts of the body heal more quickly than others: thoseof the scalp, face, and neck, for example, heal more quickly than thoseover the buttock or sacrum, probably because of their greatervascularity. The extent of the wound influences the rate of healing; it is onlynatural that a long and deep wound should take longer to heal than ashort and superficial one, because there is so much more work to bedone in the conversion of blood-clot into granulation tissue, and thisagain into scar tissue that will be strong enough to stand the strain onthe edges of the wound. THE TRANSPLANTATION OR GRAFTING OF TISSUES Conditions are not infrequently met with in which healing is promotedand restoration of function made possible by the transference of aportion of tissue from one part of the body to another; the tissuetransferred is known as the _graft_ or the _transplant_. The simplestexample 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 itsvitality until it has formed an organic connection with the tissue inwhich it is placed, so that it may derive the necessary nourishment fromits new bed. When these conditions are fulfilled the tissues of thegraft continue to proliferate, producing new tissue elements to replacethose that are lost and making it possible for the graft to becomeincorporated with the tissue with which it is in contact. Dead tissue, on the other hand, can do neither of these things; it isonly capable of acting as a model, or, at the most, as a scaffolding forsuch mobile tissue elements as may be derived from, the parent tissuewith which the graft is in contact: a portion of sterilised marinesponge, for example, may be observed to become permeated withgranulation 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 itbleeds when cut into, and is permeated by new nerve fibres spreading infrom the periphery towards the centre. It is instructive to associate the period of survival of the differenttissues of the body after death, with their capacity of being used forgrafting purposes; the higher tissues such as those of the centralnervous system and highly specialised glandular tissues like those ofthe kidney lose their vitality quickly after death and are thereforeuseless for grafting; connective tissues, on the other hand, such asfat, cartilage, and bone retain their vitality for several hours afterdeath, so that when they are transplanted, they readily "take" and doall that is required of them: the same is true of the skin and itsappendages. _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 withautoplastic grafts, and these are therefore preferred whenever possible. There are certain details making for success that merit attention: thegraft must not be roughly handled or allowed to dry, or be subjected tochemical irritation; it must be brought into accurate contact with thenew soil, no blood-clot intervening between the two, no movement of theone upon the other should be possible and all infection must beexcluded; it will be observed that these are exactly the same conditionsthat permit of the primary healing of wounds, with which of course thehealing of grafts is exactly comparable. _Preservation of Tissues for Grafting. _--It was at one time believedthat tissues might be taken from the operating theatre and kept in coldstorage until they were required. It is now agreed that tissues whichhave been separated from the body for some time inevitably lose theirvitality, become incapable of regeneration, and are therefore unsuitedfor grafting purposes. If it is intended to preserve a portion of tissuefor future grafting, it should be embedded in the subcutaneous tissue ofthe abdominal wall until it is wanted; this has been carried out withportions of costal cartilage and of bone. INDIVIDUAL TISSUES AS GRAFTS #The Blood# lends itself in an ideal manner to transplantation, or, asit has long been called, _transfusion_. Being always a homoplastictransfer, the new blood is not always tolerated by the old, in whichcase biochemical changes occur, resulting in hæmolysis, whichcorresponds to the disintegration of other unsuccessful homoplasticgrafts. (See article on Transfusion, _Op. Surg. _, p. 37. ) #The Skin. #--The skin was the first tissue to be used for graftingpurposes, and it is still employed with greater frequency than anyother, as lesions causing defects of skin are extremely common andwithout the aid of grafts are tedious in healing. Skin grafts may be applied to a raw surface or to one that is coveredwith granulations. _Skin grafting of raw surfaces_ is commonly indicated after operationsfor malignant disease in which considerable areas of skin must besacrificed, and after accidents, such as avulsion of the scalp bymachinery. _Skin grafting of granulating surfaces_ is chiefly employed to promotehealing in the large defects of skin caused by severe burns; thegrafting is carried out when the surface is covered by a uniform layerof healthy granulations and before the inevitable contraction of scartissue makes itself manifest. Before applying the grafts it is usual toscrape away the granulations until the young fibrous tissue underneathis exposed, but, if the granulations are healthy and can be renderedaseptic, the grafts may be placed on them directly. If it is decided to scrape away the granulations, the oozing must bearrested by pressure with a pad of gauze, a sheet of dental rubber orgreen protective is placed next the raw surface to prevent the gauzeadhering and starting the bleeding afresh when it is removed. #Methods of Skin-Grafting. #--Two methods are employed: one in which theepidermis is mainly or exclusively employed--epidermis or epithelialgrafting; the other, in which the graft consists of the whole thicknessof the true skin--cutis-grafting. _Epidermis or Epithelial Grafting. _--The method introduced by the lateProfessor Thiersch of Leipsic is that almost universally practised. Itconsists in transplanting strips of epidermis shaved from the surface ofthe skin, the razor passing through the tips of the papillæ, whichappear as tiny red points yielding a moderate ooze of blood. The strips are obtained from the front and lateral aspects of the thighor upper arm, the skin in those regions being pliable and comparativelyfree from hairs. They are cut with a sharp hollow-ground razor or with Thiersch'sgrafting knife, the blade of which is rinsed in alcohol and keptmoistened with warm saline solution. The cutting is made easier if theskin is well stretched and kept flat and perfectly steady, theoperator's left hand exerting traction on the skin behind, the hands ofthe assistant on the skin in front, one above and the other below theseat of operation. To ensure uniform strips being cut, the razor is keptparallel with the surface and used with a short, rapid, sawing movement, so that, with a little practice, grafts six or eight inches long by oneor two inches broad can readily be cut. The patient is given a generalanæsthetic, or regional anæsthesia is obtained by injections of asolution of one per cent. Novocain into the line of the lateral andmiddle cutaneous nerves; the disinfection of the skin is carried out onthe 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 directlytransferred to the surface, for which they should be made to form acomplete carpet, slightly overlapping the edges of the area and of oneanother; some blunt instrument is used to straighten out the strips, which are then subjected to firm pressure with a pad of gauze to expressblood and air-bells and to ensure accurate contact, for this must be asclose as that between a postage stamp and the paper to which it isaffixed. As a dressing for the grafted area and of that also from which thegrafts have been taken, gauze soaked in _liquid paraffin_--the patentvariety known as _ambrine_ is excellent--appears to be the best; thegauze should be moistened every other day or so with fresh paraffin, sothat, at the end of a week, when the grafts should have united, thegauze can be removed without risk of detaching them. _Dental wax_ isanother useful type of dressing; as is also _picric acid_ solution. Overthe gauze, there is applied a thick layer of cotton wool, and the wholedressing is kept in place by a firmly applied bandage, and in the caseof the limbs some form of splint should be added to prevent movement. A dressing may be dispensed with altogether, the grafts being protectedby a wire cage such as is used after vaccination, but they tend to dryup and come to resemble a scab. When the grafts have healed, it is well to protect them from injury andto prevent them drying up and cracking by the liberal application oflanoline or vaseline. The new skin is at first insensitive and is fixed to the underlyingconnective tissue or bone, but in course of time (from six weeksonwards) sensation returns and the formation of elastic tissue beneathrenders the skin pliant and movable so that it can be pinched up betweenthe finger and thumb. _Reverdin's_ method consists in planting out pieces of skin not biggerthan a pin-head over a granulating surface. It is seldom employed. _Grafts of the Cutis Vera. _--Grafts consisting of the entire thicknessof the true skin were specially advocated by Wolff and are oftenassociated with his name. They should be cut oval or spindle-shaped, tofacilitate the approximation of the edges of the resulting wound. Thegraft should be cut to the exact size of the surface it is to cover;Gillies believes that tension of the graft favours its taking. Thesegrafts may be placed either on a fresh raw surface or on healthygranulations. It is sometimes an advantage to stitch them in position, especially on the face. The dressing and the after-treatment are thesame as in epidermis grafting. There is a degree of uncertainty about the graft retaining its vitalitylong enough to permit of its deriving the necessary nourishment from itsnew surroundings; in a certain number of cases the flap dies and isthrown off as a slough--moist or dry according to the presence orabsence of septic infection. The technique for cutis-grafting must be without a flaw, and the asepsisabsolute; there must not only be a complete absence of movement, butthere must be no traction on the flap that will endanger its bloodsupply. Owing to the uncertainty in the results of cutis-grafting the_two-stage_ or _indirect method_ has been introduced, and its almostuniform success has led to its sphere of application being widelyextended. The flap is raised as in the direct method but is leftattached at one of its margins for a period ranging from 14 to 21 daysuntil its blood supply from its new bed is assured; the detachment isthen made complete. The blood supply of the proposed flap may influenceits selection and the way in which it is fashioned; for example, a flapcut from the side of the head to fill a defect in the cheek, having inits margin of attachment or pedicle the superficial temporal artery, ismore likely to take than a flap cut with its base above. Another modification is to raise the flap but leave it connected at bothends like the piers of a bridge; this method is well suited to defectsof skin on the dorsum of the fingers, hand and forearm, the bridge ofskin is raised from the abdominal wall and the hand is passed beneath itand securely fixed in position; after an interval of 14 to 21 days, whenthe flap is assured of its blood supply, the piers of the bridge aredivided (Fig. 1). With undermining it is usually easy to bring theedges of the gap in the abdominal wall together, even in children; theskin flap on the dorsum of the hand appears rather thick andprominent--almost like the pad of a boxing-glove--for some time, butthe restoration of function in the capacity to flex the fingers isgratifying in the extreme. [Illustration: FIG.  1. --Ulcer of back of Hand covered by flap of skinraised from anterior abdominal wall. The lateral edges of the flap aredivided after the graft has adhered. ] The indirect element of this method of skin-grafting may be carriedstill further by transferring the flap of skin first to one part of thebody and then, after it has taken, transferring it to a third part. Gillies has especially developed this method in the remedying ofdeformities of the face caused by gunshot wounds and by petrol burns inair-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 themto be brought together so as to form a tube of skin: after thecirculation has been restored, the lower end of the tube is detached andis brought up to the lip or cheek, or eyelid, where it is wanted; whenthis end has derived its new blood supply, the other end is detachedfrom the neck and brought up to where it is wanted. In this way, skinfrom 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 inskin-grafting; the sources of mucous membrane are limited and theelement of septic infection cannot always be excluded. _Fat. _--Adipose tissue has a low vitality, but it is easily retained andit readily lends itself to transplantation. Portions of fat are oftenobtainable at operations--from the omentum, for example, otherwise thesubcutaneous fat of the buttock is the most accessible; it may beemployed to fill up cavities of all kinds in order to obtain more rapidand sounder healing and also to remedy deformity, as in filling up adepression in the cheek or forehead. It is ultimately converted intoordinary connective tissue _pari passu_ with the absorption of the fat. The _fascia lata of the thigh_ is widely and successfully used as agraft to fill defects in the dura mater, and interposed between thebones of a joint--if the articular cartilage has been destroyed--toprevent the occurrence of ankylosis. The _peritoneum_ of hydrocele and hernial sacs and of the omentumreadily lends itself to transplantation. _Cartilage and bone_, next to skin, are the tissues most frequentlyemployed for grafting purposes; their sphere of action is so extensiveand includes so much of technical detail in their employment, that theywill be considered later with the surgery of the bones and joints andwith the methods of re-forming the nose. _Tendons and blood vessels_ readily lend themselves to transplantationand will also be referred to later. _Muscle and nerve_, on the other hand, do not retain their vitality whensevered from their surroundings and do not functionate as grafts exceptfor their connective-tissue elements, which it goes without saying aremore readily obtainable from other sources. Portions of the _ovary_ and of the _thyreoid_ have been successfullytransplanted into the subcutaneous cellular tissue of the abdominal wallby Tuffier and others. In these new surroundings, the ovary or thyreoidis vascularised and has been shown to functionate, but there is notsufficient regeneration of the essential tissue elements to "carry on";the secreting tissue is gradually replaced by connective tissue and thespecial 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 isnecessary to eliminate various extraneous influences which tend to delayor arrest the natural process of repair. Of these, one of the most important is undue movement of the affectedpart. "The first and great requisite for the restoration of injuredparts is _rest_, " said John Hunter; and physiological and mechanicalrest as the chief of natural therapeutic agents was the theme of JohnHilton's classical work--_Rest and Pain_. In this connection it must beunderstood that "rest" implies more than the mere state of physicalrepose: all physiological as well as mechanical function must beprevented as far as is possible. For instance, the constituent bones ofa joint affected with tuberculosis must be controlled by splints orother appliances so that no movement can take place between them, andthe limb may not be used for any purpose; physiological rest may besecured to an inflamed colon by making an artificial anus in the cæcum;the activity of a diseased kidney may be diminished by regulating thequantity 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 ofstrong lotions or other applications. An _unhealthy or devitalised condition of the patient's tissues_ alsohinders the reparative process. Bruised or lacerated skin heals lesskindly than skin cut with a smooth, sharp instrument; and persistentvenous congestion of a part, such as occurs, for example, in the legwhen the veins are varicose, by preventing the access of healthy blood, tends to delay the healing of open wounds. The existence of graveconstitutional 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 ofrepair in wounds. SURGICAL BACTERIOLOGY The influence of micro-organisms in the causation of disease, and therôle played by them in interfering with the natural process of repair, are so important that the science of applied bacteriology has now cometo dominate every department of surgery, and it is from the standpointof bacteriology that nearly all surgical questions have to beconsidered. The term _sepsis_ as now used in clinical surgery no longer retains itsoriginal meaning as synonymous with "putrefaction, " but is employed todenote all conditions in which bacterial infection has taken place, andmore particularly those in which pyogenic bacteria are present. In thesame way the term _aseptic_ conveys the idea of freedom from all formsof bacteria, putrefactive or otherwise; and the term _antiseptic_ isused to denote a power of counteracting bacteria and their products. #General Characters of Bacteria. #--A _bacterium_ consists of a finelygranular mass of protoplasm, enclosed in a thin gelatinous envelope. Many forms are motile--some in virtue of fine thread-like flagella, andothers through contractility of the protoplasm. The great majoritymultiply by simple fission, each parent cell giving rise to two daughtercells, and this process goes on with extraordinary rapidity. Othervarieties, 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 areremarkable for their tenacity of life, and for the resistance they offerto the action of heat and chemical germicides. Bacteria are most conveniently classified according to their shape. Thuswe recognise (1) those that are globular--_cocci_; (2) those thatresemble a rod--_bacilli_; (3) the spiral or wavy forms--_spirilla_. _Cocci_ or _micrococci_ are minute round bodies, averaging about 1 µ indiameter. The great majority are non-motile. They multiply by fission;and when they divide in such a way that the resulting cells remain inpairs, are called _diplococci_, of which the bacteria of gonorrhœa andpneumonia are examples (Fig. 5). When they divide irregularly, and formgrape-like bunches, they are known as _staphylococci_, and to thisvariety the commonest pyogenic or pus-forming organisms belong (Fig. 2). When division takes place only in one axis, so that long chains areformed, the term _streptococcus_ is applied (Fig. 3). Streptococci aremet with in erysipelas and various other inflammatory and suppurativeprocesses of a spreading character. _Bacilli_ are rod-shaped bacteria, usually at least twice as long asthey are broad (Fig. 4). Some multiply by fission, others bysporulation. Some forms are motile, others are non-motile. Tuberculosis, tetanus, anthrax, and many other surgical diseases are due to differentforms of bacilli. _Spirilla_ are long, slender, thread-like cells, more or less spiral orwavy. Some move by a screw-like contraction of the protoplasm, some byflagellæ. The spirochæte associated with syphilis (Fig. 36) is the mostimportant member of this group. #Conditions of Bacterial Life. #--Bacteria require for their growth anddevelopment a suitable food-supply in the form of proteins, carbohydrates, and salts of calcium and potassium which they break upinto simpler elements. An alkaline medium favours bacterial growth; andmoisture is a necessary condition; spores, however, can survive the wantof water for much longer periods than fully developed bacteria. Thenecessity for oxygen varies in different species. Those that requireoxygen are known as _aërobic bacilli_ or _aërobes_; those that cannotlive in the presence of oxygen are spoken of as _anaërobes_. The greatmajority of bacteria, however, while they prefer to have oxygen, areable to live without it, and are called _facultative anaërobes_. The most suitable temperature for bacterial life is from 95° to 102° F. , roughly that of the human body. Extreme or prolonged cold paralyses butdoes not kill micro-organisms. Few, however, survive being raised to atemperature of 134½° F. Boiling for ten to twenty minutes will kill allbacteria, and the great majority of spores. Steam applied in anautoclave under a pressure of two atmospheres destroys even the mostresistant spores in a few minutes. Direct sunlight, electric light, oreven diffuse daylight, is inimical to the growth of bacteria, as arealso Röntgen rays and radium emanations. #Pathogenic Properties of Bacteria. #--We are now only concerned withpathogenic bacteria--that is, bacteria capable of producing disease inthe human subject. This capacity depends upon two sets of factors--(1)certain features peculiar to the invading bacteria, and (2) otherspeculiar to the host. Many bacteria have only the power of living upondead matter, and are known as _saphrophytes_. Such as do nourish inliving tissue are, by distinction, known as _parasites_. The power agiven parasitic micro-organism has of multiplying in the body and givingrise to disease is spoken of as its _virulence_, and this varies notonly with different species, but in the same species at different timesand under varying circumstances. The actual number of organismsintroduced is also an important factor in determining their pathogenicpower. Healthy tissues can resist the invasion of a certain number ofbacteria of a given species, but when that number is exceeded, theorganisms get the upper hand and disease results. When the organismsgain access directly to the blood-stream, as a rule they produce theireffects more certainly and with greater intensity than when they areintroduced into the tissues. Further, the virulence of an organism is modified by the condition ofthe patient into whose tissues it is introduced. So long as a person isin good health, the tissues are able to resist the attacks of moderatenumbers of most bacteria. Any lowering of the vitality of theindividual, however, either locally or generally, at once renders himmore susceptible to infection. Thus bruised or torn tissue is much moreliable to infection with pus-producing organisms than tissues clean-cutwith a knife; also, after certain diseases, the liability to infectionby the organisms of diphtheria, pneumonia, or erysipelas is muchincreased. Even such slight depression of vitality as results frombodily fatigue, or exposure to cold and damp, may be sufficient to turnthe scale in the battle between the tissues and the bacteria. Age is animportant factor in regard to the action of certain bacteria. Youngsubjects are attacked by diphtheria, tuberculosis, acute osteomyelitis, and some other diseases with greater frequency and severity than thoseof more advanced years. In different races, localities, environment, and seasons, the pathogenicpowers 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 ofmore than one species of organism, for example, the tubercle bacillusand a pyogenic staphylococcus--increases the severity of the resultingdisease. If one of the varieties gain the ascendancy, the poisonsproduced by the others so devitalise the tissue cells, and diminishtheir power of resistance, that the virulence of the most activeorganisms is increased. On the other hand, there is reason to believethat the products of certain organisms antagonise one another--forexample, an attack of erysipelas may effect the cure of a patch oftuberculous lupus. Lastly, in patients suffering from chronic wasting diseases, bacteriamay invade the internal organs by the blood-stream in enormous numbersand with great rapidity, during the period of extreme debility whichshortly precedes death. The discovery of such collections of organismson post-mortem examination may lead to erroneous conclusions being drawnas to the cause of death. #Results of Bacterial Growth. #--Some organisms, such as those of tetanusand erysipelas, and certain of the pyogenic bacteria, show littletendency to pass far beyond the point at which they gain an entrance tothe body. Others, on the contrary--for example, the tubercle bacillusand the organism of acute osteomyelitis--although frequently remaininglocalised at the seat of inoculation, tend to pass to distant parts, lodging in the capillaries of joints, bones, kidney, or lungs, and thereproducing their deleterious effects. In the human subject, multiplication in the blood-stream does not occurto any great extent. In some general acute pyogenic infections, such asosteomyelitis, cellulitis, etc. , pure cultures of staphylococci or ofstreptococci may be obtained from the blood. In pneumococcal and typhoidinfections, also, the organisms may be found in the blood. It is by the vital changes they bring about in the parts where theysettle that micro-organisms disturb the health of the patient. Inderiving nourishment from the complex organic compounds in which theynourish, the organisms evolve, probably by means of a ferment, certainchemical products of unknown composition, but probably colloidal innature, and known as _toxins_. When these poisons are absorbed into thegeneral circulation they give rise to certain groups of symptoms--suchas rise of temperature, associated circulatory and respiratoryderangements, interference with the gastro-intestinal functions and alsowith those of the nervous system--which go to make up the conditionknown as blood-poisoning, toxæmia, or _bacterial intoxication_. Inaddition to this, certain bacteria produce toxins that give rise todefinite and distinct groups of symptoms--such as the convulsions oftetanus, or the paralyses that follow diphtheria. _Death of Bacteria. _--Under certain circumstances, it would appear thatthe accumulation of the toxic products of bacterial action tends tointerfere with the continued life and growth of the organismsthemselves, and in this way the natural cure of certain diseases isbrought about. Outside the body, bacteria may be killed by starvation, by want of moisture, by being subjected to high temperature, or by theaction of certain chemical agents of which carbolic acid, theperchloride and biniodide of mercury, and various chlorine preparationsare the most powerful. #Immunity. #--Some persons are insusceptible to infection by certaindiseases, from which they are said to enjoy a _natural immunity_. Inmany acute diseases one attack protects the patient, for a time atleast, from a second attack--_acquired immunity_. _Phagocytosis. _--In the production of immunity the leucocytes andcertain other cells play an important part in virtue of the power theypossess of ingesting bacteria and of destroying them by a process ofintra-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 inthe circulating blood increase greatly in numbers (_leucocytosis_), aswell as in their phagocytic action, and in the course of destroying thebacteria they produce certain ferments which enter the blood serum. These are known as _opsonins_ or _alexins_, and they act on the bacteriaby a process comparable to narcotisation, and render them an easy preyfor the phagocytes. _Artificial or Passive Immunity. _--A form of immunity can be induced bythe introduction of protective substances obtained from an animal whichhas been actively immunised. The process by which passive immunity isacquired depends upon the fact that as a result of the reaction betweenthe specific virus of a particular disease (the _antigen_) and thetissues of the animal attacked, certain substances--_antibodies_--areproduced, which when transferred to the body of a susceptible animalprotect it against that disease. The most important of these antibodiesare the _antitoxins_. From the study of the processes by which immunityis secured against the effects of bacterial action the serum and vaccinemethods of treating certain infective diseases have been evolved. The_serum treatment_ is designed to furnish the patient with a sufficiencyof antibodies to neutralise the infection. The anti-diphtheritic and theanti-tetanic act by neutralising the specific toxins of thedisease--_antitoxic serums_; the anti-streptcoccic and the serum foranthrax act upon the bacteria--_anti-bacterial serums_. A _polyvalent_ serum, that is, one derived from an animal which has beenimmunised by numerous strains of the organism derived from varioussources, is much more efficacious than when a single strain has beenused. _Clinical Use of Serums. _--Every precaution must be taken to preventorganismal contamination of the serum or of the apparatus by means ofwhich it is injected. Syringes are so made that they can be sterilisedby boiling. The best situations for injection are under the skin of theabdomen, the thorax, or the buttock, and the skin should be purified atthe seat of puncture. If the bulk of the full dose is large, it shouldbe divided and injected into different parts of the body, not more than20 c. C. Being injected at one place. The serum may be introduceddirectly into a vein, or into the spinal canal, _e. G. _ anti-tetanicserum. The immunity produced by injections of antitoxic sera lasts onlyfor a comparatively short time, seldom longer than a few weeks. _"Serum Disease" and Anaphylaxis. _--It is to be borne in mind that somepatients exhibit a supersensitiveness with regard to protective sera, aninjection being followed in a few days by the appearance of anurticarial or erythematous rash, pain and swelling of the joints, and avariable degree of fever. These symptoms, to which the name _serumdisease_ is applied, usually disappear in the course of a few days. The term _anaphylaxis_ is applied to an allied condition ofsupersensitiveness which appears to be induced by the injection ofcertain substances, including toxins and sera, that are capable ofacting as antigens. When a second injection is given after an intervalof some days, if anaphylaxis has been established by the first dose, thepatient suddenly manifests toxic symptoms of the nature of profoundshock which may even prove fatal. The conditions which render a personliable to develop anaphylaxis and the mechanism by which it isestablished are as yet imperfectly understood. _Vaccine Treatment. _--The vaccine treatment elaborated by A.  E.  Wrightconsists in injecting, while the disease is still active, speciallyprepared dead cultures of the causative organisms, and is based on thefact that these "vaccines" render the bacteria in the tissues less ableto resist the attacks of the phagocytes. The method is most successfulwhen the vaccine is prepared from organisms isolated from the patienthimself, _autogenous vaccine_, but when this is impracticable, or takesa considerable time, laboratory-prepared polyvalent _stock vaccines_ maybe used. _Clinical Use of Vaccines. _--Vaccines should not be given while apatient is in a negative phase, as a certain amount of the opsonin inthe blood is used up in neutralising the substances injected, and thismay reduce the opsonic index to such an extent that the vaccinesthemselves become dangerous. As a rule, the propriety of using a vaccinecan be determined from the general condition of the patient. The initialdose should always be a small one, particularly if the disease is acute, and the subsequent dosage will be regulated by the effect produced. Ifmarked constitutional disturbance with rise of temperature follows theuse of a vaccine, it indicates a negative phase, and calls for adiminution in the next dose. If, on the other hand, the local as well asthe general condition of the patient improves after the injection, itindicates a positive phase, and the original dose may be repeated oreven increased. Vaccines are best introduced subcutaneously, a partbeing selected which is not liable to pressure, as there is sometimesconsiderable local reaction. Repeated doses may be necessary atintervals of a few days. The vaccine treatment has been successfully employed in varioustuberculous lesions, in pyogenic infections such as acne, boils, sycosis, streptococcal, pneumococcal, and gonococcal conditions, ininfections of the accessory air sinuses, and in other diseases caused bybacteria. PYOGENIC BACTERIA From the point of view of the surgeon the most important varieties ofmicro-organisms are those that cause inflammation and suppuration--the_pyogenic bacteria_. This group includes a great many species, and theseare so widely distributed that they are to be met with under allconditions of everyday life. The nature of the inflammatory and suppurative processes will beconsidered in detail later; suffice it here to say that they are broughtabout by the action of one or other of the organisms that we have now toconsider. It is found that the _staphylococci_, which cluster into groups, tend toproduce localised lesions; while the chain-forms--_streptococci_--giverise to diffuse, spreading conditions. Many varieties of pyogenicbacteria have now been differentiated, the best known being thestaphylococcus aureus, the streptococcus, and the bacillus colicommunis. [Illustration: FIG.  2. --Staphylococcus aureus in Pus from case ofOsteomyelitis. × 1000 diam. Gram's stain. ] _Staphylococcus Aureus. _--This is the commonest organism found inlocalised inflammatory and suppurative conditions. It varies greatly inits virulence, and is found in such widely different conditions as skinpustules, boils, carbuncles, and some acute inflammations of bone. Asseen by the microscope it occurs in grape-like clusters, fission of theindividual cells taking place irregularly (Fig. 2). When grown inartificial media, the colonies assume an orange-yellow colour--hence thename _aureus_. It is of high vitality and resists more prolongedexposure to high temperatures than most non-sporing bacteria. It iscapable of lying latent in the tissues for long periods, for example, inthe marrow of long bones, and of again becoming active and causing afresh outbreak of suppuration. This organism is widely distributed: itis 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 uponwhich dust has settled, it is a continual source of infection unlessmeans are taken to exclude it from wounds. The _staphylococcus albus_ is much less common than the aureus, but hasthe same properties and characters, save that its growth on artificialmedia assumes a white colour. It is the common cause of stitchabscesses, the skin being its normal habitat. [Illustration: FIG.  3. --Streptococci in Pus from an acute abscess insubcutaneous tissue. × 1000 diam. Gram's stain. ] _Streptococcus Pyogenes. _--This organism also varies greatly in itsvirulence; in some instances--for example in erysipelas--it causes asharp attack of acute spreading inflammation, which soon subsideswithout showing any tendency to end in suppuration; under otherconditions it gives rise to a generalised infection which rapidly provesfatal. The streptococcus has less capacity of liquefying the tissuesthan the staphylococcus, so that pus formation takes place more slowly. At the same time its products are very potent in destroying the tissuesin their vicinity, and so interfering with the exudation of leucocyteswhich would otherwise exercise their protective influence. Streptococciinvade the lymph spaces, and are associated with acute spreadingconditions such as phlegmonous or erysipelatous inflammations andsuppurations, lymphangitis and suppuration in lymph glands, andinflammation of serous and synovial membranes, also with a form ofpneumonia which is prone to follow on severe operations in the mouth andthroat. Streptococci are also concerned in the production of spreadinggangrene and pyæmia. Division takes place in one axis, so that chains of varying length areformed (Fig. 3). It is less easily cultivated by artificial media thanthe staphylococcus; it forms a whitish growth. [Illustration: FIG.  4. --Bacillus coli communis in Urine, from a case ofCystitis. × 1000 diam. Leishman's stain. ] _Bacillus Coli Communis. _--This organism, which is a normal inhabitantof the intestinal tract, shows a great tendency to invade any organ ortissue whose vitality is lowered. It is causatively associated with suchconditions as peritonitis and peritoneal suppuration resulting fromstrangulated hernia, appendicitis, or perforation in any part of thealimentary canal. In cystitis, pyelitis, abscess of the kidney, suppuration in the bile-ducts or liver, and in many other abdominalconditions, it plays a most important part. The discharge from woundsinfected by this organism has usually a fœtid, or even a fæcal odour, and often contains gases resulting from putrefaction. It is a small rod-shaped organism with short flagellæ, which render itmotile (Fig. 4). It closely resembles the typhoid bacillus, but isdistinguished from it by its behaviour in artificial culture media. [Illustration: FIG.  5. --Fraenkel's Pneumococci in Pus from Empyemafollowing Pneumonia. × 100 diam. Stained with Muir's capsule stain. ] _Pneumo-bacteria. _--Two forms of organism associated withpneumonia--_Fraenkel's pneumococcus_ (one of the diplococci) (Fig. 5)and _Friedländer's pneumo-bacillus_ (a short rod-shaped form)--arefrequently met with in inflammations of the serous and synovialmembranes, in suppuration in the liver, and in various otherinflammatory and suppurative conditions. _Bacillus Typhosus. _--This organism has been found in pure culture insuppurative conditions of bone, of cellular tissue, and of internalorgans, especially during convalescence from typhoid fever. Like thestaphylococcus, it is capable of lying latent in the tissues for longperiods. _Other Pyogenic Bacteria. _--It is not necessary to do more than namesome of the other organisms that are known to be pyogenic, such as thebacillus pyocyaneus, which is found in green and blue pus, themicrococcus tetragenus, the gonococcus, actinomyces, the glandersbacillus, and the tubercle bacillus. Most of these will receive furthermention in connection with the diseases to which they give rise. #Leucocytosis. #--Most bacterial diseases, as well as certain otherpathological conditions, are associated with an increase in the numberof leucocytes in the blood throughout the circulatory system. Thiscondition of the blood, which is known as _leucocytosis_, is believed tobe due to an excessive output and rapid formation of leucocytes by thebone marrow, and it probably has as its object the arrest anddestruction of the invading organisms or toxins. To increase theresisting power of the system to pathogenic organisms, an artificialleucocytosis may be induced by subcutaneous injection of a solution ofnucleinate of soda (16 minims of a 5 per cent. Solution). The _normal_ number of leucocytes per cubic millimetre varies indifferent individuals, and in the same individual under differentconditions, from 5000 to 10, 000: 7500 is a normal average, and anythingabove 12, 000 is considered abnormal. When leucocytosis is present, thenumber may range from 12, 000 to 30, 000 or even higher; 40, 000 is lookedupon as a high degree of leucocytosis. According to Ehrlich, thefollowing may be taken as the standard proportion of the various formsof leucocytes in normal blood: polynuclear neutrophile leucocytes, 70 to72 per cent. ; lymphocytes, 22 to 25 per cent. ; eosinophile cells, 2 to 4per cent. ; large mononuclear and transitional leucocytes, 2 to 4 percent. ; mast-cells, 0. 5 to 2 per cent. In estimating the clinical importance of a leucocytosis, it is notsufficient merely to count the aggregate number of leucocytes present. Adifferential count must be made to determine which variety of cells isin excess. In the majority of surgical affections it is chiefly thegranular polymorpho-nuclear neutrophile leucocytes that are in excess(_ordinary leucocytosis_). In some cases, and particularly in parasiticdiseases such as trichiniasis and hydatid disease, the eosinophileleucocytes also show a proportionate increase (_eosinophilia_). The term_lymphocytosis_ is applied when there is an increase in the number ofcirculating lymphocytes, as occurs, for example, in lymphatic leucæmia, and in certain cases of syphilis. Leucocytosis is met with in nearly all acute infective diseases, and inacute pyogenic inflammatory affections, particularly in those attendedwith suppuration. In exceptionally acute septic conditions the extremevirulence of the toxins may prevent the leucocytes reacting, andleucocytosis may be absent. The absence of leucocytosis in a disease inwhich it is usually present is therefore to be looked upon as a graveomen, particularly when the general symptoms are severe. In some casesof malignant disease the number of leucocytes is increased to 15, 000 or20, 000. A few hours after a severe hæmorrhage also there is usually aleucocytosis of from 15, 000 to 30, 000, which lasts for three or fourdays (Lyon). In cases of hæmorrhage the leucocytosis is increased byinfusion of fluids into the circulation. After all operations there isat least a transient leucocytosis (_post-operative leucocytosis_)(F.  I.  Dawson). The leucocytosis begins soon after the infection manifests itself--forexample, by shivering, rigor, or rise of temperature. The number ofleucocytes rises somewhat rapidly, increases while the condition isprogressing, and remains high during the febrile period, but there is noconstant correspondence between the number of leucocytes and the heightof the temperature. The arrest of the inflammation and its resolutionare accompanied by a fall in the number of leucocytes, while theoccurrence of suppuration is attended with a further increase in theirnumber. In interpreting the "blood count, " it is to be kept in mind that a_physiological leucocytosis_ occurs within three or four hours of takinga meal, especially one rich in proteins, from 1500 to 2000 being addedto the normal number. In this _digestion leucocytosis_ the increase ischiefly in the polynuclear neutrophile leucocytes. Immediately beforeand after delivery, particularly in primiparæ, there is usually amoderate degree of leucocytosis. If the labour is normal and thepuerperium uncomplicated, the number of leucocytes regains the normal inabout a week. Lactation has no appreciable effect on the number ofleucocytes. In new-born infants the leucocyte count is abnormally high, ranging from 15, 000 to 20, 000. In children under one year of age, thenormal average is from 10, 000 to 20, 000. _Absence of Leucocytosis--Leucopenia. _--In certain infective diseasesthe number of leucocytes in the circulating blood is abnormallylow--3000 or 4000--and this condition is known as _leucopenia_. Itoccurs in typhoid fever, especially in the later stages of the disease, in tuberculous lesions unaccompanied by suppuration, in malaria, and inmost cases of uncomplicated influenza. The occurrence of leucocytosis inany of these conditions is to be looked upon as an indication that amixed infection has taken place, and that some suppurative process ispresent. The absence of leucocytosis in some cases of virulent septic poisoninghas already been referred to. It will be evident that too much reliance must not be placed upon asingle observation, particularly in emergency cases. Whenever possible, a series of observations should be made, the blood being examined aboutfour hours after meals, and about the same hour each day. The clinical significance of the blood count in individual diseases willbe further referred to. _The Iodine or Glycogen Reaction. _--The leucocyte count may besupplemented by staining films of the blood with a watery solution ofiodine and potassium iodide. In all advancing purulent conditions, inseptic poisonings, in pneumonia, and in cancerous growths associatedwith ulceration, a certain number of the polynuclear leucocytes arestained a brown or reddish-brown colour, due to the action of the iodineon some substance in the cells of the nature of glycogen. This reactionis absent in serous effusions, in unmixed tuberculous infections, inuncomplicated typhoid fever, and in the early stages of cancerousgrowths. 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 occursin the tissues in response to irritation. These changes represent thereaction of the tissue elements to the irritant, and constitute theattempt made by nature to arrest or to limit its injurious effects, andto repair the damage done by it. The phenomena which characterise the inflammatory reaction can beinduced by any form of irritation--such, for example, as mechanicalinjury, the application of heat or of chemical substances, or the actionof pathogenic bacteria and their toxins--and they are essentiallysimilar in kind whatever the irritant may be. The extent to which theprocess may go, however, and its effects on the part implicated and onthe system as a whole, vary with different irritants and with theintensity and duration of their action. A mechanical, a thermal, or achemical irritant, acting alone, induces a degree of reaction directlyproportionate to its physical properties, and so long as it does notcompletely destroy the vitality of the part involved, the changes in thetissues are chiefly directed towards repairing the damage done to thepart, and the inflammatory reaction is not only compatible with theoccurrence of ideal repair, but may be looked upon as an integral stepin the reparative process. The irritation caused by infection with bacteria, on the other hand, iscumulative, as the organisms not only multiply in the tissues, but inaddition produce chemical poisons (toxins) which aggravate theirritative effects. The resulting reaction is correspondinglyprogressive, and has as its primary object the expulsion of the irritantand the limitation of its action. If the natural protective effort issuccessful, the resulting tissue changes subserve the process of repair, but if the bacteria gain the upper hand in the struggle, theinflammatory reaction becomes more intense, certain of the tissueelements succumb, and the process for the time being is a destructiveone. During the stage of bacterial inflammation, reparative processesare 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 takesplace. In applying the antiseptic principle to the treatment of wounds, ourmain object is to exclude or to eliminate the bacterial factor, and soto prevent the inflammatory reaction going beyond the stage in which itis protective, and just in proportion as we succeed in attaining thisobject, do we favour the occurrence of ideal repair. #Sequence of Changes in Bacterial Inflammation. #--As the form ofinflammation with which we are most concerned is that due to the actionof bacteria, in describing the process by which the protective influenceof the inflammatory reaction is brought into play, we shall assume thepresence of a bacterial irritant. The introduction of a colony of micro-organisms is quickly followed byan accumulation of wandering cells, and proliferation ofconnective-tissue cells in the tissues at the site of infection. Thevarious cells are attracted to the bacteria by a peculiar chemical orbiological power known as _chemotaxis_, which seems to result fromvariations 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 dilatedand the rate of the current in them being for a time increased--_activehyperæmia_. Soon, however, the rate of the blood flow becomes slowerthan normal, and in course of time the current may cease (_stasis_), andthe blood in the vessels may even coagulate (_thrombosis_). Coincidentlywith these changes in the vessels, the leucocytes in the blood of theinflamed part rapidly increase in number, and they become viscous andadhere to the vessel wall, where they may accumulate in large numbers. In course of time the leucocytes pass through the vesselwall--_emigration of leucocytes_--and move towards the seat ofinfection, giving rise to a marked degree of _local leucocytosis_. Through the openings by which the leucocytes have escaped from thevessels, red corpuscles may be passively extruded--_diapedesis of redcorpuscles_. These processes are accompanied by changes in theendothelium of the vessel walls, which result in an increased formationof lymph, which transudes into the meshes of the connective tissuegiving rise to an _inflammatory œdema_, or, if the inflammation is on afree surface, forming an _inflammatory exudate_. The quantity andcharacters of this exudate vary in different parts of the body, andaccording to the nature, virulence, and location of the organismscausing the inflammation. Thus it may be _serous_, as in some forms ofsynovitis; _sero-fibrinous_, as in certain varieties of peritonitis, thefibrin tending to limit the spread of the inflammation by formingadhesions; _croupous_, when it coagulates on a free surface and forms afalse membrane, as in diphtheria; _hæmorrhagic_ when mixed with blood;or _purulent_, when suppuration has occurred. The protective effects ofthe inflammatory reaction depend for the most part upon the transudationof lymph and the emigration of leucocytes. The lymph contains theopsonins which act on the bacteria and render them less able to resistthe attack of the phagocytes, as well as the various protectiveantibodies which neutralise the toxins. The polymorph leucocytes are theprincipal agents in the process of phagocytosis (p. 22), and togetherwith the other forms of phagocytes they ingest and destroy the bacteria. If the attempt to repel the invading organisms is successful, theirritant 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 restorethe condition to the normal, and _repair_ ensues after the manneralready described. In certain situations, notably in tendon sheaths, inthe cavities of joints, and in the interior of serous cavities, forexample the pleura and peritoneum, the restoration to the normal is notperfect, adhesions forming between the opposing surfaces. If, however, the reaction induced by the infection is insufficient tocheck the growth and spread of the organisms, or to inhibit their toxinproduction, local necrosis of tissue may take place, either in the formof suppuration or of gangrene, or the toxins absorbed into thecirculation may produce blood-poisoning, which may even prove fatal. #Clinical Aspects of Inflammation. #--It must clearly be understood thatinflammation is not to be looked upon as a disease in itself, but ratheras an evidence of some infective process going on in the tissues inwhich it occurs, and of an effort on the part of these tissues toovercome the invading organisms and their products. The chief danger tothe patient lies, not in the reactive changes that constitute theinflammatory process, but in the fact that he is liable to be poisonedby 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 tothese may be added, interference with function in the inflamed part, andgeneral constitutional disturbance. Variations in these signs andsymptoms depend upon the acuteness of the condition, the nature of thecausative organism and of the tissue attacked, the situation of the partin relation to the surface, and other factors. The _heat_ of the inflamed part is to be attributed to the increasedquantity of blood present in it, and the more superficial the affectedarea the more readily is the local increase of temperature detected bythe hand. This clinical point is best tested by placing the palm of thehand and fingers for a few seconds alternately over an uninflamed and aninflamed area, otherwise under similar conditions as to coverings andexposure. In this way even slight differences may be recognised. _Redness_, similarly, is due to the increased afflux of blood to theinflamed part. The shade of colour varies with the stage of theinflammation, being lighter and brighter in the early, hyperæmic stages, and darker and duskier when the blood flow is slowed or when stasis hasoccurred and the oxygenation of the blood is defective. In thethrombotic stage the part may assume a purplish hue. The _swelling_ is partly due to the increased amount of blood in theaffected part and to the accumulation of leucocytes and proliferatedtissue cells, but chiefly to the exudate in the connectivetissue--_inflammatory œdema_. The more open the structure of the tissueof the part, the greater is the amount of swelling--witness the markeddegree of œdema that occurs in such parts as the scrotum or the eyelids. _Pain_ is a symptom seldom absent in inflammation. _Tenderness_--thatis, pain elicited on pressure--is one of the most valuable diagnosticsigns we possess, and is often present before pain is experienced by thepatient. That the area of tenderness corresponds to the area ofinflammation is almost an axiom of surgery. Pain and tenderness are dueto the irritation of nerve filaments of the part, rendered all the moresensitive by the abnormal conditions of their blood supply. Ininflammatory conditions of internal organs, for example the abdominalviscera, the pain is frequently referred to other parts, usually to anarea supplied by branches from the same segment of the cord as thatsupplying the inflamed part. For purposes of diagnosis, attention should be paid to the terms inwhich the patient describes his pain. For example, the pain caused byan inflammation of the skin is usually described as of a _burning_ or_itching_ character; that of inflammation in dense tissues likeperiosteum or bone, or in encapsuled organs, as _dull_, _boring_, or_aching_. When inflammation is passing on to suppuration the painassumes a _throbbing_ character, and as the pus reaches the surface, or"points, " as it is called, sharp, _darting_, or _lancinating_ pains areexperienced. Inflammation involving a nerve-trunk may cause a _boring_or a _tingling_ pain; while the implication of a serous membrane such asthe pleura or peritoneum gives rise to a pain of a sharp, _stabbing_character. _Interference with the function_ of the inflamed part is always presentto a greater or less extent. #Constitutional Disturbances. #--Under the term constitutionaldisturbances are included the presence of fever or elevation oftemperature; certain changes in the pulse rate and the respiration;gastro-intestinal and urinary disturbances; and derangements of thecentral nervous system. These are all due to the absorption of toxinsinto the general circulation. _Temperature. _--A marked rise of temperature is one of the most constantand important concomitants of acute inflammatory conditions, and thetemperature chart forms a fairly reliable index of the state of thepatient. The toxins interfere with the nerve-centres in the medulla thatregulate the balance between the production and the loss of body heat. Clinically the temperature is estimated by means of a self-registeringthermometer placed, for from one to five minutes, in close contact withthe skin in the axilla, or in the mouth. Sometimes the thermometer isinserted into the rectum, where, however, the temperature is normally¾° F. Higher than in the axilla. _In health_ the temperature of the body is maintained at a mean of about98. 4° F. (37° C. ) by the heat-regulating mechanism. It varies from hourto hour even in health, reaching its maximum between four and eight inthe evening, when it may rise to 99° F. , and is at its lowest betweenfour and six in the morning, when it may be about 97° F. The temperature is more easily disturbed in children than in adults, andmay become markedly elevated (104° or 105° F. ) from comparatively slightcauses; 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 ofchilliness down the back and in the limbs, which may be so marked thatthe patient shivers violently, while the skin becomes cold, pale, andshrivelled--_cutis anserina_. This is a nervous reaction due to a wantof correspondence between the internal and the surface temperature ofthe body, and is known clinically as a _rigor_. When the temperaturerises gradually the chill is usually slight and may be unobserved. Evenduring the cold stage, however, the internal temperature is alreadyraised, and by the time the chill has passed off its maximum has beenreached. The _pulse_ is always increased in frequency, and usually variesdirectly with the height of the temperature. _Respiration_ is moreactive during the progress of an inflammation; and bronchial catarrh iscommon apart from any antecedent respiratory disease. _Gastro-intestinal disturbances_ take the form of loss of appetite, vomiting, diminished secretion of the alimentary juices, and weakeningof the peristalsis of the bowel, leading to thirst, dry, furred tongue, and constipation. Diarrhœa is sometimes present. The _urine_ is usuallyscanty, of high specific gravity, rich in nitrogenous substances, especially urea and uric acid, and in calcium salts, while sodiumchloride is deficient. Albumin and hyaline casts may be present in casesof severe inflammation with high temperature. The significance ofgeneral _leucocytosis_ has already been referred to. #General Principles of Treatment. #--The capacity of the inflammatoryreaction for dealing with bacterial infections being limited, it oftenbecomes necessary for the surgeon to aid the natural defensiveprocesses, as well as to counteract the local and general effects of thereaction, and to relieve symptoms. The ideal means of helping the tissues is by removing the focus ofinfection, and when this can be done, as for example in a carbuncle oran anthrax pustule, the infected area may be completely excised. Whenthe focus is not sufficiently limited to admit of this, the infectedtissue may be scraped away with the sharp spoon, or destroyed bycaustics or by the actual cautery. If this is inadvisable, the organismsmay be attacked by strong antiseptics, such as pure carbolic acid. Moist dressings favour the removal of bacteria by promoting the escapeof the inflammatory exudate, in which they are washed out. #Artificial Hyperæmia. #--When such direct means as the above areimpracticable, much can be done to aid the tissues in their struggle byimproving the condition of the circulation in the inflamed area, so asto ensure that a plentiful supply of fresh arterial blood reaches it. The beneficial effects of _hot fomentations and poultices_ depend ontheir causing a dilatation of the vessels, and so inducing a hyperæmiain the affected area. It has been shown experimentally that repeated, short applications of moist heat (not exceeding 106° F. ) are moreefficacious than continuous application. It is now believed that theso-called _counter-irritants_--mustard, iodine, cantharides, actualcautery--act in the same way; and the method of treating erysipelas byapplying a strong solution of iodine around the affected area is basedon the same principle. [Illustration: FIG.  6. --Passive Hyperæmia of Hand and Forearm induced byBier's Bandage. ] While these and similar methods have long been employed in the treatmentof inflammatory conditions, it is only within comparatively recent yearsthat their mode of action has been properly understood, and to AugustBier belongs the credit of having put the treatment of inflammation on ascientific and rational basis. Recognising the "beneficent intention" ofthe inflammatory reaction, and the protective action of the leucocytosiswhich accompanies the hyperæmic stages of the process, Bier was led tostudy the effects of increasing the hyperæmia by artificial means. As aresult of his observations, he has formulated a method of treatmentwhich consists in inducing an artificial hyperæmia in the inflamed area, either by obstructing the venous return from the part (_passivehyperæmia_), or by stimulating the arterial flow through it (_activehyperæmia_). _Bier's Constricting Bandage. _--To induce a _passive hyperæmia_ in alimb, an elastic bandage is applied some distance above the inflamedarea sufficiently tightly to obstruct the venous return from the distalparts without arresting in any way the inflow of arterial blood (Fig.  6). If the constricting band is correctly applied, the parts beyondbecome swollen and œdematous, and assume a bluish-red hue, but theyretain their normal temperature, the pulse is unchanged, and there is nopain. If the part becomes blue, cold, or painful, or if any existingpain is increased, the band has been applied too tightly. The hyperæmiais kept up from twenty to twenty-two hours out of the twenty-four, andin the intervals the limb is elevated to get rid of the œdema and toempty it of impure blood, and so make room for a fresh supply of healthyblood when the bandage is re-applied. As the inflammation subsides, theperiod during which the band is kept on each day is diminished; but thetreatment should be continued for some days after all signs ofinflammation have subsided. This method of treating acute inflammatory conditions necessitatesclose supervision until the correct degree of tightness of the band hasbeen determined. [Illustration: FIG.  7. --Passive Hyperæmia of Finger induced by Klapp'sSuction Bell. ] _Klapp's Suction Bells. _--In inflammatory conditions to which theconstricting band cannot be applied, as for example an acute mastitis, abubo in the groin, or a boil on the neck, the affected area may berendered hyperæmic by an appropriately shaped glass bell applied over itand exhausted by means of a suction-pump, the rarefaction of the air inthe 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 thesuction applied for from five to ten minutes at a time, with acorresponding interval between the applications. Each sitting lasts forfrom half an hour to an hour, and the treatment may be carried out onceor twice a day according to circumstances. This apparatus acts in thesame way as the old-fashioned _dry cup_, and is more convenient andequally efficacious. [Illustration: FIG.  8. --Passive Hyperæmia induced by Klapp's SuctionBell for Inflammation of Inguinal Gland. ] _Active hyperæmia_ is induced by the local application of heat, particularly by means of hot air. It has not proved so useful in acuteinflammation as passive hyperæmia, but is of great value in hasteningthe absorption of inflammatory products and in overcoming adhesions andstiffness in tendons and joints. _General Treatment. _--The patient should be kept at rest, preferably inbed, to diminish the general tissue waste; and the diet should berestricted to fluids, such as milk, beef-tea, meat juices or gruel, andthese may be rendered more easily assimilable by artificial digestion ifnecessary. To counteract the general effect of toxins absorbed intothe circulation, specific antitoxic sera are employed in certain formsof infection, such as diphtheria, streptococcal septicæmia, and tetanus. In other forms of infection, vaccines are employed to increase theopsonic power of the blood. When such means are not available, thecirculating toxins may to some extent be diluted by giving plenty ofbland fluids by the mouth or normal salt solution by the rectum. The elimination of the toxins is promoted by securing free action of theemunctories. A saline purge, such as half an ounce of sulphate ofmagnesium in a small quantity of water, ensures a free evacuation of thebowels. The kidneys are flushed by such diluent drinks as equal parts ofmilk and lime water, or milk with a dram of liquor calcis saccharatusadded to each tumblerful. Barley-water and "Imperial drink, " whichconsists of a dram and a half of cream of tartar added to a pint ofboiling water and sweetened with sugar after cooling, are also usefuland non-irritating diuretics. The skin may be stimulated by Dover'spowder (10 grains) or liquor ammoniæ acetatis in three-dram doses everyfour hours. Various drugs administered internally, such as quinine, salol, salicylate of iron, and others, have a reputation, more or lessdeserved, as internal antiseptics. Weakness of the heart, as indicated by the condition of the pulse, istreated by the use of such drugs as digitalis, strophanthus, orstrychnin, 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 resemblescoffee-grounds from admixture with altered blood--the so-calledpost-operative hæmatemesis--the best means of arresting the vomiting isby washing out the stomach. Thirst is relieved by rectal injections ofsaline solution. The introduction of saline solution into the veins orby the rectum is also useful in diluting and hastening the eliminationof circulating toxins. In surgical inflammations, as a rule, nothing is gained by lowering thetemperature, unless at the same time the cause is removed. When severeor prolonged pyrexia becomes a source of danger, the use of hot or coldsponging, or even the cold bath, is preferable to the administration ofdrugs. _Relief of Symptoms. _--For the relief of _pain_, rest is essential. Theinflamed part should be placed in a splint or other appliance which willprevent movement, and steps must be taken to reduce its functionalactivity as far as possible. Locally, warm and moist dressings, such asa poultice or fomentation, may be used. To make a fomentation, a pieceof flannel or lint is wrung out of very hot water or antiseptic lotionand applied under a sheet of mackintosh. Fomentations should be renewedas often as they cool. An ordinary india-rubber bag filled with hotwater and fixed over the fomentation, by retaining the heat, obviatesthe necessity of frequently changing the application. The addition of afew drops of laudanum sprinkled on the flannel has a soothing effect. Lead and opium lotion is a useful, soothing application employed as afomentation. We prefer the application of lint soaked in a 10 per cent. Aqueous or glycerine solution of ichthyol, or smeared with ichthyolointment (1 in 3). Belladonna and glycerine, equal parts, may be used. Dry cold obtained by means of icebags, or by Leiter's lead tubes throughwhich a continuous stream of ice-cold water is kept flowing, issometimes soothing to the patient, but when the vessels in the inflamedpart are greatly congested its use is attended with considerable risk, as it not only contracts the arterioles supplying the part, but alsodiminishes the outflow of venous blood, and so may determine gangrene oftissues already devitalised. A milder form of employing cold is by means of evaporating lotions: athin piece of lint or gauze is applied over the inflamed part and keptconstantly moist with the lotion, the dressing being left freely exposedto allow of continuous evaporation. A useful evaporating lotion is madeup as follows: take of chloride of ammonium, half an ounce; rectifiedspirit, 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 mayendanger the vitality of the tissues by pressing on the blood vessels tosuch an extent as to cause stasis, and by concentrating the local actionof the toxins. Under such conditions the tension should be relieved andthe exudate with its contained toxins removed by making an incision intothe inflamed tissues, and applying a suction bell. When the exudate hascollected in a synovial cavity, such as a joint or bursa, it may bewithdrawn by means of a trocar and cannula. There are other methods ofwithdrawing blood and exudate from an inflamed area, for example byleeches or wet-cupping, but they are seldom employed now. Before applying leeches the part must be thoroughly cleansed, and ifthe leech is slow to bite, may be smeared with cream. The leech isretained in position under an inverted wine-glass or wide test-tube tillit takes hold. After it has sucked its fill it usually drops off, havingwithdrawn a dram or a dram and a half of blood. If it be desirable towithdraw more blood, hot fomentations should be applied to the bite. Asit is sometimes necessary to employ considerable pressure to stop thebleeding, leeches should, if possible, be applied over a bone which willfurnish the necessary resistance. The use of styptics may be called for. _Wet-cupping_ has almost entirely been superseded by the use of Klapp'ssuction bells. _General blood-letting_ consists in opening a superficial vein(venesection) and allowing from eight to ten ounces of blood to flowfrom it. It is seldom used in the treatment of surgical forms ofinflammation. _Counter-irritants. _--In deep-seated inflammations, counter-irritantsare sometimes employed in the form of mustard leaves or blisters, according to the degree of irritation required. A mustard leaf orplaster should not be left on longer than ten or fifteen minutes, unlessit is desired to produce a blister. Blistering may be produced by a_cantharides plaster_, or by painting with _liquor epispasticus_. Theplaster should be left on from eight to ten hours, and if it has failedto raise a blister, a hot fomentation should be applied to the part. _Liquor epispasticus_, alone or mixed with equal parts of collodion, ispainted on the part with a brush. Several paintings are often requiredbefore a blister is raised. The preliminary removal of the naturalgrease from the skin favours the action of these applications. The treatment of inflammation in special tissues and organs will beconsidered in the sections devoted to regional surgery. #Chronic Inflammation. #--A variety of types of chronic and subacuteinflammation 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 suchimportant diseases as tuberculosis and syphilis, and in which differenttypes of chronic inflammation are caused by infection with a specificorganism, all having the common character, however, that abundantgranulation tissue is formed in which cellular changes are more inevidence than changes in the blood vessels, and in which the subsequentdegeneration and necrosis of the granulation tissue results in thebreaking down and destruction of the tissue in which it is formed. Another group is that in which chronic inflammation is due to mild orattenuated forms of pyogenic infection affecting especially the lymphglands 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 notfrankly suppurate as do the acute types, but are attended with ahyperplasia of the tissue elements which results in enlargement of theaffected glands of a persistent, and sometimes of a relapsing character. Similar varieties of _osteomyelitis_ are met with that do not, like theacute forms, go on to suppuration or to death of bone, but result inthickening of the bone affected, both on the surface and in theinterior, resulting in obliteration of the medullary canal. A third group of chronic inflammations are those that begin as an acutepyogenic inflammation, which, instead of resolving completely, persistsin a chronic form. It does so apparently because there is some factoraiding the organisms and handicapping the tissues, such as the presenceof 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 inthis group, chronic inflammation and repair are practicallyinterchangeable terms. There are other groups of chronic inflammation, the origin of whichcontinues to be the subject of controversy. Reference is here made tothe chronic inflammations of the synovial membrane of joints, of tendonsheaths and of bursæ--_chronic synovitis_, _teno-synovitis_ and_bursitis_; of the fibrous tissues of joints--chronic forms of_arthritis_; of the blood vessels--chronic forms of _endarteritis_ andof _phlebitis_ and of the peripheral nerves--_neuritis_. Also in thebreast and in the prostate, with the waning of sexual life there mayoccur a formation of fibrous tissue--chronic _interstitial mastitis_, _chronic prostatitis_, having analogies with the chronic interstitialinflammations of internal organs like the kidney--_chronic interstitialnephritis_; and in the breast and prostate, as in the kidney, theformation of fibrous tissue leads to changes in the secreting epitheliumresulting in the formation of cysts. Lastly, there are still other types of chronic inflammation attendedwith the formation of fibrous tissue on such a liberal scale as tosuggest analogies with new growths. The best known of these are thesystematic forms of fibromatosis met with in the central nervous systemand in the peripheral nerves--_neuro-fibromatosis_; in the submucouscoat of the stomach--_gastric fibromatosis_; and in thecolon--_intestinal fibromatosis_. These conditions will be described with the tissues and organs in whichthey occur. In the _treatment of chronic inflammations_, pending further knowledgeas to their causation, and beyond such obvious indications as to helpthe tissues by removing a foreign body or a piece of dead bone, thereare employed--empirically--a number of procedures such as the inductionof hyperæmia, exposure to the X-rays, and the employment of blisters, cauteries, and setons. Vaccines may be had recourse to in those ofbacterial 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--_Sapræmia_--_Septicæmia_--_Pyæmia_. Suppuration, or the formation of pus, is one of the results of theaction of bacteria on the tissues. The invading organism is usually oneof the staphylococci, less frequently a streptococcus, and still lessfrequently one of the other bacteria capable of producing pus, such asthe bacillus coli communis, the gonococcus, the pneumococcus, or thetyphoid bacillus. So long as the tissues are in a healthy condition they are able towithstand the attacks of moderate numbers of pyogenic bacteria ofordinary virulence, but when devitalised by disease, by injury, or byinflammation due to the action of other pathogenic organisms, suppuration ensues. It would appear, for example, that pyogenic organisms can pass throughthe healthy urinary tract without doing any damage, but if the pelvis ofthe kidney, the ureter, or the bladder is the seat of stone, they giverise to suppuration. Similarly, a calculus in one of the salivary ductsfrequently results in an abscess forming in the floor of the mouth. Whenthe lumen of a tubular organ, such as the appendix or the Fallopian tubeis blocked also, the action of pyogenic organisms is favoured andsuppuration ensues. #Pus. #--The fluid resulting from the process of suppuration is knownas _pus_. In its typical form it is a yellowish creamy substance, ofalkaline reaction, with a specific gravity of about 1030, and it has apeculiar mawkish odour. If allowed to stand in a test-tube it does notcoagulate, but separates into two layers: the upper, transparent, straw-coloured fluid, the _liquor puris_ or pus serum, closelyresembling blood serum in its composition, but containing less proteinand more cholestrol; it also contains leucin, tyrosin, and certainalbumoses which prevent coagulation. The layer at the bottom of the tube consists for the most part ofpolymorph leucocytes, and proliferated connective tissue and endothelialcells (_pus corpuscles_). Other forms of leucocytes may be present, especially in long-standing suppurations; and there are usually some redcorpuscles, dead bacteria, fat cells and shreds of tissue, cholestrolcrystals, and other detritus in the deposit. If a film of fresh pus is examined under the microscope, the pus cellsare seen to have a well-defined rounded outline, and to contain a finelygranular protoplasm and a multi-partite nucleus; if still warm, thecells may exhibit amœboid movement. In stained films the nuclei take thestain well. In older pus cells the outline is irregular, the protoplasmcoarsely granular, and the nuclei disintegrated, no longer taking thestain. _Variations from Typical Pus. _--Pus from old-standing sinuses is oftenwatery in consistence (ichorous), with few cells. Where the granulationsare vascular and bleed easily, it becomes sanious from admixture withred corpuscles; while, if a blood-clot be broken down and the debrismixed with the pus, it contains granules of blood pigment and is said tobe "grumous. " The _odour_ of pus varies with the different bacteriaproducing it. Pus due to ordinary pyogenic cocci has a mawkish odour;when putrefactive organisms are present it has a putrid odour; when itforms in the vicinity of the intestinal canal it usually contains thebacillus coli communis and has a fæcal odour. The _colour_ of pus also varies: when due to one or other of thevarieties of the bacillus pyocyaneus, it is usually of a blue or greencolour; when mixed with bile derivatives or altered blood pigment, itmay be of a bright orange colour. In wounds inflicted with rough ironimplements from which rust is deposited, the pus often presents the samecolour. The pus may form and collect within a circumscribed area, constituting alocalised _abscess_; or it may infiltrate the tissues over a widearea--_diffuse suppuration_. ACUTE CIRCUMSCRIBED ABSCESS Any tissue of the body may be the seat of an acute abscess, and thereare many routes by which the bacteria may gain access to the affectedarea. For example: an abscess in the integument or subcutaneouscellular tissue usually results from infection by organisms which haveentered through a wound or abrasion of the surface, or along the ductsof the skin; an abscess in the breast from organisms which have passedalong the milk ducts opening on the nipple, or along the lymphaticswhich accompany these. An abscess in a lymph gland is usually due toinfection passing by way of the lymph channels from the area of skin ormucous membrane drained by them. Abscesses in internal organs, such asthe kidney, liver, or brain, usually result from organisms carried inthe blood-stream from some focus of infection elsewhere in the body. A knowledge of the possible avenues of infection is of clinicalimportance, as it may enable the source of a given abscess to be tracedand dealt with. In suppuration in the Fallopian tube (pyosalpynx), forexample, the fact that the most common origin of the infection is in thegenital passage, leads to examination for vaginal discharge; and if noneis present, the abscess is probably due to infection carried in theblood-stream from some primary focus about the mouth, such as a gumboilor 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 lymphglands the infection has come through the afferent lymphatics; if in thecellular tissue, it has spread from the neck or chest wall; if in thehair follicles, it is a local infection through the skin. #Formation of an Abscess. #--When pyogenic bacteria are introduced intothe tissue there ensues an inflammatory reaction, which is characterisedby dilatation of the blood vessels, exudation of large numbers ofleucocytes, and proliferation of connective-tissue cells. Thesewandering cells soon accumulate round the focus of infection, and form aprotective barrier which tends to prevent the spread of the organismsand to restrict their field of action. Within the area thuscircumscribed the struggle between the bacteria and the phagocytes takesplace, and in the process toxins are formed by the organisms, a certainnumber of the leucocytes succumb, and, becoming degenerated, set freecertain proteolytic enzymes or ferments. The toxins causecoagulation-necrosis of the tissue cells with which they come incontact, the ferments liquefy the exudate and other albuminoussubstances, and in this way _pus_ is formed. If the bacteria gain the upper hand, this process of liquefaction whichis characteristic of suppuration, extends into the surrounding tissues, the protective barrier of leucocytes is broken down, and thesuppurative process spreads. A fresh accession of leucocytes, however, forms a new barrier, and eventually the spread is arrested, and thecollection of pus so hemmed in constitutes an _abscess_. Owing to the swelling and condensation of the parts around, the pus thusformed is under considerable pressure, and this causes it to burrowalong the lines of least resistance. In the case of a subcutaneousabscess the pus usually works its way towards the surface, and "points, "as it is called. Where it approaches the surface the skin becomes softand thin, and eventually sloughs, allowing the pus to escape. An abscess forming in the deeper planes is prevented from pointingdirectly to the surface by the firm fasciæ and other fibrous structures. The pus therefore tends to burrow along the line of the blood vesselsand in the connective-tissue septa, till it either finds a weak spot orcauses a portion of fascia to undergo necrosis and so reaches thesurface. Accordingly, many abscess cavities resulting from deep-seatedsuppuration are of irregular shape, with pouches and loculi in variousdirections--an arrangement which interferes with their successfultreatment by incision and drainage. The relief of tension which follows the bursting of an abscess, theremoval of irritation by the escape of pus, and the casting off ofbacteria 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; andlater this is replaced by cicatricial tissue. As a result of thesubsequent contraction of the cicatricial tissue, the scar is usuallydepressed below the level of the surrounding skin surface. If an abscess is prevented from healing--for example, by the presence ofa foreign body or a piece of necrosed bone--a sinus results, and from itpus escapes until the foreign body is removed. #Clinical Features of an Acute Circumscribed Abscess. #--In the initialstages the usual symptoms of inflammation are present. Increasedelevation of temperature, with or without a rigor, progressiveleucocytosis, and sweating, mark the transition between inflammation andsuppuration. An increasing leucocytosis is evidence that a suppurativeprocess is spreading. The local symptoms vary with the seat of the abscess. When it issituated superficially--for example, in the breast tissue--the affectedarea is hot, the redness of inflammation gives place to a dusky purplecolour, with a pale, sometimes yellow, spot where the pus is near thesurface. The swelling increases in size, the firm brawny centre becomessoft, projects as a cone beyond the level of the rest of the swollenarea, and is usually surrounded by a zone of induration. By gently palpating with the finger-tips over the softened area, a fluidwave may be detected--_fluctuation_--and when present this is a certainindication of the existence of fluid in the swelling. Its recognition, however, is by no means easy, and various fallacies are to be guardedagainst in applying this test clinically. When, for example, the wallsof the abscess are thick and rigid, or when its contents are underexcessive tension, the fluid wave cannot be elicited. On the other hand, a sensation closely resembling fluctuation may often be recognised inœdematous tissues, in certain soft, solid tumours such as fatty tumoursor vascular sarcomata, in aneurysm, and in a muscle when it is palpatedin its transverse axis. When pus has formed in deeper parts, and before it has reached thesurface, œdema of the overlying skin is frequently present, and the skinpits on pressure. With the formation of pus the continuous burning or boring pain ofinflammation 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 whichfrequently arises is to decide whether or not pus has actually formed. It may be accepted as a working rule in practice that when an acuteinflammation has lasted for four or five days without showing signs ofabatement, suppuration has almost certainly occurred. In deep-seatedsuppuration, marked œdema of the skin and the occurrence of rigors andsweating may be taken to indicate the formation of pus. There are cases on record where rapidly growing sarcomatous andangiomatous tumours, aneurysms, and the bruises that occur inhæmophylics, have been mistaken for acute abscesses and incised, withdisastrous results. #Treatment of Acute Abscesses. #--The dictum of John Bell, "Where thereis pus, let it out, " summarises the treatment of abscess. The extent andsituation of the incision and the means taken to drain the cavity, however, vary with the nature, site, and relations of the abscess. In asuperficial abscess, for example a bubo, or an abscess in the breast orface where a disfiguring scar is undesirable, a small puncture should bemade where the pus threatens to point, and a Klapp's suction bell beapplied as already described (p. 39). A drain is not necessary, and inthe intervals between the applications of the bell the part is coveredwith a moist antiseptic dressing. In abscesses deeply placed, as for example under the gluteal or pectoralmuscles, one or more incisions should be made, and the cavity drained byglass or rubber tubes or by strips of rubber tissue. The wound should be dressed the next day, and the tube shortened, in thecase of a rubber tube, by cutting off a portion of its outer end. On thesecond day or later, according to circumstances, the tube is removed, and after this the dressing need not be repeated oftener than everysecond or third day. Where pus has formed in relation to important structures--as, forexample, in the deeper planes of the neck--_Hilton's method_ of openingthe abscess may be employed. An incision is made through the skin andfascia, a grooved director is gently pushed through the deeper tissuestill pus escapes along its groove, and then the track is widened bypassing in a pair of dressing forceps and expanding the blades. A tube, or strip of rubber tissue, is introduced, and the subsequent treatmentcarried out as in other abscesses. When the drain lies in proximity to alarge blood vessel, care must be taken not to leave it in position longenough to cause ulceration of the vessel wall by pressure. In some abscesses, such as those in the vicinity of the anus, the cavityshould be laid freely open in its whole extent, stuffed with iodoform orbismuth gauze, and treated by the open method. It is seldom advisable to wash out an abscess cavity, and squeezing outthe pus is also to be avoided, lest the protective zone be broken downand the infection be diffused into the surrounding tissues. The importance of taking precautions against further infection inopening an abscess can scarcely be exaggerated, and the rapidity withwhich healing occurs when the access of fresh bacteria is prevented isin marked contrast to what occurs when such precautions are neglectedand further infection is allowed to take place. _Acute Suppuration in a Wound. _--If in the course of an operationinfection of the wound has occurred, a marked inflammatory reaction soonmanifests itself, and the same changes as occur in the formation of anacute abscess take place, modified, however, by the fact that the puscan more readily reach the surface. In from twenty-four to forty-eighthours the patient is conscious of a sensation of chilliness, or mayeven 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 100or 110. On exposing the wound it is found that the parts for some distancearound are red, glazed, and œdematous. The discoloration and swellingare most intense in the immediate vicinity of the wound, the edges ofwhich are everted and moist. Any stitches that may have been introducedare tight, and the deep ones may be cutting into the tissues. There isheat, and a constant burning or throbbing pain, which is increased bypressure. If the stitches be cut, pus escapes, the wound gapes, and itssurfaces are found to be inflamed and covered with pus. The open method is the only safe means of treating such wounds. Theinfected surface may be sponged over with pure carbolic acid, the excessof which is washed off with absolute alcohol, and the wound eitherdrained by tubes or packed with iodoform gauze. The practice of scrapingsuch surfaces with the sharp spoon, squeezing or even of washing themout with antiseptic lotions, is attended with the risk of furtherdiffusing the organisms in the tissue, and is only to be employed underexceptional circumstances. Continuous irrigation of infected wounds ortheir immersion in antiseptic baths is sometimes useful. The freeopening up of the wound is almost immediately followed by a fall in thetemperature. The surrounding inflammation subsides, the discharge of puslessens, and healing takes place by the formation of granulationtissue--the so-called "healing by second intention. " Wound infection may take place from _catgut_ which has not beenefficiently prepared. The local and general reactions may be slight, and, as a rule, do not appear for seven or eight days after theoperation, and, it may be, not till after the skin edges have united. The suppuration is strictly localised to the part of the wound wherecatgut was employed for stitches or ligatures, and shows little tendencyto spread. The infected part, however, is often long of healing. Theirritation in these cases is probably due to toxins in the catgut andnot to bacteria. When suppuration occurs in connection with buried sutures ofunabsorbable materials, such as silk, silkworm gut, or silver wire, itis apt to persist till the foreign material is cast off or removed. Suppuration may occur in the track of a skin stitch, producing a _stitchabscess_. The infection may arise from the material used, especiallycatgut or silk, or, more frequently perhaps, from the growth ofstaphylococcus albus from the skin of the patient when this has beenimperfectly disinfected. The formation of pus under these conditions maynot be attended with any of the usual signs of suppuration, and beyondsome induration around the wound and a slight tenderness on pressurethere may be nothing to suggest the presence of an abscess. _Acute Suppuration of a Mucous Membrane. _--When pyogenic organisms gainaccess to a mucous membrane, such as that of the bladder, urethra, ormiddle ear, the usual phenomena of acute inflammation and suppurationensue, followed by the discharge of pus on the free surface. It wouldappear that the most marked changes take place in the submucous tissue, causing the covering epithelium in places to die and leave smallsuperficial ulcers, for example in gonorrhœal urethritis, thecicatricial contraction of the scar subsequently leading to theformation 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 someorganism--commonly the _streptococcus pyogenes_--into the cellularconnective tissue of the integument, intermuscular septa, tendonsheaths, or other structures. Infection always takes place through abreach of the surface, although this may be superficial andinsignificant, 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 inflammationbecomes manifest. The cellulitis, also, may develop at some distancefrom the seat of inoculation, the organisms having travelled by thelymphatics. The virulence of the organisms, the loose, open nature of the tissues inwhich they develop, and the free lymphatic circulation by means of whichthey are spread, account for the diffuse nature of the process. Sometimes numbers of cocci are carried for a considerable distance fromthe primary area before they are arrested in the lymphatics, and thusseveral patches of inflammation may appear with healthy areas between. The pus infiltrates the meshes of the cellular tissue, there issloughing of considerable portions of tissue of low vitality, such asfat, fascia, or tendon, and if the process continues for some timeseveral collections of pus may form. _Clinical Features. _--The reaction in cases of diffuse cellulitis issevere, 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 isproportionately increased in frequency, and is small, feeble, and oftenirregular. The face is flushed, the tongue dry and brown, and thepatient may become delirious, especially during the night. Leucocytosisis present in cases of moderate severity; but in severe cases thevirulence of the toxins prevents reaction taking place, and leucocytosisis absent. The local manifestations vary with the relation of the seat of theinflammation to the surface. When the superficial cellular tissue isinvolved, the skin assumes a dark bluish-red colour, is swollen, œdematous, and the seat of burning pain. To the touch it is firm, hot, and tender. When the primary focus is in the deeper tissues, theconstitutional disturbance is aggravated, while the local signs aredelayed, and only become prominent when pus forms and approaches thesurface. It is not uncommon for blebs containing dark serous fluid toform on the skin. The infection frequently spreads along the line of themain lymph vessels of the part (_septic lymphangitis_) and may reach thelymph glands (_septic lymphadenitis_). With the formation of pus the skin becomes soft and boggy at severalpoints, and eventually breaks, giving exit to a quantity of thickgrumous discharge. Sometimes several small collections under the skinfuse, 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 orgrating sensation transmitted to the fingers on making firm pressure onthe part. If it is not let out by incision, the pus, travelling along the lines ofleast resistance, tends to point at several places on the surface, or toopen into joints or other cavities. _Prognosis. _--The occurrence of _septicæmia_ is the most serious risk, and it is in cases of diffuse suppurative cellulitis that this form ofblood-poisoning assumes its most aggravated forms. The toxins of thestreptococci are exceedingly virulent, and induce local death of tissueso rapidly that the protective emigration of leucocytes fails to takeplace. In some cases the passage of masses of free cocci in thelymphatics, or of infective emboli in the blood vessels, leads to theformation of _pyogenic abscesses_ in vital organs, such as the brain, lungs, liver, kidneys, or other viscera. _Hæmorrhage_ from erosion ofarterial or venous trunks may take place and endanger life. _Treatment. _--The treatment of diffuse cellulitis depends to a largeextent on the situation and extent of the affected area, and on thestage of the process. _In the limbs_, for example, where the application of a constrictingband is practicable, Bier's method of inducing passive hyperæmia yieldsexcellent results. If pus is formed, one or more small incisions aremade and a light moist dressing placed over the wounds to absorb thedischarge, but no drain is inserted. The whole of the inflamed areashould be covered with gauze wrung out of a 1 in 10 solution of ichthyolin glycerine. The dressing is changed as often as necessary, and in theintervals when the band is off, gentle active and passive movementsshould be carried out to prevent the formation of adhesions. Afterincisions have been made, we have found the _immersion_ of the limb, fora few hours at a time, in a water-bath containing warm boracic lotion oreusol a useful adjuvant to the passive hyperæmia. _Continuous irrigation_ of the part by a slow, steady stream of lotion, at the body temperature, such as eusol, or Dakin's solution, or boracicacid, or frequent washing with peroxide of hydrogen, has been found ofvalue. A suitably arranged splint adds to the comfort of the patient; and thelimb should be placed in the attitude which, in the event of stiffnessresulting, will least interfere with its usefulness. The elbow, forexample, should be flexed to a little less than a right angle; at thewrist, the hand should be dorsiflexed and the fingers flexed slightlytowards the palm. Massage, passive movement, hot and cold douching, and other measures, may be necessary to get rid of the chronic œdema, 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, smallincisions being made to admit of the escape of pus. If these measures fail or are impracticable, it may be necessary to makeone or more free incisions, and to insert drainage-tubes, portions ofrubber dam, or iodoform worsted. The general treatment of toxæmia must be carried out, and in cases dueto infection by streptococci, anti-streptococcic serum may be used. In a few cases, amputation well above the seat of disease, by removingthe source of toxin production, offers the only means of saving thepatient. WHITLOW The clinical term whitlow is applied to an acute infection, usuallyfollowed by suppuration, commonly met with in the fingers, lessfrequently in the toes. The point of infection is often trivial--apin-prick, a puncture caused by a splinter of wood, a scratch, or evenan imperceptible lesion of the skin. Several varieties of whitlow are recognised, but while it is convenientto describe them separately, it is to be clearly understood thatclinically they merge one into another, and it is not always possible todetermine in which connective-tissue plane a given infection hasoriginated. _Initial Stage. _--Attention is usually first attracted to the conditionby a sensation of tightness in the finger and tenderness when the partis squeezed or knocked against anything. In the course of a few hoursthe part becomes red and swollen; there is continuous pain, which soonassumes a throbbing character, particularly when the hand is dependent, and may be so severe as to prevent sleep, and the patient may feelgenerally out of sorts. If a constricting band is applied at this stage, the infection canusually be checked and the occurrence of suppuration prevented. If thisfails, or if the condition is allowed to go untreated, the inflammatoryreaction increases and terminates in suppuration, giving rise to one orother of the forms of whitlow to be described. _The Purulent Blister. _--In the most superficial variety, pus formsbetween the rete Malpighii and the stratum corneum of the skin, thelatter 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 oflabouring men who have recently resumed work after a spell of idleness. When the blister forms near the tip of the finger, the pus burrows underthe nail--which corresponds to the stratum corneum--raising it from itsbed. There is some local heat and discoloration, and considerable pain andtenderness, but little or no constitutional disturbance. Superficiallymphangitis may extend a short distance up the forearm. By clippingaway the raised epidermis, and if necessary the nail, the pus is allowedto escape, and healing speedily takes place. _Whitlow at the Nail Fold. _--This variety, which is met with among thosewho handle septic material, occurs in the sulcus between the nail andthe skin, and is due to the introduction of infective matter at the rootof the nail (Fig. 9, b). A small focus of suppuration forms under thenail, with swelling and redness of the nail fold, causing intense painand discomfort, interfering with sleep, and producing a constitutionalreaction out of all proportion to the local lesion. To allow the pus to escape, it is necessary, under local anæsthesia, tocut away the nail fold as well as the portion of nail in the infectedarea, or, it may be, to remove the nail entirely. If only a smallopening 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 itselfas a cellulitis of the pulp of the finger (Fig. 9, c), which sometimesspreads towards the palm of the hand. The finger becomes red, swollen, and tense; there is severe throbbing pain, which is usually worst atnight and prevents sleep, and the part is extremely tender on pressure. When the palm is invaded there may be marked œdema of the back of thehand, the dense integument of the palm preventing the swelling fromappearing on the front. The pus may be under such tension thatfluctuation cannot be detected. The patient is usually able to flex thefinger to a certain extent without increasing the pain--a point whichindicates that the tendon sheaths have not been invaded. Thesuppurative process may, however, spread to the tendon sheaths, or evento the bone. Sometimes the excessive tension and virulent toxins induceactual gangrene of the distal part, or even of the whole finger. Thereis considerable constitutional disturbance, the temperature oftenreaching 101° or 102° F. The treatment consists in applying a constriction band and making anincision over the centre of the most tender area, care being taken toavoid opening the tendon sheath lest the infection be conveyed to it. Moist dressings should be employed while the suppuration lasts. Carbolicfomentations, however, are to be avoided on account of the risk ofinducing gangrene. _Whitlow of the Tendon Sheaths. _--In this form the main incidence of theinfection is on the sheaths of the flexor tendons, but it is not alwayspossible to determine whether it started there or spread thither fromthe subcutaneous cellular tissue (Fig. 9, d). In some cases bothconnective tissue planes are involved. The affected finger becomes red, painful, and swollen, the swelling spreading to the dorsum. Theinvolvement of the tendon sheath is usually indicated by the patientbeing unable to flex the finger, and by the pain being increased when heattempts to do so. On account of the anatomical arrangement of thetendon sheaths, the process may spread into the forearm--directly in thecase of the thumb and little finger, and after invading the palm in thecase of the other fingers--and there give rise to a diffuse cellulitiswhich may result in sloughing of fasciæ and tendons. When the infectionspreads into the common flexor sheath under the transverse carpal(anterior annular) ligament, it is not uncommon for the intercarpal andwrist joints to become implicated. Impaired movement of tendons andjoints is, therefore, a common sequel to this variety of whitlow. The _treatment_ consists in inducing passive hyperæmia by Bier's method, and, if this is done early, suppuration may be avoided. If pus forms, small incisions are made, under local anæsthesia, to relieve the tensionin the sheath and to diminish the risk of the tendons sloughing. No formof drain should be inserted. In the fingers the incisions should be madein the middle line, and in the palm they should be made over themetacarpal bones to avoid the digital vessels and nerves. If pus hasspread under the transverse carpal ligament, the incision must be madeabove the wrist. Passive movements and massage must be commenced asearly as possible and be perseveringly employed to diminish theformation of adhesions and resulting stiffness. _Subperiosteal Whitlow. _--This form is usually an extension of thesubcutaneous or of the thecal variety, but in some cases theinflammation begins in the periosteum--usually of the terminal phalanx. It may lead to necrosis of a portion or even of the entire phalanx. Thisis usually recognised by the persistence of suppuration long after theacute 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, andlateral mobility and grating may be elicited. Recovery does not takeplace until the dead bone is removed, and the usefulness of the fingeris often seriously impaired by fibrous or bony ankylosis of theinterphalangeal joints. This may render amputation advisable when astiff 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 deepervarieties of whitlow. In the _region of the elbow-joint_, cellulitis is common around theolecranon. It may originate as an inflammation of the olecranon bursa, or may invade the bursa secondarily. In exceptional cases theelbow-joint is also involved. Cellulitis of the _axilla_ may originate in suppuration in the lymphglands, following an infected wound of the hand, or it may spread from aseptic wound on the chest wall or in the neck. In some cases it isimpossible to discover the primary seat of infection. A firm, brawnyswelling forms in the armpit and extends on to the chest wall. It isattended with great pain, which is increased on moving the arm, andthere is marked constitutional disturbance. When suppuration occurs, itsspread is limited by the attachments of the axillary fascia, and the pustends to burrow on to the chest wall beneath the pectoral muscles, andupwards towards the shoulder-joint, which may become infected. When thepus forms in the axillary space, the treatment consists in making freeincisions, which should be placed on the thoracic side of the axilla toavoid the axillary vessels and nerves. If the pus spreads on to thechest wall, the abscess should be opened below the clavicle by Hilton'smethod, 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 theknee_ it frequently occurs in relation to the prepatellar bursa and tothe popliteal lymph glands, and may endanger the knee-joint. It is alsomet with in the _groin_ following on inflammation and suppuration of theinguinal glands, and cases are recorded in which the sloughing processhas implicated the femoral vessels and led to secondary hæmorrhage. Cellulitis of the scalp, orbit, neck, pelvis, and perineum will beconsidered with the diseases of these regions. CHRONIC SUPPURATION While it is true that a chronic pyogenic abscess is sometimes metwith--for example, in the breast and in the marrow of long bones--in thegreat majority of instances the formation of a chronic or cold abscessis the result of the action of the tubercle bacillus. It is thereforemore 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 acutaneous or mucous surface. It usually represents the path by which thedischarge escapes from an abscess cavity that has been prevented fromclosing completely, either from mechanical causes or from the persistentformation of discharge which must find an exit. A sinus is lined bygranulation tissue, and when it is of long standing the opening may bedragged below the level of the surrounding skin by contraction of thescar tissue around it. As a sinus will persist until the obstacle toclosure of the original abscess is removed, it is necessary that thisshould be sought for. It may be a foreign body, such as a piece of deadbone, an infected ligature, or a bullet, acting mechanically or bykeeping up discharge, and if the body is removed the sinus usuallyheals. The presence of a foreign body is often suggested by a mass ofredundant granulations at the mouth of the sinus. If a sinus passesthrough a muscle, the repeated contractions tend to prevent healinguntil the muscle is kept at rest by a splint, or put out of action bydivision of its fibres. The sinuses associated with empyema areprevented from healing by the rigidity of the chest wall, and will onlyclose after an operation which admits of the cavity being obliterated. In any case it is necessary to disinfect the track, and, it may be, toremove the unhealthy granulations lining it, by means of the sharpspoon, or to excise it bodily. To encourage healing from the bottom thecavity should be packed with bismuth or iodoform gauze. The healing oflong and tortuous sinuses is often hastened by the injection of Beck'sbismuth paste (p. 145). If disfigurement is likely to follow fromcicatricial contraction--for example, in a sinus over the lower jawassociated with a carious tooth--the sinus should be excised and the rawsurfaces approximated with stitches. The _tuberculous sinus_ is described under Tuberculosis. A #fistula# is an abnormal canal passing from a mucous surface to theskin or to another mucous surface. Fistulæ resulting from suppurationusually 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 tothe anus, as a fistula-in-ano. Intestinal fistulæ are sometimes met within the abdominal wall after strangulated hernia, operations forappendicitis, tuberculous peritonitis, and other conditions. In theperineum, fistulæ frequently complicate stricture of the urethra. Fistulæ also occur between the bladder and vagina (_vesico-vaginalfistula_), or between the bladder and the rectum (_recto-vesicalfistula_). The _treatment_ of these various forms of fistula will be described inthe sections dealing with the regions in which they occur. _Congenital fistulæ_, such as occur in the neck from imperfect closureof branchial clefts, or in the abdomen from unobliterated fœtal ductssuch as the urachus or Meckel's diverticulum, will be described in theirproper places. CONSTITUTIONAL MANIFESTATIONS OF PYOGENIC INFECTION We have here to consider under the terms Sapræmia, Septicæmia, andPyæmia certain general effects of pyogenic infection, which, althoughtheir clinical manifestations may vary, are all associated with theaction of the same forms of bacteria. They may occur separately or incombination, or one may follow on and merge into another. #Sapræmia#, or septic intoxication, is the name applied to a form ofpoisoning resulting from the absorption into the blood of the toxicproducts of pyogenic bacteria. These products, which are of the natureof alkaloids, act immediately on their entrance into the circulation, and produce effects in direct proportion to the amount absorbed. As thetoxins are gradually eliminated from the body the symptoms abate, and ifno more are introduced they disappear. Sapræmia in these respects, therefore, is comparable to poisoning by any other form of alkaloid, such as strychnin or morphin. _Clinical Features. _--The symptoms of sapræmia seldom manifestthemselves within twenty-four hours of an operation or injury, becauseit takes some time for the bacteria to produce a sufficient dose oftheir poisons. The onset of the condition is marked by a feeling ofchilliness, sometimes amounting to a rigor, and a rise of temperature to102°, 103°, or 104° F. , with morning remissions (Fig. 10). The heart'saction is markedly depressed, and the pulse is soft and compressible. The appetite is lost, the tongue dry and covered with a thinbrownish-red fur, so that it has the appearance of "dried beef. " Theurine is scanty and loaded with urates. In severe cases diarrhœa andvomiting of dark coffee-ground material are often prominent features. Death is usually impending when the skin becomes cold and clammy, themucous membranes livid, the pulse feeble and fluttering, the dischargesinvoluntary, and when a low form of muttering delirium is present. [Illustration: FIG.  10. --Charts of Acute sapræmia from (a) case ofcrushed foot, and (b) case of incomplete abortion. ] A local form of septic infection is always present--it may be anabscess, an infected compound fracture, or an infection of the cavity ofthe uterus, for example, from a retained portion of placenta. _Treatment. _--The first indication is the immediate and complete removalof the infected material. The wound must be freely opened, allblood-clot, discharge, or necrosed tissue removed, and the areadisinfected by washing with sterilised salt solution, peroxide ofhydrogen, or eusol. Stronger lotions are to be avoided as being likelyto depress the tissues, and so interfere with protective phagocytosis. On account of its power of neutralising toxins, iodoform is useful inthese cases, and is best employed by packing the wound with iodoformgauze, and treating it by the open method, if this is possible. The general treatment is carried out on the same lines as for otherinfective conditions. #Chronic sapræmia or Hectic Fever. #--Hectic fever differs from acutesapræmia merely in degree. It usually occurs in connection withtuberculous conditions, such as bone or joint disease, psoas abscess, orempyema, which have opened externally, and have thereby become infectedwith pyogenic organisms. It is gradual in its development, and is of amild type throughout. [Illustration: FIG.  11. --Chart of Hectic Fever. ] The pulse is small, feeble, and compressible, and the temperature risesin the afternoon or evening to 102° or 103° F. (Fig. 11), the cheeksbecoming characteristically flushed. In the early morning thetemperature falls to normal or below it, and the patient breaks into aprofuse perspiration, which leaves him pale, weak, and exhausted. Hebecomes rapidly and markedly emaciated, even although in some cases theappetite remains good and is even voracious. The poisons circulating in the blood produce _waxy degeneration_ incertain viscera, notably the liver, spleen, kidneys, and intestines. Theprocess begins in the arterial walls, and spreads thence to theconnective-tissue structures, causing marked enlargement of the affectedorgans. Albuminuria, ascites, œdema of the lower limbs, clubbing of thefingers, and diarrhœa are among the most prominent symptoms of thiscondition. The _prognosis_ in hectic fever depends on the completeness with whichthe further absorption of toxins can be prevented. In many cases thiscan only be effected by an operation which provides for free drainage, and, if possible, the removal of infected tissues. The resulting woundis best treated by the open method. Even advanced waxy degeneration doesnot contra-indicate this line of treatment, as the diseased organsusually recover if the focus from which absorption of toxic material istaking place is completely eradicated. [Illustration: FIG.  12. --Chart of case of Septicæmia followed byPyæmia. ] #Septicæmia. #--This form of blood-poisoning is the result of the actionof pyogenic bacteria, which not only produce their toxins at the primaryseat of infection, but themselves enter the blood-stream and are carriedto other parts, where they settle and produce further effects. _Clinical Features. _--There may be an incubation period of some hoursbetween the infection and the first manifestation of acute septicæmia. In such conditions as acute osteomyelitis or acute peritonitis, we seethe most typical clinical pictures of this condition. The onset ismarked by a chill, or a rigor, which may be repeated, while thetemperature rises to 103° or 104° F. , although in very severe cases thetemperature may remain subnormal throughout, the virulence of the toxinspreventing reaction. It is in the general appearance of the patient andin the condition of the pulse that we have our best guides as to theseverity of the condition. If the pulse remains firm, full, and regular, and does not exceed 110 or even 120, while the temperature is moderatelyraised, the outlook is hopeful; but when the pulse becomes small andcompressible, and reaches 130 or more, especially if at the same timethe temperature is low, a grave prognosis is indicated. The tongue isoften dry and coated with a black crust down the centre, while the sidesare red. It is a good omen when the tongue becomes moist again. Thirstis most distressing, especially in septicæmia of intestinal origin. Persistent vomiting of dark-brown material is often present, anddiarrhœa with blood-stained stools is not uncommon. The urine is smallin amount, and contains a large proportion of urates. As the poisonsaccumulate, the respiration becomes shallow and laboured, the face of adull ashy grey, the nose pinched, and the skin cold and clammy. Capillary hæmorrhages sometimes take place in the skin or mucousmembranes; and in a certain proportion of cases cutaneous eruptionssimulating those of scarlet fever or measles appear, and are apt to leadto errors in diagnosis. In other cases there is slight jaundice. Themental state is often one of complete apathy, the patient failing torealise the gravity of his condition; sometimes there is delirium. The _prognosis_ is always grave, and depends on the possibility ofcompletely eradicating the focus of infection, and on the reserve forcethe patient has to carry him over the period during which he iseliminating the poison already circulating in his blood. The _treatment_ is carried out on the same lines as in sapræmia, but itis less likely to be successful owing to the organisms having enteredthe circulation. When possible, the primary focus of infection should bedealt with. #Pyæmia# is a form of blood-poisoning characterised by the developmentof secondary foci of suppuration in different parts of the body. Toxinsare thus introduced into the blood, not only at the primary seat ofinfection, but also from each of these metastatic collections. Likesepticæmia, this condition is due to pyogenic bacteria, the_streptococcus pyogenes_ being the commonest organism found. The primaryinfection is usually in a wound--for example, a compound fracture--butcases occur in which the point of entrance of the bacteria is notdiscoverable. The dissemination of the organisms takes place through themedium of infected emboli which form in a thrombosed vein in thevicinity of the original lesion, and, breaking loose, are carriedthence in the blood-stream. These emboli lodge in the minute vessels ofthe lungs, spleen, liver, kidneys, pleura, brain, synovial membranes, orcellular tissue, and the bacteria they contain give rise to secondaryfoci of suppuration. Secondary abscesses are thus formed in those parts, and these in turn may be the starting-point of new emboli which giverise to fresh areas of pus formation. The organs above named are thecommonest situations of pyæmic abscesses, but these may also occur inthe bone marrow, the substance of muscles, the heart and pericardium, lymph glands, subcutaneous tissue, or, in fact, in any tissue of thebody. Organisms circulating in the blood are prone to lodge on thevalves of the heart and give rise to endocarditis. [Illustration: FIG.  13. --Chart of Pyæmia following on AcuteOsteomyelitis. ] _Clinical Features. _--Before antiseptic surgery was practised, pyæmiawas a common complication of wounds. In the present day it is not onlyinfinitely less common, but appears also to be of a less severe type. Its rarity and its mildness may be related as cause and effect, becauseit was formerly found that pyæmia contracted from a pyæmic patient wasmore virulent than that from other sources. In contrast with sapræmia and septicæmia, pyæmia is late of developing, and it seldom begins within a week of the primary infection. The firstsign is a feeling of chilliness, or a violent rigor lasting for perhapshalf an hour, during which time the temperature rises to 103°, 104°, or105° F. In the course of an hour it begins to fall again, and thepatient breaks into a profuse sweat. The temperature may fall severaldegrees, but seldom reaches the normal. In a few days there is a secondrigor with rise of temperature, and another remission, and such attacksmay be repeated at diminishing intervals during the course of theillness (Figs. 12 and 13). The pulse is soft, and tends to remainabnormally rapid even when the temperature falls nearly to normal. The face is flushed, and wears a drawn, anxious expression, and the eyesare bright. A characteristic sweetish odour, which has been compared tothat of new-mown hay, can be detected in the breath and may pervade thepatient. The appetite is lost; there may be sickness and vomiting andprofuse diarrhœa; and the patient emaciates rapidly. The skin iscontinuously hot, and has often a peculiar pungent feel. Patches oferythema sometimes appear scattered over the body. The skin may assume adull sallow or earthy hue, or a bright yellow icteric tint may appear. The conjunctivæ also may be yellow. In the latter stages of the diseasethe pulse becomes small and fluttering; the tongue becomes dry andbrown; sordes collect on the teeth; and a low muttering form of deliriumsupervenes. Secondary infection of the parotid gland frequently occurs, and givesrise to a suppurative parotitis. This condition is associated withsevere pain, gradually extending from behind the angle of the jaw on tothe face. There is also swelling over the gland, and eventuallysuppuration and sloughing of the gland tissue and overlying skin. Secondary abscesses in the lymph glands, subcutaneous tissue, or jointsare often so insidious and painless in their development that they areonly discovered accidentally. When the abscess is evacuated, healingoften takes place with remarkable rapidity, and with little impairmentof function. The general symptoms may be simulated by an attack of malaria. _Prognosis. _--The prognosis in acute pyæmia is much less hopeless thanit once was, a considerable proportion of the patients recovering. Inacute cases the disease proves fatal in ten days or a fortnight, deathbeing due to toxæmia. Chronic cases often run a long course, lasting forweeks or even months, and prove fatal from exhaustion and waxy diseasefollowing on prolonged suppuration. _Treatment. _--In such conditions as compound fractures and severelacerated wounds, much can be done to avert the conditions which lead topyæmia, by applying a Bier's constricting bandage as soon as there isevidence of infection having taken place, or even if there is reason tosuspect that the wound is not aseptic. If sepsis is already established, and evidence of general infection ispresent, the wound should be opened up sufficiently to admit of thoroughdisinfection and drainage, and the constricting bandage applied to aidthe defensive processes going on in the tissues. If these measures fail, amputation of the limb may be the only means of preventing furtherdissemination of infective material from the primary source ofinfection. Attempts have been made to interrupt the channel along which theinfective emboli spread, by ligating or resecting the main vein of theaffected part, but this is seldom feasible except in the case of theinternal jugular vein for infection of the transverse sinus. Secondary abscesses must be aspirated or opened and drained wheneverpossible. The general treatment is conducted on the same lines as on other formsof 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 cellulardeath of tissue taking place on a free surface. It is essentially of thesame nature as the process of suppuration, only that the purulentdischarge, instead of collecting in a closed cavity and forming anabscess, at once escapes on the surface. An _ulcer_ is an open wound or sore in which there are present certainconditions tending to prevent it undergoing the natural process ofrepair. Of these, one of the most important is the presence ofpathogenic bacteria, which by their action not only prevent healing, butso irritate and destroy the tissues as to lead to an actual increase inthe size of the sore. Interference with the nutrition of a part by œdemaor chronic venous congestion may impede healing; as may also indurationof the surrounding area, by preventing the contraction which is such animportant factor in repair. Defective innervation, such as occurs ininjuries and diseases of the spinal cord, also plays an important partin delaying repair. In certain constitutional conditions, too--forexample, Bright's disease, diabetes, or syphilis--the vitiated state ofthe tissues is an impediment to repair. Mechanical causes, such asunsuitable dressings or ill-fitting appliances, may also act in the samedirection. #Clinical Examination of an Ulcer. #--In examining any ulcer, weobserve--(1) Its _base_ or _floor_, noting the presence or absence ofgranulations, their disposition, size, colour, vascularity, and whetherthey are depressed or elevated in relation to the surrounding parts. (2)The _discharge_ as to quantity, consistence, colour, composition, andodour. (3) The _edges_, noting particularly whether or not the marginalepithelium is attempting to grow over the surface; also their shape, regularity, thickness, and whether undermined or overlapping, everted ordepressed. (4) The _surrounding tissues_, as to whether they arecongested, œdematous, inflamed, indurated, or otherwise. (5) Whether ornot there is _pain_ or tenderness in the raw surface or itssurroundings. (6) The _part of the body_ on which it occurs, becausecertain ulcers have special seats of election--for example, the varicoseulcer in the lower third of the leg, the perforating ulcer on the soleof the foot, and so on. #The Healing Sore. #--If a portion of skin be excised aseptically, and noattempt made to close the wound, the raw surface left is soon coveredover with a layer of coagulated blood and lymph. In the course of a fewdays this is replaced by the growth of _granulations_, which are ofuniform size, of a pinkish-red colour, and moist with a slight serousexudate containing a few dead leucocytes. They grow until they reach thelevel of the surrounding skin, and so fill the gap with a fine velvetymass of granulation tissue. At the edges, the young epithelium may beseen spreading in over the granulations as a fine bluish-white pellicle, which gradually covers the sore, becoming paler in colour as itthickens, and eventually forming the smooth, non-vascular covering ofthe 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 thebedside, so that we may determine how far, and in what particulars, these differ from the type; and that we may in addition recognise theconditions that have to be counteracted before the characters of thetypical healing sore are assumed. For purposes of contrast we may indicate the characters of an open sorein which bacterial infection with pathogenic bacteria has taken place. The layer of coagulated blood and lymph becomes liquefied and is thrownoff, and instead of granulations being formed, the tissues exposed onthe floor of the ulcer are destroyed by the bacterial toxins, with theformation of minute sloughs and a quantity of pus. The discharge is profuse, thin, acrid, and offensive, and consists ofpus, broken-down blood-clot, and sloughs. The edges are inflamed, irregular, and ragged, showing no sign of growing epithelium--on thecontrary, the sore may be actually increasing in area by thebreaking-down of the tissues at its margins. The surrounding parts arehot, red, swollen, and œdematous; and there is pain and tenderness bothin the sore itself and in the parts around. #Classification of Ulcers. #--The nomenclature of ulcers is much involvedand gives rise to great confusion, chiefly for the reason that no onebasis of classification has been adopted. Thus some ulcers are namedaccording to the causes at work in producing or maintaining them--forexample, the traumatic, the septic, and the varicose ulcer; some fromthe constitutional element present, as the gouty and the diabetic ulcer;and others according to the condition in which they happen to be whenseen by the surgeon, such as the weak, the inflamed, and the callousulcer. So long as we retain these names it will be impossible to find a singlebasis for classification; and yet many of the terms are so descriptiveand so generally understood that it is undesirable to abolish them. Wemust therefore remain content with a clinical arrangement of ulcers, --itcannot be called a classification, --considering any given ulcer from twopoints of view: first its _cause_, and second its _present condition_. This method of studying ulcers has the practical advantage that itfurnishes us with the main indications for treatment as well as fordiagnosis: the cause must be removed, and the condition so modified asto convert the ulcer into an aseptic healing sore. A. #Arrangement of Ulcers according to their Cause. #--Although any givenulcer may be due to a combination of causes, it is convenient todescribe 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 bydirectly destroying the skin, or by so diminishing its vitality that itis rendered a suitable soil for bacteria. If these gain access, in thecourse of a few days the damaged area of skin becomes of a greyishcolour, blebs form on it, and it undergoes necrosis, leaving anunhealthy raw surface when the slough separates. _Heat_ and _prolonged exposure to the Röntgen rays_ or _to radiumemanations_ act in a similar way. The _pressure_ of improperly padded splints or other appliances may sofar interfere with the circulation of the part pressed upon, that theskin sloughs, leaving an open sore. This is most liable to occur inpatients who suffer from some nerve lesion--such as anteriorpoliomyelitis, or injury of the spinal cord or nerve-trunks. Splint-pressure sores are usually situated over bony prominences, suchas the malleoli, the condyles of the femur or humerus, the head of thefibula, the dorsum of the foot, or the base of the fifth metatarsalbone. On removing the splint, the skin of the part pressed upon is foundto 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 bymalingerers and hysterical subjects. [Illustration: FIG.  14. --Leg Ulcers associated with Varicose Veins andPigmentation of the Skin. ] _Ulcers due to Imperfect Circulation. _--Imperfect circulation is animportant causative factor in ulceration, especially when it is the_venous return_ that is defective. This is best illustrated in theso-called _leg ulcer_, which occurs most frequently on the front andmedial aspect of the lower third of the leg. At this point theanastomosis between the superficial and deep veins of the leg is lessfree than elsewhere, so that the extra stress thrown upon the surfaceveins interferes with the nutrition of the skin (Hilton). The importanceof imperfect venous return in the causation of such ulcers is evidencedby the fact that as soon as the condition of the circulation is improvedby confining the patient to bed and elevating the limb, the ulcer beginsto heal, even although all methods of local treatment have hithertoproved ineffectual. In a considerable number of cases, but by no meansin all, this form of ulcer is associated with the presence of varicoseveins, and in such cases it is spoken of as the _varicose ulcer_ (Fig. 14). The presence of varicose veins is frequently associated with adiffuse brownish or bluish pigmentation of the skin of the lower thirdof 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 ofthe surface and permit of infection which leads to ulceration. Varicoseulcers may also originate from the bursting of a small peri-phlebiticabscess. Varicose veins in immediate relation to the base of a large chroniculcer usually become thrombosed, and in time are reduced to fibrouscords, and therefore in such cases hæmorrhage is not a commoncomplication. In smaller and more superficial ulcers, however, thedestructive process is liable to implicate the wall of the vessel beforethe occurrence of thrombosis, and to lead to profuse and it may bedangerous bleeding. These ulcers are at first small and superficial, but from want of care, from continued standing or walking, or from injudicious treatment, theygradually become larger and deeper. They are not infrequently multiple, and this, together with their depth, may lead to their being mistakenfor ulcers due to syphilis. The base of the ulcer is covered withimperfectly formed, soft, œdematous granulations, which give off a thinsero-purulent discharge. The edges are slightly inflamed, and show noevidence of healing. The parts around are usually pigmented and slightlyœdematous, and as a rule there is little pain. This variety of ulcer isparticularly prone to pass into the condition known as callous. In _anæmic_ patients, especially young girls, ulcers are occasionallymet with which have many of the clinical characters of those associatedwith imperfect venous return. They are slow to heal, and tend to passinto the condition known as weak. _Ulcers due to Interference with Nerve-Supply. _--Any interference withthe nerve-supply of the superficial tissues predisposes to ulceration. For example, _trophic_ ulcers are liable to occur in injuries ordiseases of the spinal cord, in cerebral paralysis, in limbs weakened bypoliomyelitis, in ascending or peripheral neuritis, or after injuries ofnerve-trunks. The _acute bed-sore_ is a rapidly progressing form of ulceration, oftenamounting to gangrene, of portions of skin exposed to pressure whentheir 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 whichoccurs in association with the different forms of peripheral neuritis, and with various lesions of the brain and spinal cord, such as generalparalysis, locomotor ataxia, or syringo-myelia (Fig. 15). It also occursin patients suffering from glycosuria, and is usually associated witharterio-sclerosis--local or general. Perforating ulcer is met with mostfrequently under the head of the metatarsal bone of the great toe. Acallosity forms and suppuration occurs under it, the pus escapingthrough a small hole in the centre. The process slowly and graduallyspreads 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 toebeing dorsiflexed by the unopposed extensors. The depth of the trackbeing so disproportionate to its superficial area, the condition closelysimulates a tuberculous sinus, for which it is liable to be mistaken. The raw surface is absolutely insensitive, so that the probe can befreely employed without the patient even being aware of it or sufferingthe least discomfort--a significant fact in diagnosis. The cavity isfilled with effete and decomposing epidermis, which has a most offensiveodour. The chronic and intractable character of the ulcer is due tointerference with the trophic nerve-supply of the parts, and to the factthat the epithelium of the skin grows in and lines the track leadingdown to the deepest part of the ulcer and so prevents closure. Whilethey are commonest on the sole of the foot and other parts subjected topressure, perforating ulcers are met with on the sides and dorsum of thefoot and toes, on the hands, and on other parts where no pressure hasbeen exerted. The _tuberculous ulcer_, so often seen in the neck, in the vicinity ofjoints, or over the ribs and sternum, usually results from the burstingthrough the skin of a tuberculous abscess. The base is soft, pale, andcovered with feeble granulations and grey shreddy sloughs. The edges areof a dull blue or purple colour, and gradually thin out towards theirfree margins, and in addition are characteristically undermined, so thata probe can be passed for some distance between the floor of the ulcerand the thinned-out edges. Thin, devitalised tags of skin often stretchfrom side to side of the ulcer. The outline is irregular; smallperforations 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 andsubcutaneous tissue which bears certain resemblances to tuberculosis. Itis met with almost exclusively between the knee and the ankle, and itusually affects both legs. It is commonest in girls of delicateconstitution, in whose family history there is evidence of a tuberculoustaint. The patient often presents other lesions of a tuberculouscharacter, notably enlarged cervical glands, and phlyctenularophthalmia. The tubercle bacillus has rarely been found, but we havealways observed characteristic epithelioid cells and giant cells insections made from the edge or floor of the ulcer. [Illustration: FIG.  16. --Bazin's Disease in a girl æt.  16. ] The condition begins by the formation in the skin and subcutaneoustissue of dusky or livid nodules of induration, which soften andulcerate, forming small open sores with ragged and undermined edges, notunlike those resulting from the breaking down of superficial syphiliticgummata (Fig. 16). Fresh crops of nodules appear in the neighbourhood ofthe ulcers, and in turn break down. While in the nodular stage theaffection is sometimes painful, but with the formation of the ulcer thepain subsides. The disease runs a chronic course, and may slowly extend over a widearea in spite of the usual methods of treatment. After lasting for somemonths, or even years, however, it may eventually undergo spontaneouscure. The most satisfactory treatment is to excise the affected tissuesand fill the gap with skin-grafts. [Illustration: FIG.  17. --Syphilitic Ulcers in region of Knee, showingpunched-out appearance and raised indurated edges. ] The _syphilitic ulcer_ is usually formed by the breaking down of acutaneous or subcutaneous gumma in the tertiary stage of syphilis. Whenthe gummatous tissue is first exposed by the destruction of the skin ormucous membrane covering it, it appears as a tough greyish slough, compared to "wash leather, " which slowly separates and leaves a more orless circular, deep, punched-out gap which shows a few feeble unhealthygranulations and small sloughs on its floor. The edges are raised andindurated; 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 healat one part while they spread at another, the affected area assumes asinuous or serpiginous outline. Syphilitic ulcers may be met with in anypart 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 ribsand sternum. On healing, they usually leave a depressed and adherentcicatrix. The _scorbutic ulcer_ occurs in patients suffering from scurvy, and ischaracterised by its prominent granulations, which show a markedtendency to bleed, with the formation of clots, which dry and form aspongy crust on the surface. In _gouty_ patients small ulcers which are exceedingly irritable andpainful are liable to occur. _Ulcers associated with Malignant Disease. _--Cancer and sarcoma whensituated in the subcutaneous tissue may destroy the overlying skin sothat the substance of the tumour is exposed. The fungating masses thusproduced are sometimes spoken of as malignant ulcers, but as they areessentially different in their nature from all other forms of ulcers, and call for totally different treatment, it is best to consider themalong with the tumours with which they are associated. Rodent ulcer, which is one form of cancer of the skin, will be discussed with newgrowths of the skin. B. #Arrangement of Ulcers according to their Condition. #--Having arrivedat an opinion as to the cause of a given ulcer, and placed it in one orother of the preceding groups, the next question to ask is, In whatcondition 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 whilethe destructive process is extending at another. _The Healing Condition. _--The process of healing in an ulcer has alreadybeen studied, and we have learned that it takes place by the formationof 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 norspreading--may be in one of several conditions. _The Weak Condition. _--Any ulcer may get into a weak state fromreceiving a blood supply which is defective either in quantity or inquality. The granulations are small and smooth, and of a pale yellow orgrey colour, the discharge is small in amount, and consists of thinserum and a few pus cells, and as this dries on the edges it forms scabswhich interfere with the growth of epithelium. Should the part become œdematous, either from general causes, such asheart or kidney disease, or from local causes, such as varicose veins, the granulations share in the œdema, and there is an abundant serousdischarge. The excessive use of moist dressings leads to a third variety of weakulcer--namely, one in which the granulations become large, soft, pale, and flabby, projecting beyond the level of the skin and overlapping theedges, which become pale and sodden. The term "proud flesh" is popularlyapplied to such redundant granulations. [Illustration: FIG.  18. --Callous Ulcer, showing thickened edges andindurated swelling of surrounding parts. ] _The Callous Condition. _--This condition is usually met with in ulcerson the lower third of the leg, and is often associated with the presenceof varicose veins. It is chiefly met with in hospital practice. The wantof healing is mainly due to impeded venous return and to œdema andinduration of the surrounding skin and cellular tissues (Fig. 18). Theinduration results from coagulation and partial organisation of theinflammatory effusion, and prevents the necessary contraction of thesore. The base of a callous ulcer lies at some distance below the levelof the swollen, thickened, and white edges, and presents a glazedappearance, such granulations as are present being unhealthy andirregular. 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 oftenoffensive. The prolonged hyperæmia of the tissues in relation to a callous ulcer ofthe leg often leads to changes in the underlying bones. The periosteumis abnormally thick and vascular, the superficial layers of the bonebecome injected and porous, and the bones, as a whole, are thickened. Inthe macerated bone "the surface is covered with irregular, stalactite-like processes or foliaceous masses, which, to a certainextent, follow the line of attachment of the interosseous membrane andof the intermuscular septa" (Cathcart) (Fig. 19). When the wholethickness 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 aflat, porous node, which in its turn may be eroded. These changes asseen in the macerated specimen are often mistaken for diseaseoriginating in the bone. [Illustration: FIG.  19. --Tibia and Fibula, showing changes due tochronic 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. Theyare small in size and have prominent granulations, and by the aid of aprobe points of excessive tenderness may be discovered. These, Hiltonbelieved, correspond to exposed nerve filaments. _Ulcers which are spreading_ may be met with in one of severalconditions. _The Inflamed Condition. _--Any ulcer may become acutely inflamed fromthe access of fresh organisms, aided by mechanical irritation fromtrauma, ill-fitting splints or bandages, or want of rest, or fromchemical irritants, such as strong antiseptics. The best clinicalexample of an inflamed ulcer is the venereal soft sore. The base of theulcer becomes red and angry-looking, the granulations disappear, and acopious discharge of thin yellow pus, mixed with blood, escapes. Sloughsof granulation tissue or of connective tissue may form. The edges becomered, ragged, and everted, and the ulcer increases in size by spreadinginto the inflamed and œdematous surrounding tissues. Such ulcers arefrequently multiple. Pain is a constant symptom, and is often severe, and there is usually some constitutional disturbance. The _phagedænic condition_ is the result of an ulcer being infected withspecially virulent bacteria. It occurs in syphilitic ulcers, and rapidlyleads to a widespread destruction of tissue. It is also met with in thethroat in some cases of scarlet fever, and may give rise to fatalhæmorrhage by ulcerating into large blood vessels. All the local andconstitutional signs of a severe septic infection are present. #Treatment of Ulcers. #--An ulcer is not only an immediate cause ofsuffering to the patient, crippling and incapacitating him for his work, but is a distinct and constant menace to his health: the prolongeddischarge reduces his strength; the open sore is a possible source ofinfection by the organisms of suppuration, erysipelas, or other specificdiseases; phlebitis, with formation of septic emboli, leading to pyæmia, is liable to occur; and in old persons it is not uncommon for ulcers oflong standing to become the seat of cancer. In addition, the offensiveodour of many ulcers renders the patient a source of annoyance anddiscomfort to others. The primary object of treatment in any ulcer is tobring it into the condition of a healing sore. When this has beeneffected, nature will do the rest, provided extraneous sources ofirritation are excluded. Steps must be taken to facilitate the venous return from the ulceratedpart, and to ensure that a sufficient supply of fresh, healthy bloodreaches it. The septic element must be eliminated by disinfecting theulcer and its surroundings, and any other sources of irritation must beremoved. If the patient's health is below par, good nourishing food, tonics, andgeneral hygienic treatment are indicated. _Management of a Healing Sore. _--Perhaps the best dressing for a healingsore is a layer of Lister's perforated oiled-silk protective, which ismade to cover the raw surface and the skin for about a quarter of aninch beyond the margins of the sore. Over this three or four thicknessesof sterilised gauze, wrung out of eusol, creolin, or sterilised water, are applied, and covered by a pad of absorbent wool. As far as possiblethe part should be kept at rest, and the position should be adjusted soas to favour the circulation in the affected area. The dressing may be renewed at intervals, and care must be taken toavoid any rough handling of the sore. Any discharge that lies on thesurface should be removed by a gentle stream of lotion rather than bywiping. The area round the sore should be cleansed before the freshdressing is applied. In some cases, healing goes on more rapidly under a dressing of weakboracic ointment (one-quarter the strength of the pharmacopœialpreparation). The growth of epithelium may be stimulated by a 6 to 8 percent. Ointment of scarlet-red. Dusting powders and poultice dressings are best avoided in the treatmentof healing sores. In extensive ulcers resulting from recent burns, if the granulations arehealthy and aseptic, skin-grafts may safely be placed on them directly. If, however, their asepticity cannot be relied upon, it is necessary toscrape away the superficial layer of the granulations, the young fibroustissue underneath being conserved, as it is sufficiently vascular tonourish the grafts placed on it. #Treatment of Special Varieties of Ulcers. #--Before beginning to treat agiven ulcer, two questions have to be answered--first, What are thecausative conditions present? and second, In what condition do I findthe ulcer?--in other words, In what particulars does it differ from ahealthy healing sore? If the cause is a local one, it must be removed; if a constitutionalone, means must be taken to counteract it. This done, the condition ofthe ulcer must be so modified as to bring it into the state of a healingsore, after which it will be managed on the lines already laid down. #Treatment in relation to the Cause of the Ulcer. #--_TraumaticGroup. _--The _prophylaxis_ of these ulcers consists in excludingbacteria, by cleansing crushed or bruised parts, and applying steriliseddressings and properly adjusted splints. If there is reason to fear thatthe disinfection has not been complete, a Bier's constricting bandageshould be applied for some hours each day. These measures will oftenprevent a grossly injured portion of skin dying, and will ensureasepticity should it do so. In the event of the skin giving way, thesame form of dressing should be continued till the slough has separatedand a healthy granulating surface is formed. The protective dressingappropriate to a healing sore is then substituted. _Pressure sores_ aretreated on the same lines. The treatment of ulcers caused by _burns and scalds_ will be describedlater. In _ulcers of the leg due to interference with the venous return_, theprimary indication is to elevate the limb in order to facilitate theflow of the blood in the veins, and so admit of fresh blood reaching thepart. The limb may be placed on pillows, or the foot of the bed raisedon blocks, so that the ulcer lies on a higher level than the heart. Should varicose veins be present, the question of operative treatmentmust be considered. When an _imperfect nerve supply_ is the main factor underlying ulcerformation, prophylaxis is the chief consideration. In patients sufferingfrom spinal injuries or diseases, cerebral paralysis, or affections ofthe peripheral nerves, all sources of irritation, such as ill-fittingsplints, tight bandages, moist applications, and hot bottles, should beavoided. Any part liable to pressure, from the position of the patientor otherwise, must be carefully protected by pads of wool, air-cushions, or water-bags, and must be kept absolutely dry. The skin should behardened by daily applications of methylated spirit. Should an ulcer form in spite of these precautions, the mildestantiseptics must be employed for bathing and dressing it, and as far aspossible all dressings should be dry. The _perforating ulcer_ of the foot calls for special treatment. Toavoid pressure on the sole of the foot, the patient must be confined tobed. As the main local obstacle to healing is the down-growth ofepithelium along the sides of the ulcer, this must be removed by theknife or sharp spoon. The base also should be excised, and any bonewhich may have become involved should be gouged away, so as to leave ahealthy and vascular surface. The cavity thus formed is stuffed withbismuth or iodoform gauze and encouraged to heal from the bottom. As theparts are insensitive an anæsthetic is not required. After the ulcer hashealed, the patient should wear in his boot a thick felt sole with ahole cut out opposite the situation of the cicatrix. When a joint hasbeen opened into, the difficulty of thoroughly getting rid of allunhealthy and infected granulations is so great that amputation may beadvisable, but it is to be remembered that ulceration may recur in thestump if pressure is put upon it. The treatment of any nervous diseaseor glycosuria which may coexist is, of course, indicated. Exposure of the plantar nerves by an incision behind the medialmalleolus, and subjecting them to forcible stretching, has been employedby Chipault and others in the treatment of perforating ulcers of thefoot. The ulcer that forms in relation to callosities on the sole of the footis treated by paring away all the thickened skin, after softening itwith soda fomentations, removing the unhealthy granulations, andapplying stimulating dressings. _Treatment of Ulcers due to Constitutional Causes. _--When ulcers areassociated with such diseases as tuberculosis, syphilis, diabetes, Bright's disease, scurvy, or gout, these must receive appropriatetreatment. The local treatment of the _tuberculous ulcer_ calls for specialmention. If the ulcer is of limited extent and situated on an exposedpart of the body, the most satisfactory method is complete removal, bymeans of the knife, scissors, or sharp spoon, of the ulcerated surfaceand of all the infected area around it, so as to leave a healthy surfacefrom which granulations may spring up. Should the raw surface left belikely 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 coveredparts, or when operative treatment is contra-indicated, the use oftuberculin and exposure to the Röntgen rays have proved beneficial. Theinduction of passive hyperæmia, 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 arsenicalpreparations of the "606" or "914" groups or to full doses of iodide ofpotassium and mercury, and the local application of black wash. When theulceration has lasted for a long time, however, and is widespread anddeep, the duration of treatment is materially shortened by a thoroughscraping with the sharp spoon. #Treatment in relation to the Condition of the Ulcer. #--_Ulcers in aweak condition. _--If the weak condition of the ulcer is due to anæmiaor kidney disease, these affections must first be treated. Locally, theimperfect granulations should be scraped away, and some stimulatingagent applied to the raw surface to promote the growth of healthygranulations. For this purpose the sore may be covered with gauzesmeared with a 6 to 8 per cent. Ointment of scarlet-red, the surroundingparts being protected from the irritant action of the scarlet-red by alayer of vaseline. A dressing of gauze moistened with eusol or ofboracic lint wrung out of red lotion (2 grains of sulphate of zinc, and10 minims of compound tincture of lavender, to an ounce of water), andcovered with a layer of gutta-percha tissue, is also useful. When the condition has resulted from the prolonged use of moistdressings, these must be stopped, the redundant granulations clippedaway with scissors, the surface rubbed with silver nitrate or sulphateof copper (blue-stone), and dry dressings applied. When the ulcer has assumed the characters of a healing sore, skin-graftsmay be applied to hasten cicatrisation. _Ulcers in a callous condition_ call for treatment in threedirections--(1) The infective element must be eliminated. When the ulceris foul, relays of charcoal poultices (three parts of linseed meal toone of charcoal), maintained for thirty-six to forty-eight hours, areuseful as a preliminary step. The base of the ulcer and the thickenededges should then be freely scraped with a sharp spoon, and theresulting raw surface sponged over with undiluted carbolic acid oriodine, after which an antiseptic dressing is applied, and changed dailytill healthy granulations appear. (2) The venous return must befacilitated by elevation of the limb and massage. (3) The induration ofthe surrounding parts must be got rid of before contraction of the soreis possible. For this purpose the free application of blisters, as firstrecommended by Syme, leaves little to be desired. Liquor epispasticuspainted over the parts, or a large fly-blister (emplastrum cantharidis)applied all round the ulcer, speedily disperses the inflammatoryproducts which cause the induration. The use of elastic pressure or ofstrapping, of hot-air baths, or the making of multiple incisions in theskin around the ulcer, fulfils the same object. As soon as the ulcer assumes the characters of a healing sore, it shouldbe covered with skin-grafts, which furnish a much better cicatrix thanthat which forms when the ulcer is allowed to heal without such aid. A more radical method of treatment consists in excising the wholeulcer, including its edges and about a quarter of an inch of thesurrounding tissue, as well as the underlying fibrous tissue, andgrafting the raw surface. _Ambulatory Treatment. _--When the circumstances of the patient forbidhis lying up in bed, the healing of the ulcer is much delayed. He shouldbe instructed to take every possible opportunity of placing the limb inan elevated position, and must constantly wear a firm bandage of_elastic webbing_. This webbing is porous and admits of evaporation ofthe skin and wound secretions--an advantage it has over Martin's rubberbandage. The bandage should extend from the toes to well above the knee, and should always be applied while the patient is in the recumbentposition with the leg elevated, preferably before getting out of bed inthe morning. Additional support is given to the veins if the bandage isapplied as a figure of eight. We have found the following method satisfactory in out-patientpractice. The patient lying on a couch, the limb is raised abouteighteen inches and kept in this position for five minutes--till theexcess of blood has left it. With the limb still raised, the ulcer withthe 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 withliquid starch; while the starch is drying the limb is kept elevated. With this appliance the patient may continue to work, and the dressingdoes 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 superaddedinfection, antiseptic measures are employed to overcome the infection, and ichthyol or other soothing applications may be used to allay thepain. The _phagedænic ulcer_ calls for more energetic means of disinfection;the whole of the affected surface is touched with the actual cautery ata white heat, or is painted with pure carbolic acid. Relays of charcoalpoultices are then applied until the spread of the disease is arrested. For the _irritable ulcer_ the most satisfactory treatment is completeexcision 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 œdema_; _Acute emphysematous_ or _gas gangrene_; _Cancrum oris_, _etc_. Bed-sores: _Acute_; _chronic_. Gangrene or mortification is the process by which a portion of tissuedies _en masse_, as distinguished from the molecular or cellular deathwhich constitutes ulceration. The dead portion is known as a _slough_. In this chapter we shall confine our attention to the process as itaffects the limbs and superficial parts, leaving gangrene of the viscerato be described in regional surgery. TYPES OF GANGRENE Two distinct types of gangrene are met with, which, from their mostobvious 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 dueto a simple _interference with the blood supply_ of a part; while themain factor in the production of moist gangrene is _bacterialinfection_. The cardinal signs of gangrene are: change in the colour of the part, coldness, loss of sensation and motor power, and, lastly, loss ofpulsation in the arteries. #Dry Gangrene# or #Mummification# is a comparatively slow form of localdeath due, as a rule, to a diminution in the arterial blood supply ofthe affected part, resulting from such causes as the gradual narrowingof the lumen of the arteries by disease of their coats, or the blockingof the main vessel by an embolus. As the fluids in the tissues are lost by evaporation the part becomesdry and shrivelled, and as the skin is usually intact, infection doesnot take place, or if it does, the want of moisture renders the part anunsuitable soil, and the organisms do not readily find a footing. Anyspread of the process that may take place is chiefly influenced by theanatomical distribution of the blocked arteries, and is arrested as soonas it reaches an area rich in anastomotic vessels. The dead portion isthen cast off, the irritation resulting from the contact of the deadwith the still living tissue inducing the formation of granulations onthe proximal side of the junction, and these by slowly eating into thedead portion produce a furrow--the _line of demarcation_--whichgradually deepens until complete separation is effected. As the musclesand bones have a richer blood supply than the integument, the death ofskin and subcutaneous tissues extends higher than that of muscles andbone, with the result that the stump left after spontaneous separationis conical, the end of the bone projecting beyond the soft parts. _Clinical Features. _--The part undergoing mortification becomes colderthan normal, the temperature falling to that of the surroundingatmosphere. In many instances, but not in all, the onset of the processis accompanied by severe neuralgic pain in the part, probably due toanæmia of the nerves, to neuritis, or to the irritation of the exposedaxis cylinders by the dead and dying tissues around them. This pain soonceases and gives place to a complete loss of sensation. The dead partbecomes dry, horny, shrivelled, and semi-transparent--at first of a darkbrown, but finally of a black colour, from the dissemination of bloodpigment throughout the tissues. There is no putrefaction, and thereforeno putrid odour; and the condition being non-infective, there is notnecessarily any constitutional disturbance. In itself, therefore, drygangrene does not involve immediate risk to life; the danger lies in thefact that the breach of surface at the line of demarcation furnishes apossible means of entrance for bacteria, which may lead to infectivecomplications. #Moist Gangrene# is an acute process, the dead part retaining its fluidsand so affording a favourable soil for the development of bacteria. Theaction of the organisms and their toxins on the adjacent tissues leadsto a rapid and wide spread of the process. The skin becomes moist andmacerated, and bullæ, containing dark-coloured fluid or gases, formunder the epidermis. The putrefactive gases evolved cause the skin tobecome emphysematous and crepitant and produce an offensive odour. Thetissues assume a greenish-black colour from the formation in them of asulphide of iron resulting from decomposition of the blood pigment. Under certain conditions the dead part may undergo changes resemblingmore closely those of ordinary post-mortem decomposition. Owing to itsnature the spread of the gangrene is seldom arrested by the naturalprotective processes, and it usually continues until the conditionproves fatal from the absorption of toxins into the circulation. The _clinical features_ vary in the different varieties of moistgangrene, but the local results of bacterial action and theconstitutional disturbance associated with toxin absorption are presentin all; the prognosis therefore is grave in the extreme. From what has been said, it will be gathered that in dry gangrene thereis no urgent call for operation to save the patient's life, the primaryindication being to prevent the access of bacteria to the dead part, andespecially to the surface exposed at the line of demarcation. In moistgangrene, on the contrary, organisms having already obtained a footing, immediate removal of the dead and dying tissues, as a rule, offers theonly hope of saving life. VARIETIES OF GANGRENE #Varieties of Gangrene essentially due to Interference with theCirculation# While the varieties of gangrene included in this group depend primarilyon interference with the circulation, it is to be borne in mind that theclinical course of the affection may be profoundly influenced bysuperadded infection with micro-organisms. Although the bacteria do notplay the most important part in producing tissue necrosis, theirsubsequent introduction is an accident of such importance that it maychange the whole aspect of affairs and convert a dry form of gangreneinto one of the moist type. Moreover, the low state of vitality of thetissues, 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 localdeath produced by a _gradual_ diminution in the quantity of bloodpassing through the parts, as a result of arterio-sclerosis or otherchronic disease of the arteries leading to diminution of their calibre. It is the most characteristic example of the dry type of gangrene. Asthe term indicates, it occurs in old persons, but the patient's age isto be reckoned by the condition of his arteries rather than by thenumber of his years. Thus the vessels of a comparatively young man whohas suffered from syphilis and been addicted to alcohol are more liableto atheromatous degeneration leading to this form of gangrene than arethose 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 itusually attacks only one foot, it is not uncommon for the other foot tobe affected after an interval, and in some cases it is bilateral fromthe outset. It must clearly be understood that any form of gangrene mayoccur in old persons, the term senile being here restricted to thatvariety which results from arterio-sclerosis. [Illustration: FIG.  20. --Senile Gangrene of the Foot, showing line ofdemarcation. ] _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, oreven to the leg (Fig. 20). There is often a history of some slightinjury preceding its onset. The vitality of the tissues is so low thatthe balance between life and death may be turned by the most trivialinjury, such as a cut while paring a toe-nail or a corn, a blistercaused by an ill-fitting shoe or the contact of a hot-bottle. In somecases the actual gangrene is determined by thrombosis of the poplitealor tibial arteries, which are already narrowed by obliteratingendarteritis. It is common to find that the patient has been troubled for a long timebefore the onset of definite signs of gangrene, with cold feet, withtingling and loss of feeling, or a peculiar sensation as if walking oncotton 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 toeand gradually increases in size; or a blister containing blood-stainedfluid may form. Streaks or patches of dark-blue mottling appear higherup on the foot or leg. In other cases a small sore surrounded by acongested areola forms in relation to the nail and refuses to heal. Suchsores on the toes of old persons are always to be looked upon withsuspicion and treated with the greatest care; and the urine should beexamined for sugar. There is often severe, deep-seated pain of aneuralgic character, with cramps in the limb, and these may persist longafter a line of demarcation has formed. The dying part loses sensibilityto touch and becomes cold and shrivelled. All the physical appearances and clinical symptoms associated with drygangrene supervene, and the dead portion is delimited by a line ofdemarcation. If this forms slowly and irregularly it indicates a veryunsatisfactory condition of the circulation; while, if it forms quicklyand decidedly, the presumption is that the circulation in the partsabove is fairly good. The separation of the dead part is always attendedwith the risk of infection taking place, and should this occur, thetemperature rises and other evidences of toxæmia appear. _Prophylaxis. _--The toes and feet of old people, the condition of whosecirculation predisposes them to gangrene, should be protected fromslight injuries such as may be received while paring nails, cuttingcorns, or wearing ill-fitting boots. The patient should also be warnedof the risk of exposure to cold, the use of hot-bottles, and of placingthe feet near a fire. Attempts have been made to improve the peripheralcirculation by establishing an anastomosis between the main artery of alimb and its companion vein, so that arterial blood may reach theperipheral capillaries--reversal of the circulation--but the clinicalresults have proved disappointing. (See _Op. Surg. _, p. 29. ) _Treatment. _--When there is evidence that gangrene has occurred, thefirst indication is to prevent infection by purifying the part, andafter careful drying to wrap it in a thick layer of absorbent andantiseptic wool, retained in place by a loosely applied bandage. Aslight degree of elevation of the limb is an advantage, but it must notbe sufficient to diminish the amount of blood entering the part. Hot-bottles are to be used with the utmost caution. As absolute drynessis essential, ointments or other greasy dressings are to be avoided, asthey tend to prevent evaporation from the skin. Opium should be givenfreely to alleviate pain. Stimulation is to be avoided, and the patientshould 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 aline of demarcation to form and allowing the dead part to be separated. This takes place so slowly, however, that it necessitates the patientbeing laid up for many weeks, or even months; and we agree with themajority in advising early amputation. In this connection it is worthy of note that there are certain points atwhich gangrene naturally tends to become arrested--namely, at the highlyvascular areas in the neighbourhood of joints. Thus gangrene of thegreat toe often stops when it reaches the metatarso-phalangeal joint; orif it trespasses this limit it may be arrested either at thetarso-metatarsal or at the ankle joint. If these be passed, it usuallyspreads up the leg to just below the knee before signs of arrestmentappear. Further, it is seen from pathological specimens that the spreadis greater on the dorsal than on the plantar aspect, and that the deathof skin and subcutaneous tissues extends higher than that of bone andmuscle. These facts furnish us with indications as to the seat and method ofamputation. Experience has proved that in senile gangrene of the lowerextremity the most reliable and satisfactory results are obtained byamputating in the region of the knee, care being taken to perform theoperation so as to leave the prepatellar anastomosis intact by retainingthe patella in the anterior flap. The most satisfactory operation inthese cases is Gritti's supra-condylar amputation. Hæmorrhage is easilycontrolled by digital pressure, and the use of a tourniquet should bedispensed with, as the constriction of the limb is liable to interferewith the vitality of the flaps. When the tibial vessels can be felt pulsating at the ankle it may bejustifiable, if the patient urgently desires it, to amputate lower thanthe knee; but there is considerable risk of gangrene recurring in thestump and necessitating a second operation. That amputation for senile gangrene performed between the ankle and theknee seldom succeeds, is explained by the fact that the vascularobstruction is usually in the upper part of the posterior tibial artery, and the operation is therefore performed through tissues with aninadequate blood supply. It is not uncommon, indeed, on amputating abovethe knee, to find even the popliteal artery plugged by a clot. Thisshould be removed at the amputation by squeezing the vessel from abovedownward by a "milking" movement, or by "catheterising the artery" withthe aid of a cannula with a terminal aperture. It is to be borne in mind that the object of amputation in these casesis merely to remove the gangrenous part, and so relieve the patient ofthe discomfort and the risks from infection which its presence involves. While it is true that in many of these patients the operation is borneremarkably well, it must be borne in mind that those who suffer fromsenile gangrene are of necessity bad lives, and a guarded opinion shouldbe expressed as to the prospects of survival. The possibility of thedisease 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 gangreneresulting from the _sudden_ occlusion of the main artery of a part, whether by the impaction of an embolus or the formation of a thrombus inits lumen, when the collateral circulation is not sufficiently free tomaintain the vitality of the tissues. There is sudden pain at the site of impaction of the embolus, and thepulses beyond are lost. The limb becomes cold, numb, insensitive, andpowerless. It is often pale at first--hence the term "white gangrene"sometimes applicable to the early appearances, which closely resemblethose presented by the limb of a corpse. If the part is aseptic it shrivels, and presents the ordinary featuresof dry gangrene. It is liable, however, especially in the lowerextremity and when the veins also are obstructed, to become infected andto assume the characters of the moist type. The extent of the gangrene depends upon the site of impaction of theembolus, thus if the _abdominal aorta_ becomes suddenly occluded by anembolus at its bifurcation, the obstruction of the iliacs and femoralsinduces symmetrical gangrene of both extremities as high as the inguinalligaments. When gangrene follows occlusion of the _external iliac_ or ofthe _femoral artery_ above the origin of its deep branch, the death ofthe limb extends as high as the middle or upper third of the thigh. Whenthe _femoral_ below the origin of its deep branch or the _poplitealartery_ is obstructed, the veins remaining pervious, the anastomosisthrough the profunda is sufficient to maintain the vascular supply, andgangrene does not necessarily follow. The rupture of a poplitealaneurysm, 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 spreadswell up the leg. When the _axillary artery_ is the seat of embolic impaction, andgangrene ensues, the process usually reaches the middle of the upperarm. Gangrene following the blocking of the _brachial_ at itsbifurcation usually extends as far as the junction of the lower andmiddle thirds of the forearm. Gangrene due to thrombosis or embolism is sometimes met with in patientsrecovering from typhus, typhoid, or other fevers, such as thatassociated with child-bed. It occurs in peripheral parts, such as thetoes, fingers, nose, or ears. _Treatment. _--The general treatment of embolic gangrene is the same asthat for the senile form. Success has followed opening the artery andremoving the embolus. The artery is exposed at the seat of impactionand, having been clamped above and below, a longitudinal opening is madeand the clot carefully extracted with the aid of forceps; it issometimes unexpectedly long (one recorded from the femoral arterymeasured nearly 34 inches); the wound in the artery is then sewn up withfine silk soaked in paraffin. When amputation is indicated, it must beperformed sufficiently high to ensure a free vascular supply to theflaps. #Gangrene following Ligation of Arteries. #--After the ligation of anartery in its continuity--for example, in the treatment of aneurysm--thelimb may for some days remain in a condition verging on gangrene, thedistal parts being cold, devoid of sensation, and powerless. As thecollateral circulation is established, the vitality of the tissues isgradually restored and these symptoms pass off. In some cases, however, --and especially in the lower extremity--gangrene ensues andpresents the same characters as those resulting from embolism. It tendsto be of the dry type. The occlusion of the vein as well as the arteryis not found to increase the risk of gangrene. #Gangrene from Mechanical Constriction of the Vessels of the part. #--Theapplication of a bandage or plaster-of-Paris case too tightly, or of atourniquet for too long a time, has been known to lead to death of thepart beyond; but such cases are rare, as are also those due to thepressure 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 theexcessive _pressure of splints_ over bony prominences, such as thelateral malleolus, the medial condyle of the humerus, or femur, or overthe dorsum of the foot. This is especially liable to occur when thenutrition of the skin is depressed by any interference with itsnerve-supply, such as follows injuries to the spine or peripheralnerves, disease of the brain, or acute anterior poliomyelitis. When thesplint is removed the skin pressed upon is found to be of a pale yellowor grey colour, and is surrounded by a ring of hyperæmia. If protectedfrom infection, the clinical course is that of dry gangrene. Bed-sores, which are closely allied to pressure sores, will be describedat the end of this chapter. When a localised portion of tissue, for example, a piece of skin, is soseverely _crushed_ or _bruised_ that its blood vessels are occluded andits structure destroyed, it dies, and, if not infected with bacteria, dries up, and the shrivelled brown skin is slowly separated by thegrowth of granulation tissue beneath and around it. Fingers, toes, or even considerable portions of limbs may in the sameway be suddenly destroyed by severe trauma, and undergo mummification. If organisms gain access, typical moist gangrene may ensue, or changessimilar to those of ordinary post-mortem decomposition may take place. _Treatment. _--The first indication is to exclude bacteria by purifyingthe damaged part and its surroundings, and applying dry, non-irritatingdressings. When these measures are successful, dry gangrene ensues. The raw surfaceleft after the separation of the dead skin may be allowed to heal bygranulation, or may be covered by skin-grafts. In the case of a fingeror a limb it is not necessary to wait until spontaneous separation takesplace, as this is often a slow process. When a well-marked line ofdemarcation has formed, amputation may be performed just sufficientlyfar above it to enable suitable flaps to be made. The end of a stump, after spontaneous separation of the gangrenousportion, requires to be trimmed, sufficient bone being removed to permitof the soft parts coming together. If moist gangrene supervenes, amputation must be performed withoutdelay, 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 arekept absolutely dry--as, for example, by the picric acid method oftreatment--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 sulphuricacid, may also induce local tissue necrosis, the general appearances ofthe lesions produced being like those of severe burns. The resultingsloughs are slow to separate, and leave deep punched-out cavities whichare long of healing. #Carbolic Gangrene. #--Carbolic acid, even in comparatively weaksolution, is liable to induce dry gangrene when applied as a fomentationto a finger, especially in women and children. Thrombosis occurs in theblood vessels of the part, which at first is pale and soft, but laterbecomes dark and leathery. On account of the anæsthetic action ofcarbolic acid, the onset of the process is painless, and the patientdoes not realise his danger. A line of demarcation soon forms, but thedead part separates very slowly. #Gangrene from Frost-bite. #--It is difficult to draw the line betweenthe third degree of chilblain and the milder forms of true frost-bite;the difference is merely one of degree. Frost-bite affects chiefly thetoes and fingers--especially the great toe and the little finger--theears, and the nose. In this country it is seldom seen except in membersof the tramp class, who, in addition to being exposed to cold bysleeping in the open air, are ill-fed and generally debilitated. Thecondition usually manifests itself after the parts, having beensubjected to extreme cold, are brought into warm surroundings. The firstsymptom is numbness in the part, followed by a sense of weight, tingling, and finally by complete loss of sensation. The part attackedbecomes white and bleached-looking, feels icy cold, and is insensitiveto touch. Either immediately, or, it may be, not for several days, itbecomes discoloured and swollen, and finally contracts and shrivels. Above the dead area the limb may be the seat of excruciating pain. Thedead portion is cast off, as in other forms of dry gangrene, by theformation of a line of demarcation. To prevent the occurrence of gangrene from frost-bite it is necessary toavoid the sudden application of heat. The patient should be placed in acold room, and the part rubbed with snow, or put in a cold bath, andhave light friction applied to it. As the circulation is restored thegeneral surroundings and the local applications are gradually madewarmer. Elevation of the part, wrapping it in cotton wool, and removalto a warmer room, are then permissible, and stimulants and warm drinksmay be given with caution. When by these means the occurrence ofgangrene is averted, recovery ensues, its onset being indicated by thewhite parts assuming a livid red hue and becoming the seat of an acuteburning sensation. A condition known as _Trench feet_ was widely prevalent amongst thetroops in France during the European War. Although allied to frost-bite, cold appears to play a less important part in its causation thanhumidity and constriction of the limbs producing ischæmia of the feet. Changes were found in the endothelium of the blood vessels, the axiscylinders of nerves, and the muscles. The condition does not occur incivil life. #Diabetic Gangrene. #--This form of gangrene is prone to occur in personsover fifty years of age who suffer from glycosuria. The arteries areoften markedly diseased. In some cases the existence of the glycosuriais unsuspected before the onset of the gangrene, and it is only onexamining the urine that the cause of the condition is discovered. Thegangrenous process seldom begins as suddenly as that associated withembolism, and, like senile gangrene, which it may closely simulate inits early stages, it not infrequently begins after a slight injury toone of the toes. It but rarely, however, assumes the dry, shrivellingtype, as a rule being attended with swelling, œdema, and dusky rednessof the foot, and severe pain. According to Paget, the dead part remainswarm longer than in other forms of senile gangrene; there is a greatertendency for patches of skin at some distance from the primary seat ofdisease to become gangrenous, and for the death of tissue to extendupwards in the subcutaneous planes, leaving the overlying skinunaffected. The low vitality of the tissues favours the growth ofbacteria, and if these gain access, the gangrene assumes the charactersof the moist type and spreads rapidly. The rules for amputation are the same as those governing the treatmentof senile gangrene, the level at which the limb is removed dependingupon whether the gangrene is of the dry or moist type. The generaltreatment for diabetes must, of course, be employed whether amputationis performed or not. Paget recommended that the dietetic treatmentshould not be so rigid as in uncomplicated diabetes, and that opiumshould be given freely. The _prognosis_ even after amputation is unfavourable. In many cases thepatient dies with symptoms of diabetic coma within a few days of theoperation; or, if he survives this, he may eventually succumb todiabetes. In others there is sloughing of the flaps and death resultsfrom toxæmia. Occasionally the other limb becomes gangrenous. On theother hand, the glycosuria may diminish or may even disappear afteramputation. #Gangrene associated with Spasm of Blood Vessels. #--#Raynaud's Disease#, or symmetrical gangrene, is supposed to be due to spasm of thearterioles, resulting from peripheral neuritis. It occurs oftenest inwomen, between the ages of eighteen and thirty, who are the subjects ofuterine disorders, anæmia, or chlorosis. Cold is an aggravating factor, as the disease is commonest during the winter months. The digits of bothhands or the toes of both feet are simultaneously attacked, and thedisease seldom spreads beyond the phalanges or deeper than the skin. The first evidence is that the fingers become cold, white, andinsensitive to touch and pain. These attacks of _local syncope_ recur atvarying intervals for months or even years. They last for a few minutesor even for some hours, and as they pass off the parts become hyperæmicand painful. A more advanced stage of the disease is known as _local asphyxia_. Thecirculation through the fingers becomes exceedingly sluggish, and theparts assume a dull, livid hue. There is swelling and burning orshooting pain. This may pass off in a few days, or may increase inseverity, with the formation of bullæ, and end in dry gangrene. As arule, the slough which forms is comparatively small and superficial, but it may take some months to separate. The condition tends to recur insuccessive winters. The _treatment_ consists in remedying any nervous or uterine disorderthat may be present, keeping the parts warm by wrapping them in cottonwool, and in the use of hot-air or electric baths, the parts beingimmersed in water through which a constant current is passed. Whengangrene occurs, it is treated on the same lines as other forms of drygangrene, but if amputation is called for it is only with a view toremoving 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 bearscertain analogies to Raynaud's disease in that spasm of the vesselsplays a part in determining the local death. The main arteries are narrowed by hyperplastic endarteritis followed bythrombosis, and similar changes are found in the veins. The condition isusually 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 andweakness of the limbs which pass off with rest--_intermittentclaudication_. During these attacks the large arteries--femoral, brachial, and subclavian--can be felt as firm cords, while pulsation islost in the peripheral vessels. Gangrene eventually ensues, is attendedwith great pain and runs a slow course. It is treated on the same linesas Raynaud's disease. #Gangrene from Ergot. #--Gangrene may occur from interference with bloodsupply, the result of tetanic contraction of the minute vessels, such asresults in ill-nourished persons who eat large quantities of coarse ryebread contaminated with the _claviceps purpurea_ and containing theergot of rye. It has also occurred in the fingers of patients who havetaken ergot medicinally over long periods. The gangrene, which attacksthe 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 thestarting-point, the anæsthesia produced by the ergotin preventing thepatient taking notice of them. Alcoholism is a potent predisposingcause. As it is impossible to predict how far the process will spread, it isadvisable to wait for the formation of a line of demarcation beforeoperating, 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 thefirst, and, spreading rapidly, result in extensive necrosis of tissue, and often end fatally. The infection is usually a mixed one in which anaërobic bacteriapredominate. The anaërobe most constantly present is the _bacillusærogenes capsulatus_, usually in association with other anaërobes, andsometimes with pyogenic diplo- and streptococci. According to the mode ofaction of the associated organisms and the combined effects of theirtoxins on the tissues, the gangrenous process presents differentpathological and clinical features. Some combinations, for example, result in a rapidly spreading cellulitis with early necrosis ofconnective tissue accompanied by thrombosis throughout the capillary andvenous circulation of the parts implicated; other combinations causegreat œdema of the part, and others again lead to the formation of gasesin the tissues, particularly in the muscles. These different effects do not appear to be due to a specific action ofany one of the organisms present, but to the combined effect of aparticular group living in symbiosis. According as the cellulitic, the œdematous, or the gaseouscharacteristics predominate, the clinical varieties of bacillarygangrene may be separately described, but it must be clearly understoodthat they frequently overlap and cannot always be distinguished from oneanother. #Clinical Varieties of Bacillary Gangrene. #--#Acute infective gangrene#is the form most commonly met with in civil practice. It may follow suchtrivial injuries as a pin-prick or a scratch, the signs of acutecellulitis rapidly giving place to those of a spreading gangrene. Or itmay ensue on a severe railway, machinery, or street accident, whenlacerated and bruised tissues are contaminated with gross dirt. Oftenwithin a few hours of the injury the whole part rapidly becomes painful, swollen, œdematous, and tense. The skin is at first glazed, and perhapspaler than normal, but soon assumes a dull red or purplish hue, andbullæ form on the surface. Putrefactive gases may be evolved in thetissues, and their presence is indicated by emphysematous crackling whenthe part is handled. The spread of the disease is so rapid that itsprogress is quite visible from hour to hour, and may be traced by theoccurrence 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 sorapidly that the local changes indicative of gangrene have not time tooccur, 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 thehand. ] Rigors may occur, but the temperature is not necessarily raised--indeed, it is sometimes subnormal. The pulse is small, feeble, rapid, andirregular. Unless amputation is promptly performed, death usuallyfollows within thirty-six or forty-eight hours. Even early operationdoes not always avert the fatal issue, because the quantity of toxinabsorbed and its extreme virulence are often more than even a robustsubject can outlive. _Treatment. _--Every effort must be made to purify all such wounds as arecontaminated by earth, street dust, stable refuse, or other forms ofgross dirt. Devitalised and contaminated tissue is removed with theknife or scissors and the wound purified with antiseptics of thechlorine group or with hydrogen peroxide. If there is a reasonableprospect that infection has been overcome, the wound may be at oncesutured, but if this is doubtful it is left open and packed orirrigated. When acute gangrene has set in no treatment short of amputation is ofany avail, and the sooner this is done, the greater is the hope ofsaving the patient. The limb must be amputated well beyond the apparentlimits of the infected area, and stringent precautions must be taken toavoid discharge from the already gangrenous area reaching the operationwound. An assistant or nurse, who is to take no other part in theoperation, is told off to carry out the preliminary purification, and tohold the limb during the operation. #Malignant Œdema. #--This form of acute gangrene has been defined as"a spreading inflammatory œdema attended with emphysema, and ultimatelyfollowed by gangrene of the skin and adjacent parts. " The predominantorganism is the _bacillus of malignant œdema_ or _vibrion septique_ ofPasteur, which is found in garden soil, dung, and various putrefyingsubstances. It is anaërobic, and occurs as long, thick rods withsomewhat 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-shapedoutline. Other pathogenic organisms are also present and aid thespecific bacillus in its action. At the bedside it is difficult, if not impossible, to distinguish itfrom acute infective gangrene. Both follow on the same kinds of injuryand run an exceedingly rapid course. In malignant œdema, however, theincidence of the disease is mainly on the superficial parts, whichbecome œdematous and emphysematous, and acquire a marbled appearancewith the veins clearly outlined. Early disappearance of sensation is aparticularly grave symptom. Bullæ form on the skin, and the tissueshave "a peculiar heavy but not putrid odour. " The constitutional effectsare extremely severe, and death may ensue within a few hours. #Acute Emphysematous# or #Gas Gangrene# was prevalent in certain areasat various periods during the European War. It follows infection oflacerated wounds with the _bacillus ærogenes capsulatus_, usually incombination with other anaërobes, and its main incidence is on themuscles, which rapidly become infiltrated with gas that spreadsthroughout the whole extent of the muscle, disintegrating its fibres andleading to necrosis. The gangrenous process spreads with appallingrapidity, the limb becoming enormously swollen, painful, and crepitantor even tympanitic. Patches of coppery or purple colour appear on theskin, and bullæ containing blood-stained serum form on the surface. Thetoxæmia is profound, and the face and lips assume a characteristiccyanosis. The condition is attended with a high mortality. Only in theearly stages and when the infection is limited are local measuressuccessful in arresting the spread; in more severe cases amputation isthe only means of saving life. #Cancrum Oris# or #Noma#. --This disease is believed to be due to aspecific bacillus, which occurs in long delicate rods, and is chieflyfound at the margin of the gangrenous area. It is prone to attackunhealthy children from two to five years of age, especially duringtheir convalescence from such diseases as measles, scarlet fever, ortyphoid, but may attack adults when they are debilitated. It is mostcommon in the mouth, but sometimes occurs on the vulva. In the mouth itbegins as an ulcerative stomatitis, more especially affecting the gumsor inner aspect of the cheek. The child lies prostrated, and from theopen mouth foul-smelling saliva, streaked with blood, escapes; the faceis of an ashy-grey colour, the lips dark and swollen. On the inneraspect of the cheek is a deeply ulcerated surface, with sloughy shredsof dark-brown or black tissue covering its base; the edges areirregular, firm, and swollen, and the surrounding mucous membrane isinfiltrated and œdematous. In the course of a few hours a dark spotappears 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 adark-red area which extends over the cheek (Fig. 23). The tissueimplicated is at first firm and indurated, but as it loses its vitalityit becomes doughy and sodden. Finally a slough forms, and, when itseparates, the cheek is perforated. Meanwhile the process spreads inside the mouth, and the gums, the floorof the mouth, or even the jaws, may become gangrenous and the teeth fallout. The constitutional disturbance is severe, the temperature raised, and the pulse feeble and rapid. The extremely fœtid odour which pervades the room or even the house thepatient occupies, is usually sufficient to suggest the diagnosis ofcancrum oris. The odour must not be mistaken for that due todecomposition of sordes on the teeth and gums of a debilitated patient. The _prognosis_ is always grave in the extreme, the main risks beinggeneral toxæmia and septic pneumonia. When recovery takes place there isserious deformity, and considerable portions of the jaws may be lost bynecrosis. [Illustration: FIG.  23. --Cancrum oris. (From a photograph lent by Sir George T. Beatson. )] _Treatment. _--The only satisfactory treatment is thorough removal underan anæsthetic of all the sloughy tissue, with the surrounding zone inwhich the organisms are active. This is most efficiently accomplished bythe knife or scissors, cutting until the tissue bleeds freely, afterwhich the raw surface is painted with undiluted carbolic acid anddressed with iodoform gauze. It may be necessary to remove large piecesof bone when the necrotic process has implicated the jaws. The mouthmust be constantly sprayed with peroxide of hydrogen, and washed outwith a disinfectant and deodorant lotion, such as Condy's fluid. Thepatient's general condition calls for free stimulation. The deformity resulting from these necessarily heroic measures is not sogreat as might be expected, and can be further diminished by plasticoperations, which should be undertaken before cicatricial contractionhas 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 diseasesassociated with stagnation of blood in the peripheral veins. Anyinterference with the nerve-supply of the skin, whether from injury ordisease of the central nervous system or of the peripheral nerves, strongly predisposes to the formation of bed-sores. Prolonged andexcessive pressure over a bony prominence, especially if the parts bemoist with skin secretions, urine, or wound discharges, determines theformation of a sore. Excoriations, which may develop into truebed-sores, sometimes form where two skin surfaces remain constantlyapposed, as in the region of the scrotum or labium, under pendulousmammæ, 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 acuteand the chronic bed-sore. The _acute_ bed-sore usually occurs over the sacrum or buttock. Itdevelops rapidly after spinal injuries and in the course of certainbrain diseases. The part affected becomes red and congested, while thesurrounding parts are œdematous and swollen, blisters form, and the skinloses its vitality (Fig. 24). In advanced cases of general paralysis of the insane, a peculiar form ofacute bed-sore beginning as a blister, and passing on to the formationof a black, dry eschar, which slowly separates, occurs on such parts asthe medial side of the knee, the angle of the scapula, and the heel. The _chronic_ bed-sore begins as a dusky reddish purple patch, whichgradually becomes darker till it is almost black. The parts around areœdematous, and a blister may form. This bursts and exposes the papillæof the skin, which are of a greenish hue. A tough greyish-black sloughforms, and is slowly separated. It is not uncommon for the gangrenousarea to continue to spread both in width and in depth till it reachesthe periosteum or bone. Bed-sores over the sacrum sometimes implicatethe vertebral canal and lead to spinal meningitis, which usually provesfatal. In old and debilitated patients the septic absorption taking place froma bed-sore often proves a serious complication of other surgicalconditions. From this cause, for example, old people may succumb duringthe treatment of a fractured thigh. The granulating surface left on the separation of the slough tends toheal comparatively rapidly. _Prevention of Bed-sores. _--The first essential in the prevention ofbed-sores is the regular changing of the patient's position, so that noone part of the body is continuously pressed upon for any length oftime. Ring-pads of wool, air-cushions, or water-beds are necessary toremove pressure from prominent parts. Absolute dryness of the skin isall-important. At least once a day, the sacrum, buttocks, shoulder-blades, heels, elbows, malleoli, or other parts exposed topressure, must be sponged with soap and water, thoroughly dried, andthen rubbed with methylated spirit, which is allowed to dry on the skin. Dusting the part with boracic acid powder not only keeps it dry, butprevents the development of bacteria in the skin secretions. In operation cases, care must be taken that irritating chemicals used topurify the skin do not collect under the patient and remain in contactwith the skin of the sacrum and buttocks during the time he is on theoperating-table. There is reason to believe that the so-called"post-operation bed-sore" may be due to such causes. A similar resulthas been known to follow soiling of the sheets by the escape of aturpentine enema. _Treatment. _--Once a bed-sore has formed, every effort must be made toprevent its spread. Alcohol is used to cleanse the broken surface, anddry absorbent dressings are applied and frequently changed. It issometimes found necessary to employ moist or oily substances, such asboracic poultices, eucalyptus ointment, or balsam of Peru, to facilitatethe separation of sloughs, or to promote the growth of granulations. Inpatients 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 surfaceleft 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 infectivedisease of the skin or of a mucous membrane due to the action of astreptococcus. Infection invariably takes place through an abrasion ofthe surface, although this may be so slight that it escapes observationeven when sought for. The streptococci are found most abundantly in thelymph 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 clinicalvariety, infection usually occurring through some slight abrasion in theregion 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 faceand scalp as far back as the nape of the neck. It stops, however, at thechin, and never extends on to the front of the neck. There is greatœdema of the face, the eyes becoming closed up, and the featuresunrecognisable. The inflammation may spread to the meninges, theintracranial venous sinuses, the eye, or the ear. In some cases theerysipelas invades the mucous membrane of the mouth, and spreads to thefauces and larynx, setting up an œdema of the glottis which may provedangerous to life. Erysipelas occasionally attacks an operation wound that has becomeseptic; and it may accompany septic infection of the genital tract inpuerperal women, or the separation of the umbilical cord in infants(_erysipelas neonatorum_). After an incubation period, which varies fromfifteen to sixty hours, the patient complains of headache, pains in theback and limbs, loss of appetite, nausea, and frequently there isvomiting. He has a chill or slight rigor, initiating a rise oftemperature to 103°, 104°, or 105° F. ; and a full bounding pulse ofabout 100 (Fig. 25). The tongue is foul, the breath heavy, and, as arule, the bowels are constipated. There is frequently albuminuria, andoccasionally 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 huefrom a bright scarlet to a dull brick-red. The edges are slightly raisedabove the level of the surrounding skin, as may readily be recognised bygently stroking the part from the healthy towards the affected area. Theskin is smooth, tense, and glossy, and presents here and there blistersfilled with serous fluid. The local temperature is raised, and the partis the seat of a burning sensation and is tender to the touch, the mosttender area being the actively spreading zone which lies about half aninch beyond the red margin. [Illustration: FIG.  25. --Chart of Erysipelas occurring in a wound. ] The disease tends to spread spasmodically and irregularly, and thedirection and extent of its progress may be recognised by mapping outthe peripheral zone of tenderness. Red streaks appear along the lines ofthe superficial lymph vessels, and the deep lymphatics may sometimes bepalpated as firm, tender cords. The neighbouring glands, also, aregenerally enlarged and tender. The disease lasts for from two or three days to as many weeks, andrelapses are frequent. Spontaneous resolution usually takes place, butthe disease may prove fatal from absorption of toxins, involvement ofthe brain or meninges, or from general streptococcal infection. #Complications. #--_Diffuse suppurative cellulitis_ is the most seriouslocal complication, and results from a mixed infection with otherpyogenic bacteria. Small _localised superficial abscesses_ may formduring the convalescent stage. They are doubtless due to the action ofskin bacteria, which attack the tissues devitalised by the erysipelas. Apersistent form of _œdema_ sometimes remains after recurrent attacks oferysipelas, 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 spreadof the process. We have found that by painting with linimentum iodi, aring half an inch broad, about an inch in front of the peripheral tenderzone--not the red margin--an artificial leucocytosis is produced, andthe advancing streptococci are thereby arrested. Several coats of theiodine are applied, one after the other, and this is repeated daily forseveral days, even although the erysipelas has not overstepped the ring. Success depends upon using the liniment of iodine (the tincture is notstrong enough), and in applying it well in front of the disease. Toallay pain the most useful local applications are ichthyol ointment (1in 6), or lead and opium fomentations. The general treatment consists in attending to the emunctories, inadministrating quinine in small--two-grain--doses every four hours, orsalicylate of iron (2–5 gr. Every three hours), and in giving plenty offluid nourishment. It is worthy of note that the anti-streptococcicserum has proved of less value in the treatment of erysipelas than mighthave been expected, probably because the serum is not made from theproper strain of streptococcus. It is not necessary to isolate cases of erysipelas, provided the usualprecautions against carrying infection from one patient to another arerigidly carried out. DIPHTHERIA Diphtheria is an acute infective disease due to the action of a specificbacterium, the _bacillus diphtheriæ_ or _Klebs-Löffler bacillus_. Thedisease is usually transmitted from one patient to another, but it maybe contracted from cats, fowls, or through the milk of infected cows. Cases have occurred in which the surgeon has carried the infection fromone patient to another through neglect of antiseptic precautions. Theincubation period varies from two to seven days. #Clinical Features. #--In _pharyngeal diphtheria_, on the first orsecond day of the disease, redness and swelling of the mucous membraneof the pharynx, tonsils, and palate are well marked, and small, circulargreenish or grey patches of false membrane, composed of necrosedepithelium, fibrin, leucocytes, and red blood corpuscles, begin toappear. These rapidly increase in area and thickness, till they coalesceand form a complete covering to the parts. In the pharynx the falsemembrane is less adherent to the surface than it is when the diseaseaffects the air-passages. The diphtheritic process may spread from thepharynx to the nasal cavities, causing blocking of the nares, with aprofuse ichorous discharge from the nostrils, and sometimes severeepistaxis. The infection may spread along the nasal duct to theconjunctiva. The middle ear also may become involved by spread along theauditory (Eustachian) tube. The lymph glands behind the angle of the jaw enlarge and become tender, and may suppurate from superadded infection. There is pain onswallowing, and often earache; and the patient speaks with a nasalaccent. He becomes weak and anæmic, and loses his appetite. There isoften albuminuria. Leucocytosis is usually well marked before theinjection of antitoxin; after the injection there is usually adiminution in the number of leucocytes. The false membrane may separateand be cast off, after which the patient gradually recovers. Death maytake place from gradual failure of the heart's action or from syncopeduring 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 itselfby a short, dry, croupy cough, and hoarseness of the voice. The firstdifficulty in breathing usually takes place during the night, and onceit begins, it rapidly gets worse. Inspiration becomes noisy, sometimesstridulous or metallic or sibilant, and there is marked indrawing of theepigastrium and lower intercostal spaces. The hoarseness becomes moremarked, the cough more severe, and the patient restless. The difficultyof breathing occurs in paroxysms, which gradually increase in frequencyand severity, until at length the patient becomes asphyxiated. Theduration of the disease varies from a few hours to four or five days. After the acute symptoms have passed off, various localisedparalyses may develop, affecting particularly the nerves of the palataland orbital muscles, less frequently the lower limbs. #Diagnosis. #--The finding of the Klebs-Löffler bacillus is the onlyconclusive evidence of the disease. The bacillus may be obtained byswabbing the throat with a piece of aseptic--not antiseptic--cotton woolor clean linen rag held in a pair of forceps, and rotated so as toentangle portions of the false membrane or exudate. The swab thusobtained is placed in a test-tube, previously sterilised by having hadsome water boiled in it, and sent to a laboratory for investigation. Toidentify the bacillus a piece of the membrane from the swab is rubbed ona cover glass, dried, and stained with methylene blue or other basicstain; or cultures may be made on agar or other suitable medium. When abacteriological examination is impossible, or when the clinical featuresdo not coincide with the results obtained, the patient should always betreated on the assumption that he suffers from diphtheria. So much doubtexists as to the real nature of membranous croup and its relationship totrue diphtheria, that when the diagnosis between the two is uncertainthe safest plan is to treat the case as one of diphtheria. In children, diphtheria may occur on the vulva, vagina, prepuce, orglans penis, and give rise to difficulty in diagnosis, which is onlycleared up by demonstration of the bacillus. #Treatment. #--An attempt may be made to destroy or to counteract theorganisms by swabbing the throat with strong antiseptic solutions, suchas 1 in 1000 corrosive sublimate or 1 in 30 carbolic acid, or byspraying 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 passedeither through the mouth or nose. When this is impracticable, nutrientenemata are called for. In laryngeal diphtheria, the interference with respiration may call forintubation of the larynx, or tracheotomy, but the antitoxin treatmenthas greatly diminished the number of cases in which it becomes necessaryto have recourse to these measures. Intubation consists in introducing through the mouth into the larynx atube which allows the patient to breathe freely during the period whilethe membrane is becoming separated and thrown off. This is best donewith the apparatus of O'Dwyer; but when this instrument is notavailable, a simple gum-elastic catheter with a terminal opening (assuggested by Macewen and Annandale) may be employed. When intubation is impracticable, the operation of tracheotomy iscalled for if the patient's life is endangered by embarrassment ofrespiration. Unless the patient is in hospital with skilled assistanceavailable, tracheotomy is the safer of the two procedures. TETANUS Tetanus is a disease resulting from infection of a wound by a specificmicro-organism, the _bacillus tetani_, and characterised by increasedreflex excitability, hypertonus, and spasm of one or more groups ofvoluntary muscles. _Etiology and Morbid Anatomy. _--The tetanus bacillus, which is a perfectanaërobe, is widely distributed in nature and can be isolated fromgarden earth, dung-heaps, and stable refuse. It is a slender rod-shapedbacillus, with a single large spore at one end giving it the shape of adrum-stick (Fig. 26). The spores, which are the active agents inproducing tetanus, are highly resistant to chemical agents, retain theirvitality in a dry condition, and even survive boiling for five minutes. The organism does not readily establish itself in the human body, andseems to flourish best when it finds a nidus in necrotic tissue and isaccompanied by aërobic organisms, which, by using up the oxygen in thetissues, provide for it a suitable environment. The presence of aforeign body in the wound seems to favour its action. The infection isfor all practical purposes a local one, the symptoms of the diseasebeing due to the toxins produced in the wound of infection acting uponthe 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 nervefibres supplying the voluntary muscles. Its first effect on the motorganglia of the cord is to render them hypersensitive, so that they areexcited by mild stimuli, which under ordinary conditions would produceno reaction. As the toxin accumulates the reflex arc is affected, withthe result that when a stimulus reaches the ganglia a motor dischargetakes place, which spreads by ascending and descending collaterals tothe reflex apparatus of the whole cord. As the toxin spreads it causesboth motor hyper-tonus and hyper-excitability, which accounts for thetonic contraction and the clonic spasms characteristic of tetanus. [Illustration: FIG.  26. --Bacillus of Tetanus from scraping of a wound offinger, × 1000 diam. Basic fuchsin stain. ] #Clinical Varieties of Tetanus. #--_Acute_ or _FulminatingTetanus_. --This variety is characterised by the shortness of theincubation period, the rapidity of its progress, the severity of itssymptoms, and its all but universally fatal issue in spite oftreatment, death taking place in from one to four days. Thecharacteristic symptoms may appear within three or four days of theinfliction of the wound, but the incubation period may extend to threeweeks, and the wound may be quite healed before the disease declaresitself--_delayed tetanus_. Usually, however, the wound is inflamed andsuppurating, with ragged and sloughy edges. A slight feverish attack maymark the onset of the tetanic condition, or the patient may feelperfectly well until the spasms begin. If careful observations be made, it may be found that the muscles in the immediate neighbourhood of thewound are the first to become contracted; but in the majority ofinstances the patient's first complaint is of pain and stiffness in themuscles of mastication, notably the masseter, so that he has difficultyin opening the mouth--hence the popular name "lock-jaw. " The muscles ofexpression soon share in the rigidity, and the face assumes a taut, mask-like aspect. The angles of the mouth may be retracted, producing agrinning 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 toattribute the pain and stiffness to exposure to cold or rheumatism. Atan early stage the diaphragm and the muscles of the anterior abdominalwall become contracted; later the muscles of the back and thorax areinvolved; and lastly those of the limbs. Although this is the typicalorder of involvement of the different groups of muscles, it is notalways adhered to. To this permanent tonic contraction of the muscles there are soon addedclonic spasms. These spasms are at first slight and transient, withprolonged intervals between the attacks, but rapidly tend to become morefrequent, more severe, and of longer duration, until eventually thepatient simply passes out of one seizure into another. The distribution of the spasms varies in different cases: in some it isconfined to particular groups of muscles, such as those of the neck, back, abdominal walls, or limbs; in others all these groups aresimultaneously involved. When the muscles of the back become spasmodically contracted, the bodyis raised from the bed, sometimes to such an extent that the patientrests only on his heels and occiput--the position of _opisthotonos_. Lateral arching of the body from excessive action of the muscles on oneside--_pleurosthotonos_--is not uncommon, the arching usually takingplace towards the side on which the wound of infection exists. Lessfrequently the body is bent forward so that the knees and chin almostmeet (_emprosthotonos_). Sometimes all the muscles simultaneously becomerigid, so that the body assumes a statuesque attitude (_orthotonos_). When the thoracic muscles, including the diaphragm, are thrown intospasm, the patient experiences a distressing sensation as if he weregripped in a vice, and has extreme difficulty in getting breath. Betweenthe attacks the limbs are kept rigidly extended. The clonic spasms maybe so severe as to rupture muscles or even to fracture one of the longbones. As time goes on, the clonic exacerbations become more and more frequent, and the slightest external stimulus, such as the feeling of the pulse, awhisper in the room, a noise in the street, a draught of cold air, theeffort to swallow, a question addressed to the patient or his attempt toanswer, is sufficient to determine an attack. The movements are soforcible and so continuous that the nurse has great difficulty inkeeping the bedclothes on the patient, or even in keeping him in bed. The general condition of the patient is pitiful in the extreme. He isfully conscious of the gravity of the disease, and his mind remainsclear to the end. The suffering induced by the cramp-like spasms of themuscles keeps him in a constant state of fearful apprehension of thenext seizure, and he is unable to sleep until he becomes utterlyexhausted. The temperature is moderately raised (100° to 102° F. ), or may remainnormal throughout. Shortly before death very high temperatures (110° F. )have been recorded, and it has been observed that the thermometersometimes continues to rise after death, and may reach as high as112° F. Or more. The pulse corresponds with the febrile condition. It is acceleratedduring the spasms, and may become exceedingly rapid and feeble beforedeath, probably from paralysis of the vagus. Sudden death from cardiacparalysis or from cardiac spasm is not uncommon. The respiration is affected in so far as the spasms of the respiratorymuscles produce dyspnœa, and a feeling of impending suffocation whichadds to the horrors of the disease. One of the most constant symptoms is a copious perspiration, the patientbeing literally bathed in sweat. The urine is diminished in quantity, but as a rule is normal in composition; as in other acute infectiveconditions, albumen and blood may be present. Retention of urine mayresult from spasm of the urethral muscles, and necessitate the use ofthe catheter. The fits may cease some time before death, or, on the other hand, deathmay occur during a paroxysm from fixation of the diaphragm and arrest ofrespiration. _Differential Diagnosis. _--There is little difficulty, as a rule, indiagnosing a case of fulminating tetanus, but there are severalconditions with which it may occasionally be confused. In _strychninpoisoning_, for example, the spasms come on immediately after thepatient has taken a toxic dose of the drug; they are clonic incharacter, but the muscles are relaxed between the fits. If the dose isnot lethal, the spasms soon cease. In _hydrophobia_ a history of havingbeen bitten by a rabid animal is usually forthcoming; the spasms, whichare clonic in character, affect chiefly the muscles of respiration anddeglutition, and pass off entirely in the intervals between attacks. Certain cases of _hæmorrhage into the lateral ventricles_ of the brainalso simulate tetanus, but an analysis of the symptoms will preventerrors in diagnosis. _Cerebro-spinal meningitis_ and _basal meningitis_present certain superficial resemblances to tetanus, but there is notrismus, and the spasms chiefly affect the muscles of the neck andback. _Hysteria and catalepsy_ may assume characters resembling thoseof tetanus, but there is little difficulty in distinguishing betweenthese diseases. Lastly, in the _tetany_ of children, or that followingoperations 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 ismainly one of degree. Its incubation period is longer, it is more slowand insidious in its progress, and it never reaches the same degree ofseverity. Trismus is the most marked and constant form of spasm; andwhile the trunk muscles may be involved, those of respiration as a ruleescape. Every additional day the patient lives adds to the probabilityof his ultimate recovery. When the disease does prove fatal, it is fromexhaustion, and not from respiratory or cardiac spasm. The usualduration is from six to ten weeks. #Delayed Tetanus. #--During the European War acute tetanus occasionallydeveloped many weeks or even months after a patient had been injured, and when the original wound had completely healed. It usually followedsome secondary operation, _e. G. _, for the removal of a foreign body, orthe breaking down of adhesions, which aroused latent organisms. #Local Tetanus. #--This term is applied to a form of the disease in whichthe hypertonus and spasms are localised to the muscles in the vicinityof the wound. It usually occurs in patients who have had prophylacticinjections of anti-tetanic serum, the toxins entering the blood beingprobably neutralised by the antibodies in circulation, while thosepassing along the motor nerves are unaffected. When it occurs in the _limbs_, attention is usually directed to the factby pain accompanying the spasms; the muscles are found to be hard andthere are frequent twitchings of the limb. A characteristic reflex ispresent in the lower extremity, namely, extension of the foot and legwhen the sole is tickled. _Cephalic Tetanus_ is another localised variety which follows injury inthe distribution of the facial nerve. It is characterised by theoccurrence on the same side as the injury, of facial spasm, rapidlyfollowed by more or less complete paralysis of the muscles ofexpression, with unilateral trismus and difficulty in swallowing. Othercranial nerves, particularly the oculomotor and the hypoglossal, mayalso be implicated. A remarkable feature of this condition is thatalthough 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 limitedto the muscles of mastication. It is really a mild form of chronictetanus, and the prognosis is favourable. It must not be confused withthe fixation of the jaw sometimes associated with a wisdom-toothgumboil, with tonsillitis, or with affections of the temporo-mandibulararticulation. _Tetanus neonatorum_ is a form of tetanus occurring in infants of abouta week old. Infection takes place through the umbilicus, and manifestsitself clinically by spasms of the muscles of mastication. It is almostinvariably fatal within a few days. _Prophylaxis. _--Experience in the European War has established thefact that the routine injection of anti-tetanic serum to all patientswith lacerated and contaminated wounds greatly reduces the frequency oftetanus. The sooner the serum is given after the injury, the morecertain is its effect; within twenty-four hours 1500 units injectedsubcutaneously is sufficient for the initial dose; if a longer periodhas elapsed, 2000 to 3000 units should be given intra-muscularly, asthis ensures more rapid absorption. A second injection is given a weekafter the first. The wound must be purified in the usual way, and all instruments andappliances used for operations on tetanic patients must be immediatelysterilised by prolonged boiling. _Treatment. _--When tetanus has developed the main indications are toprevent the further production of toxins in the wound, and to neutralisethose that have been absorbed into the nervous system. Thoroughpurification with antiseptics, excision of devitalised tissues, anddrainage of the wound are first carried out. To arrest the absorption oftoxins intra-muscular injections of 10, 000 units of serum are givendaily into the muscles of the affected limb, or directly into the nervetrunks leading from the focus of infection, in the hope of "blocking"the nerves with antitoxin and so preventing the passage of toxinstowards the spinal cord. To neutralise the toxins that have already reached the spinal cord, 5000units should be injected intra-thecally daily for four or five days, thefoot of the bed being raised to enable the serum to reach the upperparts of the cord. The quantity of toxin circulating in the blood is so small as to bepractically negligible, and the risk of anaphylactic shock attendingintra-venous injection outweighs any benefit likely to follow thisprocedure. Baccelli recommends the injection of 20 c. C. Of a 1 in 100 solution ofcarbolic acid into the subcutaneous tissues every four hours during theperiod that the contractions persist. Opinions vary as to theefficiency of this treatment. The intra-thecal injection of 10 c. C. Of a15 per cent. Solution of magnesium sulphate has proved beneficial inalleviating the severity of the spasms, but does not appear to have acurative effect. To conserve the patient's strength by preventing or diminishing theseverity of the spasms, he should be placed in a quiet room, and everyform of disturbance avoided. Sedatives, such as bromides, paraldehyde, or opium, must be given in large doses. Chloral is perhaps the best, andthe patient should rarely have less than 150 grains in twenty-fourhours. When he is unable to swallow, it should be given by the rectum. The administration of chloroform is of value in conserving the strengthof the patient, by abolishing the spasms, and enabling the attendants toadminister nourishment or drugs either through a stomach tube or by therectum. Extreme elevation of temperature is met by tepid sponging. It isnecessary to use the catheter if retention of urine occurs. HYDROPHOBIA Hydrophobia is an acute infective disease following on the bite of arabid animal. It most commonly follows the bite or lick of a rabid dogor cat. The virus appears to be communicated through the saliva of theanimal, and to show a marked affinity for nerve tissues; and the diseaseis most likely to develop when the patient is infected on the face orother uncovered part, or in a part richly endowed with nerves. A dog which has bitten a person should on no account be killed until itscondition has been proved one way or the other. Should rabies developand its destruction become necessary, the head and spinal cord should beretained and forwarded, packed in ice, to a competent observer. Muchanxiety to the person bitten and to his friends would be avoided ifthese rules were observed, because in many cases it will be shown thatthe animal did not after all suffer from rabies, and that the patientconsequently runs no risk. If, on the other hand, rabies is proved to bepresent, the patient should be submitted to the Pasteur treatment. _Clinical Features. _--There is almost always a history of the patienthaving been bitten or licked by an animal supposed to suffer fromrabies. The incubation period averages about forty days, but varies froma fortnight to seven or eight months, and is shorter in young than inold persons. The original wound has long since healed, and beyond aslight itchiness or pain shooting along the nerves of the part, shows nosign of disturbance. A few days of general malaise, with chills andgiddiness precede the onset of the acute manifestations, which affectchiefly the muscles of deglutition and respiration. One of the earliestsigns is that the patient has periodically a sudden catch in hisbreathing "resembling what often occurs when a person goes into a coldbath. " This is due to spasm of the diaphragm, and is frequentlyaccompanied by a loud-sounding hiccough, likened by the laity to thebarking of a dog. Difficulty in swallowing fluids may be the firstsymptom. The spasms rapidly spread to all the muscles of deglutition andrespiration, so that the patient not only has the greatest difficulty inswallowing, but has a constant sense of impending suffocation. To add tohis distress, a copious secretion of viscid saliva fills his mouth. Anyvoluntary effort, as well as all forms of external stimuli, only serveto aggravate the spasms which are always induced by the attempt toswallow 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 alwaysextreme mental agitation and despair, and the sufferer is in constantfear of his impending fate. Happily the inevitable issue is not longdelayed, death usually occurring in from two to four days from theonset. The symptoms of the disease are so characteristic that there isno difficulty in diagnosis. The only condition with which it is liableto be confused is the variety of cephalic tetanus in which the musclesof deglutition are specially involved--the so-called tetanushydrophobicus. _Prophylaxis. _--The bite of an animal suspected of being rabid should becauterised at once by means of the actual or Paquelin cautery, or by astrong chemical escharotic such as pure carbolic acid, after whichantiseptic dressings are applied. It is, however, to Pasteur's _preventive inoculation_ that we must lookfor our best hope of averting the onset of symptoms. "It may now betaken as established that a grave responsibility rests on thoseconcerned if a person bitten by a mad animal is not subjected to thePasteur treatment" (Muir and Ritchie). This method is based on the fact that the long incubation period of thedisease admits of the patient being inoculated with a modified virusproducing a mild attack, which protects him from the natural disease. _Treatment. _--When the symptoms have once developed they can only bepalliated. The patient must be kept absolutely quiet and free from allsources of irritation. The spasms may be diminished by means of chloraland bromides, or by chloroform inhalation. ANTHRAX Anthrax is a comparatively rare disease, communicable to man fromcertain of the lower animals, such as sheep, oxen, horses, deer, andother herbivora. In animals it is characterised by symptoms of acutegeneral poisoning, and, from the fact that it produces a markedenlargement of the spleen, is known in veterinary surgery as "splenicfever. " The _bacillus anthracis_ (Fig. 27), the largest of the known pathogenicbacteria, occurs in groups or in chains made up of numerous bacilli, each bacillus measuring from 6 to 8 µ in length. The organisms are foundin enormous numbers throughout the bodies of animals that have died ofanthrax, and are readily recognised and cultivated. Sporulation onlytakes place outside the body, probably because free oxygen is necessaryto the process. In the spore-free condition, the organisms are readilydestroyed by ordinary germicides, and by the gastric juice. The spores, on the other hand, have a high degree of resistance. Not only do theyremain viable in the dry state for long periods, even up to a year, butthey survive boiling for five minutes, and must be subjected to dry heatat 140° C. For several hours before they are destroyed. [Illustration: FIG.  27. --Bacillus of Anthrax in section of skin, from acase of malignant pustule; shows vesicle containing bacilli. × 400 diam. Gram's stain. ] _Clinical Varieties of Anthrax. _--In man, anthrax may manifest itself inone of three clinical forms. It may be transmitted by means of spores or bacilli directly from adiseased animal to those who, by their occupation or otherwise, arebrought into contact with it--for example, shepherds, butchers, veterinary surgeons, or hide-porters. Infection may occur on the face bythe use of a shaving-brush contaminated by spores. The path of infectionis usually through an abrasion of the skin, and the primarymanifestations are local, constituting what is known as _the malignantpustule_. In other cases the disease is contracted through the inhalation of thedried spores into the respiratory passages. This occurs oftenest inthose who work amongst wool, fur, and rags, and a form of acutepneumonia 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 meansof spores ingested into the alimentary canal in meat or milk derivedfrom diseased animals, or in infected water. #Clinical Features of Malignant Pustule. #--We shall here confineourselves to the consideration of the local lesion as it occurs in theskin--_the malignant pustule_. The point of infection is usually on an uncovered part of the body, suchas the face, hands, arms, or back of the neck, and the wound may beexceedingly minute. After an incubation period varying from a few hoursto several days, a reddish nodule resembling a small boil appears at theseat of inoculation, the immediately surrounding skin becomes swollenand indurated, and over the indurated area there appear a number ofsmall vesicles containing serum, which at first is clear but soonbecomes blood-stained (Fig. 28). Coincidently the subcutaneous tissuefor a considerable distance around becomes markedly œdematous, and theskin red and tense. Within a few hours, blood is extravasated in thecentre of the indurated area, the blisters burst, and a dark brown orblack eschar, composed of necrosed skin and subcutaneous tissue andaltered blood, forms (Fig. 29). Meanwhile the induration extends, freshvesicles form and in turn burst, and the eschar increases in size. Theneighbouring lymph glands soon become swollen and tender. The affectedpart 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--_anthracæmia_--the temperaturerises to 103° or 104° F. , the pulse becomes feeble and rapid, and othersigns of severe blood-poisoning appear: vomiting, diarrhœa, pains in thelimbs, headache and delirium, and the condition proves fatal in fromfive to eight days. _Differential Diagnosis. _--When the malignant pustule is fullydeveloped, the central slough with the surrounding vesicles and thewidespread œdema are characteristic. The bacillus can be obtained fromthe peripheral portion of the slough, from the blisters, and from theadjacent lymph vessels and glands. The occupation of the patient maysuggest the possibility of anthrax infection. [Illustration: FIG.  28. --Malignant Pustule, third day after infectionwith Anthrax, showing great œdema of upper extremity and pectoral region(cf. Fig. 29). ] [Illustration: FIG.  29. --Malignant Pustule, fourteen days afterinfection, showing black eschar in process of separation. The œdema haslargely disappeared. Treated by Sclavo's serum (cf. Fig. 28). ] _Prophylaxis. _--Any wound suspected of being infected with anthraxshould at once be cauterised with caustic potash, the actual cautery, orpure carbolic acid. _Treatment. _--The best results hitherto obtained have followed the useof the anti-anthrax serum introduced by Sclavo. The initial dose is 40c. C. , and if the serum is given early in the disease, the beneficialeffects are manifest in a few hours. Favourable results have alsofollowed the use of pyocyanase, a vaccine prepared from the bacilluspyocyaneus. By some it is recommended that the local lesion should be freelyexcised; others advocate cauterisation of the affected part with solidcaustic potash till all the indurated area is softened. Gräf has hadexcellent results by the latter method in a large series of cases, theœdema subsiding in about twenty-four hours and the constitutionalsymptoms rapidly improving. Wolff and Wiewiorowski, on the other hand, have had equally good results by simply protecting the local lesion witha mild antiseptic dressing, and relying upon general treatment. The general treatment consists in feeding and stimulating the patient asfreely as possible. Quinine, in 5 to 10 grain doses every four hours, and powdered ipecacuanha, in 40 to 60 grain doses every four hours, havealso been employed with apparent benefit. GLANDERS Glanders is due to the action of a specific bacterium, the _bacillusmallei_, which resembles the tubercle bacillus, save that it is somewhatshorter and broader, and does not stain by Gram's method. It requireshigher temperatures for its cultivation than the tubercle bacillus, andits growth on potato is of a characteristic chocolate-brown colour, witha greenish-yellow ring at the margin of the growth. The bacillus malleiretains its vitality for long periods under ordinary conditions, but isreadily killed by heat and chemical agents. It does not form spores. _Clinical Features. _--Both in the lower animals and in man the bacillusgives 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 otherequine animals, horned cattle being immune. It affects the septum of thenose and adjacent parts, firm, translucent, greyish nodules containinglymphoid and epithelioid cells appearing in the mucous membrane. Thesenodules subsequently break down in the centre, forming irregularulcers, which are attended with profuse discharge, and markedinflammatory 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. Infectionalways takes place through an abraded surface, and usually on one of theuncovered 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. Thedisease has been acquired by accidental inoculation in the course ofexperimental investigations in the laboratory, and proved fatal. Theincubation period is from three to five days. The _local_ manifestations are pain and swelling in the region of theinfected wound, with inflammatory redness around it and along the linesof the superficial lymphatics. In the course of a week, small, firmnodules appear, and are rapidly transformed into pustules. These mayoccur on the face and in the vicinity of joints, and may be mistaken forthe eruption of small-pox. After breaking down, these pustules give rise to irregular ulcers, whichby their confluence lead to extensive destruction of skin. Sometimes thenasal mucous membrane becomes affected, and produces a discharge--atfirst watery, but later sanious and purulent. Necrosis of the bones ofthe nose may take place, in which case the discharge becomes peculiarlyoffensive. In nearly every case metastatic abscesses form in differentparts of the body, such as the lungs, joints, or muscles. During the development of the disease the patient feels ill, complainsof headache and pains in the limbs, the temperature rises to 104° oreven to 106° F. , and assumes a pyæmic type. The pulse becomes rapid andweak. The tongue is dry and brown. There is profuse sweating, albuminuria, and often insomnia with delirium. Death may take placewithin a week, but more frequently occurs during the second or thirdweek. _Differential Diagnosis. _--There is nothing characteristic in the siteof the primary lesion in man, and the condition may, during the earlystages, be mistaken for a boil or carbuncle, or for any acuteinflammatory condition. Later, the disease may simulate acute articularrheumatism, or may manifest all the symptoms of acute septicæmia orpyæmia. The diagnosis is established by the recognition of the bacillus. Veterinary surgeons attach great importance to the mallein test as ameans of diagnosis in animals, but in the human subject its use isattended with considerable risk and is not to be recommended. _Treatment. _--Excision of the primary nodule, followed by theapplication of the thermo-cautery and sponging with pure carbolic acid, should be carried out, provided the condition is sufficiently limited torender complete removal practicable. When secondary abscesses form in accessible situations, they must beincised, disinfected, and drained. The general treatment is carried outon the same lines as in other acute infective diseases. #Chronic Glanders. #--_In the horse_ the chronic form of glanders isknown as _farcy_, and follows infection through an abrasion of the skin, involving chiefly the superficial lymph vessels and glands. Thelymphatics become indurated and nodular, constituting what veterinarianscall _farcy pipes_ and _farcy buds_. _In man_ also the clinical features of the chronic variety of thedisease are somewhat different from those of the acute form. Here, too, infection takes place through a broken cutaneous surface, and leads to asuperficial lymphangitis with nodular thickening of the lymphatics(_farcy buds_). The neighbouring glands soon become swollen andindurated. The primary lesion meanwhile inflames, suppurates, and, afterbreaking down, leaves a large, irregular ulcer with thickened edges anda foul, purulent or bloody discharge. The glands break down in the sameway, and lead to wide destruction of skin, and the resulting sinuses andulcers are exceedingly intractable. Secondary deposits in thesubcutaneous tissue, the muscles, and other parts, are not uncommon, andthe nasal mucous membrane may become involved. The disease often runs achronic course, extending to four or five months, or even longer. Recovery takes place in about 50 per cent. Of cases, but theconvalescence is prolonged, and at any time the disease may assume thecharacters of the acute variety and speedily prove fatal. The _differential diagnosis_ is often difficult, especially in thechronic nodules, in which it may be impossible to demonstrate thebacillus. The ulcerated lesions of farcy have to be distinguished fromthose of tubercle, syphilis, and other forms of infective granuloma. _Treatment. _--Limited areas of disease should be completely excised. Thegeneral condition of the patient must be improved by tonics, good food, and favourable hygienic surroundings. In some cases potassium iodideacts beneficially. ACTINOMYCOSIS Actinomycosis is a chronic disease due to the action of an organismsomewhat higher in the vegetable scale than ordinary bacteria--the_streptothrix actinomyces_ or _ray fungus_. [Illustration: FIG.  30. --Section of Actinomycosis Colony in Pus fromAbscess of Liver, showing filaments and clubs of streptothrixactinomyces. × 400 diam. Gram's stain. ] _Etiology and Morbid Anatomy. _--The actinomyces, which has never beenmet with outside the body, gives rise in oxen, horses, and other animalsto tumour-like masses composed of granulation tissue; and in man tochronic suppurative processes which may result in a condition resemblingchronic pyæmia. The actinomyces is more complex in structure than otherpathogenic 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 yellowtint they are spoken of as "sulphur grains. " Each colony is made up of aseries of thin, interlacing, and branching _filaments_, some of whichare broken up so as to form masses or chains of _cocci_; and around theperiphery of the colony are elongated, pear-shaped, hyaline, _club-likebodies_ (Fig. 30). Infection is believed to be conveyed by the husks of cereals, especiallybarley; and the organism has been found adhering to particles of grainembedded in the tissues of animals suffering from the disease. In thehuman subject there is often a history of exposure to infection fromsuch sources, and the disease is said to be most common during theharvesting months. Around each colony of actinomyces is a zone of granulation tissue inwhich suppuration usually occurs, so that the fungus comes to lie in abath of greenish-yellow pus. As the process spreads these purulent focibecome confluent and form abscess cavities. When metastasis takes place, as it occasionally does, the fungus is transmitted by the blood vessels, as in pyæmia. _Clinical features. _--In man the disease may be met with in the skin, the organisms gaining access through an abrasion, and spreading by theformation of new nodules in the same way as tuberculosis. The region of the mouth and jaws is one of the commonest sites ofsurgical actinomycosis. Infection takes place, as a rule, along the sideof a carious tooth, and spreads to the lower jaw. A swelling is slowlyand insidiously developed, but when the loose connective tissue of theneck becomes infiltrated, the spread is more rapid. The whole regionbecomes infiltrated and swollen, and the skin ultimately gives way andfree suppuration occurs, resulting in the formation of sinuses. Thecharacteristic greenish-grey or yellow granules are seen in the pus, andwhen examined microscopically reveal the colonies of actinomyces. Less frequently the maxilla becomes affected, and the disease may spreadto the base of the skull and brain. The vertebræ may become involved byinfection taking place through the pharynx or œsophagus, and leading toa condition simulating tuberculous disease of the spine. When itimplicates the intestinal canal and its accessory glands, the lungs, pleura, and bronchial tubes, or the brain, the disease is not amenableto surgical treatment. _Differential Diagnosis. _--The conditions likely to be mistaken forsurgical actinomycosis are sarcoma, tubercle, and syphilis. In the earlystages the differential diagnosis is exceedingly difficult. In manycases it is only possible when suppuration has occurred and the funguscan be demonstrated. The slow destruction of the affected tissue by suppuration, the absenceof pain, tenderness, and redness, simulate tuberculosis, but the absenceof glandular involvement helps to distinguish it. Syphilitic lesions are liable to be mistaken for actinomycosis, all themore that in both diseases improvement follows the administration ofiodides. 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 toopposite 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 diseaseimplicates internal organs, it is almost always fatal. On external partsthe destructive process gradually spreads, and the patient eventuallysuccumbs to superadded septic infection. When, from its situation, theprimary focus admits of removal, the prognosis is more favourable. _Treatment. _--The surgical treatment is early and free removal of theaffected tissues, after which the wound is cauterised by the actualcautery, and sponged over with pure carbolic acid. The cavity is packedwith iodoform gauze, no attempt being made to close the wound. Success has attended the use of a vaccine prepared from cultures of theorganism; and the X-rays and radium, combined with the administration ofiodides in large doses, or with intra-muscular injections of a 10 percent. Solution of cacodylate of soda, have proved of benefit. MYCETOMA, OR MADURA FOOT. --Mycetoma is a chronic disease due toan organism resembling that of actinomycosis, but not identical with it. It is endemic in certain tropical countries, and is most frequently metwith in India. Infection takes place through an abrasion of the skin, and the disease usually occurs on the feet of adult males who workbarefooted in the fields. _Clinical Features. _--The disease begins on the foot as an induratedpatch, which becomes discoloured and permeated by black or yellownodules containing the organism. These nodules break down bysuppuration, and numerous minute abscesses lined by granulation tissuesare thus formed. In the pus are found yellow particles likened tofish-roe, or black pigmented granules like gunpowder. Sinuses form, andthe whole foot becomes greatly swollen and distorted by flattening ofthe sole and dorsiflexion of the toes. Areas of caries or necrosis occurin the bones, and the disease gradually extends up the leg (Fig. 32). There is but little pain, and no glandular involvement or constitutionaldisturbance. The disease runs a prolonged course, sometimes lasting fortwenty or thirty years. Spontaneous cure never takes place, and the riskto life is that of prolonged suppuration. If the disease is localised, it may be removed by the knife or sharpspoon, and the part afterwards cauterised. As a rule, amputation wellabove 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 RoyalCollege of Surgeons, Edinburgh. )] DELHI BOIL. --_Synonyms_--Aleppo boil, Biskra button, Furunculusorientalis, Natal sore. Delhi boil is a chronic inflammatory disease, most commonly met with inIndia, especially towards the end of the wet season. The disease occursoftenest on the face, and is believed to be due to an organism, althoughthis has not been demonstrated. The infection is supposed to be conveyedthrough water used for washing, or by the bites of insects. _Clinical Features. _--A red spot, resembling the mark of a mosquitobite, appears on the affected part, and is attended with itching. Afterbecoming papular and increasing to the size of a pea, desquamation takesplace, leaving a dull-red surface, over which in the course of severalweeks there develops a series of small yellowish-white spots, from whichserum exudes, and, drying, forms a thick scab. Under this scab the skinulcerates, leaving small oval sores with sharply bevelled edges, and anuneven floor covered with yellow or sanious pus. These sores vary innumber from one to forty or fifty. They may last for months and thenheal spontaneously, or may continue to spread until arrested by suitabletreatment. There is no enlargement of adjacent glands, and but littleinflammatory reaction in the surrounding tissues; nor is there anymarked constitutional disturbance. Recovery is often followed bycicatricial contraction leading to deformity of the face. The _treatment_ consists in destroying the original papule by the actualcautery, acid nitrate of mercury, or pure carbolic acid. The ulcersshould be scraped with the sharp spoon, and cauterised. CHIGOE. --Chigoe or jigger results from the introduction of theeggs of the sand-flea (_Pulex penetrans_) into the tissues. It occurs intropical Africa, South America, and the West Indies. The impregnatedfemale flea remains attached to the part till the eggs mature, when bytheir irritation they cause localised inflammation with pustules orvesicles on the surface. Children are most commonly attacked, particularly about the toe-nails and on the scrotum. The treatmentconsists in picking out the insect with a blunt needle, special carebeing taken not to break it up. The puncture is then cauterised. Theapplication of essential oils to the feet acts as a preventive. POISONING BY INSECTS. --The bites of certain insects, such asmosquitoes, midges, different varieties of flies, wasps, and spiders, may be followed by serious complications. The effects are mainly due tothe injection of an irritant acid secretion, the exact nature of whichhas not been ascertained. The local lesion is a puncture, surrounded by a zone of hyperæmia, wheals, or vesicles, and is associated with burning sensations anditching which usually pass off in a few hours, but may recur atintervals, especially when the patient is warm in bed. Scratching alsoreproduces the local signs and symptoms. Where the connective tissue isloose--for example, in the eyelid or scrotum--there is oftenconsiderable swelling; and in the mouth and fauces this may lead toœdema of the glottis, which may prove fatal. The _treatment_ consists in the local application of dilute alkaliessuch as ammonia water, solutions of carbonate or bicarbonate of soda, orsal-volatile. Weak carbolic lotions, or lead and opium lotion, areuseful in allaying the local irritation. One of the best means ofneutralising the poison is to apply to the sting a drop of a mixturecontaining equal parts of pure carbolic acid and liquor ammoniæ. Free stimulation is called for when severe constitutional symptoms arepresent. SNAKE-BITES. --We are here only concerned with the injuriesinflicted by the venomous varieties of snakes, the most important ofwhich are the hooded snakes of India, the rattle-snakes of America, thehorned snakes of Africa, the viper of Europe, and the adder of theUnited Kingdom. While the virulence of these creatures varies widely, they are allcapable of producing in a greater or less degree symptoms of acutepoisoning in man and other animals. By means of two recurved fangsattached to the upper jaw, and connected by a duct with poison-secretingglands, they introduce into their prey a thick, transparent, yellowishfluid, of acid reaction, probably of the nature of an albumose, andknown as the _venom_. The _clinical features_ resulting from the injection of the venom varydirectly in intensity with the amount of the poison introduced, and therapidity with which it reaches the circulating blood, being most markedwhen it immediately enters a large vein. The poison is innocuous whentaken into the stomach. _Locally_ the snake inflicts a double wound, passing vertically into thesubcutaneous tissue; the edges of the punctures are ecchymosed, and theadjacent vessels the seat of thrombosis. Immediately there is intensepain, and considerable swelling with congestion, which tends to spreadtowards the trunk. Extensive gangrene may ensue. There is no specialinvolvement of the lymphatics. The _general symptoms_ may come on at once if the snake is aparticularly venomous one, or not for some hours if less virulent. Inthe majority of viper or adder bites the constitutional disturbance isslight and transient, if it appears at all. Snake-bites in children areparticularly dangerous. The patient's condition is one of profound shock with faintness, giddiness, dimness of sight, and a feeling of great terror. The pupilsdilate, the skin becomes moist with a clammy sweat, and nausea withvomiting, sometimes of blood, ensues. High fever, cramps, loss ofsensation, hæmaturia, and melæna are among the other symptoms that maybe present. The pulse becomes feeble and rapid, the respiratory nervecentres are profoundly depressed, and delirium followed by coma usuallyprecedes the fatal issue, which may take place in from five toforty-eight hours. If the patient survives for two days the prognosis isfavourable. _Treatment. _--A broad ligature should be tied tightly round the limbabove the seat of infection, to prevent the poison passing into thegeneral circulation, and bleeding from the wound should be encouraged. The application of an elastic bandage from above downward to empty theblood out of the infected portion of the limb has been recommended. Thewhole of the bite should at once be excised, and crystals ofpermanganate of potash rubbed into the wound until it is black, orperoxide of hydrogen applied with the object of destroying the poison byoxidation. The general treatment consists in free stimulation with whisky, brandy, ammonia, digitalis, etc. Hypodermic injections of strychnin in dosessufficiently large to produce a slight degree of poisoning by the drugare particularly useful. The most rational treatment, when it isavailable, is the use of the _antivenin_ introduced by Fraser andCalmette. 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 theperitoneum, the intestine, the kidney, prostate and testis, and in theskin and subcutaneous cellular tissue; it is seldom met with in thebreast or in muscles, and it rarely affects the ovary, the pancreas, theparotid, or the thyreoid. _Tubercle bacilli_ vary widely in their virulence, and they are moretenacious of life than the common pyogenic bacteria. In a dry state, forexample, they can retain their vitality for months; and they can alsosurvive immersion in water for prolonged periods. They resist the actionof the products of putrefaction for a considerable time, and are notdestroyed by digestive processes in the stomach and intestine. They maybe killed in a few minutes by boiling, or by exposure to steam underpressure, or by immersion for less than a minute in 1 in 20 carboliclotion. #Methods of Infection. #--In marked contrast to what obtains in theinfective diseases that have already been described, tuberculosis rarelyresults from the _infection of a wound_. In exceptional instances, however, this does occur, and in illustration of the fact may be citedthe case of a servant who cut her finger with a broken spittooncontaining the sputum of her consumptive master; the wound subsequentlyshowed evidence of tuberculous infection, which ultimately spread upalong the lymph vessels of the arm. Pathologists, too, whose hands, before the days of rubber gloves, were frequently exposed to the contactof tuberculous tissues and pus, were liable to suffer from a form oftuberculosis of the skin of the finger, known as _anatomical tubercle_. Slight wounds of the feet in children who go about barefoot in townssometimes become infected with tubercle. Operation wounds made withinstruments contaminated with tuberculous material have also been knownto become infected. It is highly probable that the common form oftuberculosis of the skin known as "lupus" arises by direct infectionfrom without. [Illustration: FIG.  33. --Tubercle Bacilli in caseous material× 1000 diam. Z.  Neilsen stain. ] In the vast majority of cases the tubercle bacillus gains entrance tothe body by way of the mucous surfaces, the organisms being eitherinhaled or swallowed; those inhaled are mostly derived from the humansubject, those swallowed, from cattle. Bacilli, whether inhaled orswallowed, are especially apt to lodge about the pharynx and pass to thepharyngeal lymphoid tissue and tonsils, and by way of the lymph vesselsto the glands. The glands most frequently infected in this way are thecervical glands, and those within the cavity of the chest--particularlythe bronchial glands at the root of the lung. From these, infectionextends at any later period in life to the bones, joints, and internalorgans. There is reason to believe that the organisms may lie in a dormantcondition for an indefinite period in these glands, and only becomeactive long afterwards, when some depression of the patient's healthproduces conditions which favour their growth. When the organisms becomeactive in this way, the tuberculous tissue undergoes softening anddisintegration, and the infective material, by bursting into an adjacentvein, may enter the blood-stream, in which it is carried to distantparts of the body. In this way a _general tuberculosis_ may be set up, or localised foci of tuberculosis may develop in the tissues in whichthe organisms lodge. Many tuberculous patients are to be regarded aspossessing in their bronchial glands, or elsewhere, an internal store ofbacilli, to which the disease for which advice is sought owes itsorigin, and from which similar outbreaks of tuberculosis may originatein the future. _The alimentary mucous membrane_, especially that of the lower ileum andcæcum, is exposed to infection by swallowed sputum and by foodmaterials, such as milk, containing tubercle bacilli. The organisms maylodge in the mucous membrane and cause tuberculous ulceration, or theymay be carried through the wall of the bowel into the lacteals, alongwhich they pass to the mesenteric glands where they become arrested andgive rise to tuberculous disease. #Relationship of Tuberculosis to Trauma. #--Any tissue whose vitality hasbeen lowered by injury or disease furnishes a favourable nidus for thelodgment and growth of tubercle bacilli. The injury or disease, however, is to be looked upon as determining the _localisation_ of thetuberculous lesion rather than as an essential factor in its causation. In a person, for example, in whose blood tubercle bacilli arecirculating and reaching every tissue and organ of the body, theoccurrence of tuberculous disease in a particular part may be determinedby the depression of the tissues resulting from an injury of that part. There can be no doubt that excessive movement and jarring of a limbaggravates tuberculous disease of a joint; also that an injury may lightup a focus that has been long quiescent, but we do not agree withthose--Da Costa, for example--who maintain that injury may be adetermining cause of tuberculosis. The question is not one of mereacademic interest, but one that may raise important issues in the lawcourts. #Human and Bovine Tuberculosis. #--The frequency of the bovine bacillusin the abdominal and in the glandular and osseous tuberculous lesions ofchildren would appear to justify the conclusion that the disease istransmissible from the ox to the human subject, and that the milk oftuberculous cows is probably a common vehicle of transmission. #Changes in the Tissues following upon the successful Lodgment ofTubercle Bacilli. #--The action of the bacilli on the tissues results inthe formation of granulation tissue comprising characteristic tissueelements and with a marked tendency to undergo caseation. The recognition of the characteristic elements, with or withoutcaseation, is usually sufficient evidence of the tuberculous nature ofany portion of tissue examined for diagnostic purposes. The recognitionof the bacillus itself by appropriate methods of staining makes thediagnosis a certainty; but as it is by no means easy to identify theorganism in many forms of surgical tuberculosis, it may be necessary tohave recourse to experimental inoculation of susceptible animals such asguinea-pigs. The changes subsequent to the formation of tuberculous granulationtissue are liable to many variations. It must always be borne in mindthat although the bacilli have effected a lodgment and have inaugurateddisease, the relation between them and the tissues remains one of mutualantagonism; which of them is to gain and keep the upper hand in theconflict depends on their relative powers of resistance. If the tissues prevail, there ensues a process of repair. In theimmediate vicinity of the area of infection young connective tissue, andlater, fibrous tissue, is formed. This may replace the tuberculoustissue and bring about repair--a fibrous cicatrix remaining to mark thescene of the previous contest. Scars of this nature are frequentlydiscovered at the apex of the lung after death in persons who have atone time suffered from pulmonary phthisis. Under other circumstances, the tuberculous tissue that has undergone caseation, or evencalcification, is only encapsulated by the new fibrous tissue, like aforeign body. Although this may be regarded as a victory for thetissues, the cure, if such it may be called, is not necessarily apermanent one, for at any subsequent period, if the part affected isdisturbed by injury or through some other influence, the encapsulatedtubercle 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 oftuberculous disease as it is met with in the spine, or in thehip-joint, and it necessitates a prolonged course of treatment to givethe best chance of a lasting cure. If, however, at the inauguration of the tuberculous disease the bacilliprevail, the infection tends to spread into the tissues surroundingthose originally infected, and more and more tuberculous granulationtissue is formed. Finally the tuberculous tissue breaks down andliquefies, resulting in the formation of a cold abscess. In theirstruggle with the tissues, tubercle bacilli receive considerable supportand assistance from any pyogenic organisms that may be present. Atuberculous infection may exhibit its aggressive qualities in a moreserious manner by sending off detachments of bacilli, which are carriedby the lymphatics to the nearest glands, or by the blood-stream to moredistant, and it may be to all, parts of the body. When the infection isthus generalised, the condition is called _general tuberculosis_. Considering the extraordinary frequency of localised forms of surgicaltuberculosis, general dissemination of the disease is rare. #The clinical features# of surgical tuberculosis will be described withthe individual tissues and organs, as they vary widely according to thesituation of the lesion. #The general treatment# consists in combating the adverse influencesthat have been mentioned as increasing the liability to tuberculousinfection. Within recent years the value of the "open-air" treatment hasbeen widely recognised. An open-air life, even in the centre of a city, may be followed by marked improvement, especially in the hospital classof patient, whose home surroundings tend to favour the progress of thedisease. The purer air of places away from centres of population isstill better; and, according to the idiosyncrasies of the individualpatient, mountain air or that of the sea coast may be preferred. In viewof the possible discomforts and gastric disturbance which may attend asea-voyage, this should be recommended to patients suffering fromtuberculous lesions with more caution than has hitherto been exercised. The diet must be a liberal one, and should include those articles whichare at the same time easily digested and nourishing, especially proteidsand fats; milk obtained from a reliable source and underdonebutcher-meat are among the best. When the ordinary nourishment taken isinsufficient, it may be supplemented by such articles as malt extract, stout, and cod-liver oil. The last is specially beneficial in patientswho do not take enough fat in other forms. It is noteworthy that manytuberculous patients show an aversion to fat. For _the use of tuberculin in diagnosis_ and for _the vaccine treatmentof tuberculosis_ the reader is referred to text-books on medicine. In addition to increasing the resisting power of the patient, it isimportant to enable the fluids of the body, so altered, to come intocontact with the tuberculous focus. One of the obstacles to this is thatthe focus is often surrounded by tissues or fluids which have beenalmost entirely deprived of bactericidal substances. In the case ofcaseated glands in the neck, for example, it is obvious that the removalof this inert material is necessary before the tissues can be irrigatedwith fluids of high bactericidal value. Again, in tuberculous ascitesthe abdominal cavity is filled with a fluid practically devoid ofanti-bacterial substances, so that the bacilli are able to thrive andwork their will on the tissues. When the stagnant fluid is got rid of bylaparotomy, the parts are immediately douched with lymph charged withprotective substances, the bactericidal power of which may be many timesthat 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 tothe infected tissues. _Artificial Hyperæmia. _--As has been explained, the induction ofhyperæmia by the method devised by Bier, constitutes one of our mostefficient means of combating bacterial infection. The treatment oftuberculosis on this plan has been proved by experience to be a valuableaddition to our therapeutic measures, and the simplicity of itsapplication has led to its being widely adopted in practice. It resultsin an increase in the reactive changes around the tuberculous focus, anincrease in the immigration of leucocytes, and infiltration with thelymphocytes. The constricting bandage should be applied at some distance above theseat of infection; for instance, in disease of the wrist, it is put onabove the elbow, and it must not cause pain either where it is appliedor in the diseased part. The bandage is only applied for a few hourseach 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 gauzeover any wound or sinus that may be present. The process of cure takes along time--nine or even twelve months in the case of a severe jointaffection. In cases in which a constricting bandage is inapplicable, for example, in cold abscesses, tuberculous glands or tendon sheaths, Klapp's suctionbell is employed. The cup is applied for five minutes at a time and thentaken off for three minutes, and this is repeated over a period ofabout three-quarters of an hour. The pus is allowed to escape by a smallincision, and no packing or drain should be introduced. It has been found that tuberculous lesions tend to undergo curewhen the infected tissues are exposed to the rays of thesun--_heliotherapy_--therefore whenever practicable this therapeuticmeasure should be had recourse to. Since the introduction of the methods of treatment described above, andespecially by their employment at an early stage in the disease, thenumber of cases of tuberculosis requiring operative interference hasgreatly diminished. There are still circumstances, however, in which anoperation is required; for example, in disease of the lymph glands forthe removal of inert masses of caseous material, in disease of bone forthe removal of sequestra, or in disease of joints to improve thefunction of the limb. It is to be understood, however, that operativetreatment must always be preceded by and combined with other therapeuticmeasures. TUBERCULOUS ABSCESS The caseation of tuberculous granulation tissue and its liquefaction isa slow and insidious process, and is unattended with the classical signsof inflammation--hence the terms "cold" and "chronic" applied to thetuberculous abscess. In a cold abscess, such as that which results from tuberculous diseaseof the vertebræ, the clinical appearances are those of a soft, fluidswelling without heat, redness, pain, or fever. When toxic symptoms arepresent, they are usually due to a mixed infection. A tuberculous abscess results from the disintegration and liquefactionof tuberculous granulation tissue which has undergone caseation. Fluidand cells from the adjacent blood vessels exude into the cavity, andlead to variations in the character of its contents. In some cases thecontents consist of a clear amber-coloured fluid, in which are suspendedfragments of caseated tissue; in others, of a white material likecream-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 oftuberculous tissue which has not yet undergone caseation. The abscesstends to increase in size by progressive liquefaction of the innerlayers, caseation of the outer layers, and the further invasion of thesurrounding tissues by tubercle bacilli. In this way a tuberculousabscess is capable of indefinite extension and increase in size until itreaches a free surface and ruptures externally. The direction in whichit spreads is influenced by the anatomical arrangement of the tissues, and possibly to some extent by gravity, and the abscess may reach thesurface at a considerable distance from its seat of origin. The bestillustration of this is seen in the psoas abscess, which may originatein the dorsal vertebræ, extend downwards within the sheath of the psoasmuscle, and finally appear in the thigh. #Clinical Features. #--The insidious development of the tuberculousabscess is one of its characteristic features. The swelling may attain aconsiderable size without the patient being aware of its existence, and, as a matter of fact, it is often discovered accidentally. The absence oftoxæmia is to be associated with the incapacity of the wall of theabscess to permit of absorption; this is shown also by the fact thatwhen even a large quantity of iodoform is inserted into the cavity ofthe abscess, there are no symptoms of poisoning. The abscess varies insize 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 itmay present pockets or burrows running in various directions. Sometimesit is hour-glass or dumb-bell shaped, as is well illustrated in theregion of the groin in disease of the spine or pelvis, where there maybe a large sac occupying the venter ilii, and a smaller one in thethigh, the two communicating by a narrow channel under Poupart'sligament. By pressing with the fingers the pus may be displaced from onecompartment to the other. The usual course of events is that the abscessprogresses slowly, and finally reaches a free surface--generally theskin. As it does so there may be some pain, redness, and local elevationof temperature. Fluctuation becomes evident and superficial, and theskin becomes livid and finally gives way. If the case is left to nature, the discharge of pus continues, and the track opening on the skinremains as a _sinus_. The persistence of suppuration is due to thepresence in the wall of the abscess and of the sinus, of tuberculousgranulation tissue, which, so long as it remains, continues to furnishdischarge, and so prevents healing. Sooner or later pyogenic organismsgain access to the sinus, and through it to the wall of the abscess. They tend further to depress the resisting power of the tissues, andthereby aggravate and perpetuate the tuberculous disease. Thissuperadded infection with pyogenic organisms exposes the patient to thefurther risks of septic intoxication, especially in the form of hecticfever and septicæmia, and increases the liability to generaltuberculosis, and to waxy degeneration of the internal organs. The mixedinfection is chiefly responsible for the pyrexia, sweating, andemaciation which the laity associate with consumptive disease. Atuberculous abscess may in one or other of these ways be a cause ofdeath. _Residual abscess_ is the name given to an abscess that makes itsappearance months, or even years, after the apparent cure of tuberculousdisease--as, for example, in the hip-joint or spine. It is calledresidual because it has its origin in the remains of the originaldisease. [Illustration: FIG.  34. --Tuberculous Abscess in right lumbar region in awoman aged thirty. ] #Diagnosis. #--A cold abscess is to be diagnosed from a syphilitic gumma, a cyst, and from lipoma and other soft tumours. The differentialdiagnosis of these affections will be considered later; it is often madeeasier by recognising the presence of a lesion that is likely to cause acold abscess, such as tuberculous disease of the spine or of thesacro-iliac joint. When it is about to burst externally, it may bedifficult to distinguish a tuberculous abscess from one due to infectionwith pyogenic organisms. Even when the abscess is opened, theappearances of the pus may not supply the desired information, and itmay be necessary to submit it to bacteriological examination. When thepus is found to be sterile, it is usually safe to assume that thecondition is tuberculous, as in other forms of suppuration the causativeorganisms can usually be recognised. Experimental inoculation willestablish a definite diagnosis, but it implies a delay of two to threeweeks. #Treatment. #--The tuberculous abscess may recede and disappear undergeneral treatment. Many surgeons advise that so long as the abscess isquiescent it should be left alone. All agree, however, that if it showsa tendency to spread, to increase in size, or to approach the skin or amucous membrane, something should be done to avoid the danger of itsbursting and becoming infected with pyogenic organisms. Simpleevacuation of the abscess by a hollow needle may suffice, or bismuth oriodoform may be introduced after withdrawal of the contents. _Evacuation of the Abscess and Injection of Iodoform. _--The iodoform isemployed in the form of a 10 per cent. Solution in ether or the sameproportion suspended in glycerin. Either form becomes sterile soon afterit is prepared. Its curative effects would appear to depend upon theliberation of iodine, which restrains the activity of the bacilli, andupon its capacity for irritating the tissues and so inducing aprotective leucocytosis, and also of stimulating the formation of scartissue. An anæsthetic is rarely called for, except in children. Theabscess is first evacuated by means of a large trocar and cannulaintroduced obliquely through the overlying soft parts, avoiding any partwhere the skin is thin or red. If the cannula becomes blocked withcaseous material, it may be cleared with a probe, or a small quantity ofsaline solution is forced in by the syringe. The iodoform is injected bymeans of a glass-barrelled syringe, which is firmly screwed on to thecannula. The amount injected varies with the size of the abscess and theage of the patient; it may be said to range from two or three drams inthe case of children to several ounces in large abscesses in adults. Thecannula is withdrawn, the puncture is closed by a Michel's clip, and adressing applied so as to exert a certain amount of compression. If theabscess fills up again, the procedure should be repeated; in doing so, the contents show the coloration due to liberated iodine. When thecontents are semi-solid, and cannot be withdrawn even through a largecannula, an incision must be made, and, after the cavity has beenemptied, the iodoform is introduced through a short rubber tube attachedto the syringe. Experience has shown that even large abscesses, such asthose associated with spinal disease, may be cured by iodoforminjection, and this even when rupture of the abscess on the skin surfacehas appeared to be imminent. Another method of treatment which is less popular now than it used tobe, and which is chiefly applicable in abscesses of moderate size, is by_incision of the abscess and removal of the tuberculous tissue in itswall_ with the sharp spoon. An incision is made which will give freeaccess to the interior of the abscess, so that outlying pockets orrecesses may not be overlooked. After removal of the pus, the wall ofthe abscess is scraped with the Volkmann spoon or with Barker's flushingspoon, to get rid of the tuberculous tissue with which it is lined. Inusing the spoon, care must be taken that its sharp edge does notperforate the wall of a vein or other important structure. Any debriswhich may adhere to the walls is removed by rubbing with dry gauze. Theoozing of blood is arrested by packing the cavity for a few minutes withgauze. After the packing is removed, iodoform powder is rubbed into theraw surface. The soft parts divided by the incision are sutured inlayers so as to ensure primary union. If, on the other hand, there isfear of a mixed infection, especially in abscesses near the rectum oranus, it is safer to treat it by the open method, packing the cavitywith iodoform worsted or bismuth gauze, which is renewed at intervals ofa 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 thedilute non-toxic B. I. P. P. (bismuth and iodoform 2 parts, vaseline 12parts, hard paraffin, sufficient to give the consistence of butter). Thewound is closed with "bipped" silk sutures; one of these--the "waitingsuture"--is left loose to permit of withdrawal of the gauze afterforty-eight hours; the waiting suture is then tied, and delayed primaryunion is thus effected. When the skin over the abscess is red, thin, and about to give way, asis frequently the case when the abscess is situated in the subcutaneouscellular tissue, any skin which is undermined and infected with tubercleshould be removed with the scissors at the same time that the abscess isdealt with. In abscesses treated by the open method, when the cavity has becomelined with healthy granulations, it may be closed by secondary suture, or, if the granulating surface is flush with the skin, healing may behastened by skin-grafting. If the tuberculous abscess has burst and left a _sinus_, this is apt topersist because of the presence of tuberculous tissue in its wall, andof superadded pyogenic infection, or because it serves as an avenue forthe escape of discharge from a focus of tubercle in a bone or a lymphgland. [Illustration: FIG.  35. --Tuberculous Sinus injected through its openingin the forearm with bismuth paste. (Mr. Pirie Watson's case--Radiogram by Dr. Hope Fowler. )] The treatment varies with the conditions present, and must includemeasures directed to the lesion from which the sinus has originated. Theextent and direction of any given sinus may be demonstrated by the useof the probe, or, more accurately, by injecting the sinus with a pasteconsisting of white vaseline containing 10 to 30 per cent. Of bismuthsubcarbonate, and following its track with the X-rays (Fig. 35). It was found by Beck of Chicago that the injection of bismuth paste isfrequently followed by healing of the sinus, and that, if one injectionfails to bring about a cure, repeating the injection every second daymay be successful. Some caution must be observed in this treatment, assymptoms of poisoning have been observed to follow its use. If theymanifest themselves, an injection of warm olive oil should be given; theoil, left in for twelve hours or so, forms an emulsion with the bismuth, which can be withdrawn by aspiration. Iodoform suspended in glycerin maybe employed in a similar manner. When these and other non-operativemeasures fail, and the whole track of the sinus is accessible, it shouldbe laid open, scraped, and packed with bismuth or iodoform gauze untilit 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 aspecific virus. It is nearly always communicated from one individual toanother by contact infection, the discharge from a syphilitic lesionbeing the medium through which the virus is transmitted, and the seat ofinoculation is almost invariably a surface covered by squamousepithelium. The disease was unknown in Europe before the year 1493, whenit was introduced into Spain by Columbus' crew, who were infected inHaiti, where the disease had been endemic from time immemorial (Bloch). The granulation tissue which forms as a result of the reaction of thetissues to the presence of the virus is chiefly composed of lymphocytesand plasma cells, along with an abundant new formation of capillaryblood vessels. Giant cells are not uncommon, but the endothelioid cells, which are so marked a feature of tuberculous granulation tissue, arepractically absent. When syphilis is communicated from one individual to another by contactinfection, the condition is spoken of as _acquired syphilis_, and thefirst visible sign of the disease appears at the site of inoculation, and is known as _the primary lesion_. Those who have thus acquired thedisease may transmit it to their offspring, who are then said to sufferfrom _inherited syphilis_. #The Virus of Syphilis. #--The cause of syphilis, whether acquired orinherited, is the organism, described by Schaudinn and Hoffman, in 1905, under the name of _spirochæta pallida_ or _spironema pallidum_. It is adelicate, thread-like spirilla, in length averaging from 8 to 10 µ andin width about 0. 25 µ, and is distinguished from other spirochætes byits delicate shape, its dead-white appearance, together with its closelytwisted spiral form, with numerous undulations (10 to 26), which areperfectly regular, and are characteristic in that they remain the sameduring rest and in active movement (Fig. 36). In a fresh specimen, suchas 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 provedexperimentally that it remains infective only up to six hours after itsremoval from the body. Noguchi has succeeded in obtaining pure culturesfrom the infected tissues of the rabbit. [Illustration: FIG.  36. --Spirochæta pallida from scraping of hardChancre of Prepuce. × 1000 diam. Burri method. ] The spirochæte may be recognised in films made by scraping the deeperparts of the primary lesion, from papules on the skin, or from blistersartificially raised on lesions of the skin or on the immediatelyadjacent portion of healthy skin. It is readily found in the mucouspatches and condylomata of the secondary period. It is best stained byGiemsa's method, and its recognition is greatly aided by the use of theultra-microscope. The spirochæte has been demonstrated in every form of syphilitic lesion, and has been isolated from the blood--with difficulty--and from lymphwithdrawn by a hollow needle from enlarged lymph glands. The saliva ofpersons suffering from syphilitic lesions of the mouth also contains theorganism. [Illustration: FIG.  37. --Spirochæta refrigerans from scraping of Vagina. × 1000 diam. Burri method. ] In tertiary lesions there is greater difficulty in demonstrating thespirochæte, but small numbers have been found in the peripheral parts ofgummata and in the thickened patches in syphilitic disease of the aorta. Noguchi and Moore have discovered the spirochæte in the brain in anumber of cases of general paralysis of the insane. The spirochæte maypersist in the body for a long time after infection; its presence hasbeen demonstrated as long as sixteen years after the originalacquisition of the disease. In inherited syphilis the spirochæte is present in enormous numbersthroughout 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 chimpanzeeand other members of the ape tribe, obtaining primary and secondarylesions similar to those observed in man, and also containing thespirochæte. In animals the disease has been transmitted by material fromall kinds of syphilitic lesions, including even the blood in thesecondary and tertiary stages of the disease. The primary lesion is inthe form of an indurated papule, in every respect resembling thecorresponding lesion in man, and associated with enlargement andinduration of the lymph glands. The primary lesion usually appears aboutthirty days after inoculation, to be followed, in about half the cases, by secondary manifestations, which are usually of a mild character; inno instance has any tertiary lesion been observed. The severity of theaffection amongst apes would appear to be in proportion to the nearnessof the relationship of the animal to the human subject. The eye of therabbit is also susceptible to inoculation from syphilitic lesions; thematerial in a finely divided state is introduced into the anteriorchamber 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 withan ointment containing 33 per cent. Of calomel, within one hour ofinfection, suffices to neutralise the virus in man, and up to eighteenhours in monkeys. He recommends the adoption of this procedure in theprophylaxis of syphilis. Noguchi has made an emulsion of dead spirochætes which he calls_luetin_, and which gives a specific reaction resembling that oftuberculin in tuberculosis, a papule or a pustule forming at the site ofthe intra-dermal injection. It is said to be most efficacious in thetertiary and latent forms of syphilis, which are precisely those formsin which the diagnosis is surrounded with difficulties. ACQUIRED SYPHILIS In the vast majority of cases, infection takes place during the congressof the sexes. Delicate, easily abraded surfaces are then brought intocontact, and the discharge from lesions containing the virus is placedunder favourable conditions for conveying the disease from one person tothe other. In the male the possibility of infection taking place isincreased if the virus is retained under cover of a long and tightprepuce, and if there are abrasions on the surface with which it comesin contact. The frequency with which infection takes place on thegenitals during sexual intercourse warrants syphilis being considered avenereal disease, although there are other ways in which it may becontracted. Some of these imply direct contact--such, for example, as kissing, thedigital examination of syphilitic patients by doctors or nurses, orinfection of the surgeon's fingers while operating upon a syphiliticpatient. In suckling, a syphilitic wet nurse may infect a healthyinfant, or a syphilitic infant may infect a healthy wet nurse. In othercases the infection is by indirect contact, the virus being conveyedthrough the medium of articles contaminated by a syphiliticpatient--such, for example, as surgical instruments, tobacco pipes, windinstruments, table utensils, towels, or underclothing. Physiologicalsecretions, such as saliva, milk, or tears, are not capable ofcommunicating the disease unless contaminated by discharge from asyphilitic sore. While the saliva itself is innocuous, it can be, andoften is, contaminated by the discharge from mucous patches or othersyphilitic lesions in the mouth and throat, and is then a dangerousmedium of infection. Unless these extra-genital sources of infection areborne in mind, there is a danger of failing to recognise the primarylesion of syphilis in unusual positions, such as the lip, finger, ornipple. When the disease is thus acquired by innocent transfer, it isknown as _syphilis insontium_. #Stages or Periods of Syphilis. #--Following the teaching of Ricord, itis customary to divide the life-history of syphilis into three periodsor stages, referred to, for convenience, as primary, secondary, andtertiary. This division is to some extent arbitrary and artificial, asthe different stages overlap one another, and the lesions of one stagemerge insensibly into those of another. Wide variations are met with inthe manifestations of the secondary stage, and histologically there isno valid distinction to be drawn between secondary and tertiary lesions. _The primary period_ embraces the interval that elapses between theinitial infection and the first constitutional manifestations, --roughly, from four to eight weeks, --and includes the period of incubation, thedevelopment of the primary sore, and the enlargement of the nearestlymph glands. _The secondary period_ varies in duration from one to two years, duringwhich time the patient is liable to suffer from manifestations which arefor the most part superficial in character, affecting the skin and itsappendages, the mucous membranes, and the lymph glands. _The tertiary period_ has no time-limit except that it follows upon thesecondary, so that during the remainder of his life the patient isliable to suffer from manifestations which may affect the deeper tissuesand internal organs as well as the skin and mucous membranes. #Primary Syphilis. #--_The period of incubation_ represents the intervalthat elapses between the occurrence of infection and the appearance ofthe primary lesion at the site of inoculation. Its limits may be statedas varying from two to six weeks, with an average of from twenty-one totwenty-eight days. While the disease is incubating, there is nothing toshow that infection has occurred. _The Primary Lesion. _--The incubation period having elapsed, thereappears at the site of inoculation a circumscribed area of infiltrationwhich represents the reaction of the tissues to the entrance of thevirus. The first appearance is that of a sharply defined papule, rarelylarger than a split pea. Its surface is at first smooth and shiny, butas necrosis of the tissue elements takes place in the centre, it becomesconcave, and in many cases the epithelium is shed, and an ulcer isformed. Such an ulcer has an elevated border, sharply cut edges, anindurated base, and exudes a scanty serous discharge; its surface is atfirst occupied by yellow necrosed tissue, but in time this is replacedby smooth, pale-pink granulation tissue; finally, epithelium may spreadover the surface, and the ulcer heals. As a rule, the patient sufferslittle discomfort, and may even be ignorant of the existence of thelesion, unless, as a result of exposure to mechanical or septicirritation, ulceration ensues, and the sore becomes painful and tender, and yields a purulent discharge. The primary lesion may persist untilthe secondary manifestations make their appearance, that is, for severalweeks. It cannot be emphasised too strongly that the induration of the primarylesion, which has obtained for it the name of "hard chancre, " is itsmost important characteristic. It is best appreciated when the sore isgrasped from side to side between the finger and thumb. The sensation ongrasping it has been aptly compared to that imparted by a nodule ofcartilage, or by a button felt through a layer of cloth. The evidenceobtained by touch is more valuable than that obtained by inspection, afact which is made use of in the recognition of _concealedchancres_--that is, those which are hidden by a tight prepuce. Theinduration is due not only to the dense packing of the connective-tissuespaces with lymphocytes and plasma cells, but also to the formation ofnew connective-tissue elements. It is most marked in chancres situatedin 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 inneraspect of the prepuce, and in the fold between the prepuce and theglans; in the latter situation the induration imparts a "collar-like"rigidity to the prepuce, which is most apparent when it is rolled backover the corona. (2) At the orifice of the prepuce the primary lesionassumes the form of multiple linear ulcers or fissures, and as each ofthese is attended with infiltration, the prepuce cannot be pulledback--a condition known as _syphilitic phimosis_. (3) On the glans penisthe infiltration may be so superficial that it resembles a layer ofparchment, but if it invades the cavernous tissue there is a dense massof induration. (4) On the external aspect of the prepuce or on the skinof the penis itself. (5) At either end of the torn frænum, in the formof a diamond-shaped ulcer raised above the surroundings. (6) In relationto the meatus and canal of the urethra, in either of which situationsthe swelling and induration may lead to narrowing of the urethra, sothat the urine is passed with pain and difficulty and in a minutestream; stricture results only in the exceptional cases in which thechancre has ulcerated and caused destruction of tissue. A chancre withinthe orifice of the urethra is rare, and, being concealed from view, itcan only be recognised by the discharge from the meatus and by theinduration felt between the finger and thumb on palpating the urethra. _In the female_, the primary lesion is not so typical or so easilyrecognised as in men; it is usually met with on the labia; theinduration is rarely characteristic and does not last so long. Theprimary lesion may take the form of condylomata. Indurated œdema, withbrownish-red or livid discoloration of one or both labia, is diagnosticof syphilis. The hard chancre is usually solitary, but sometimes there are two ormore; when there are several, they are individually smaller than thesolitary chancre. It is the exception for a hard chancre to leave a visible scar, hence, in examining patients with a doubtful history of syphilis, littlereliance can be placed on the presence or absence of a scar on thegenitals. When the primary lesion has taken the form of an open ulcerwith purulent discharge, or has sloughed, there is a permanent scar. _Infection of the adjacent lymph glands_ is usually found to have takenplace by the time the primary lesion has acquired its characteristicinduration. Several of the glands along Poupart's ligament, on one or onboth sides, become enlarged, rounded, and indurated; they are usuallyfreely movable, and are rarely sensitive unless there is superaddedseptic infection. The term _bullet-bubo_ has been applied to them, andtheir presence is of great value in diagnosis. In a certain number ofcases, one of the main _lymph vessels_ on the dorsum of the penis istransformed into a fibrous cord easily recognisable on palpation, andwhen grasped between the fingers appears to be in size and consistencenot unlike the vas deferens. _Concealed chancre_ is the term applied when one or more chancres aresituated within the sac of a prepuce which cannot be retracted. If theinduration is well marked, the chancre can be palpated through theprepuce, and is tender on pressure. As under these conditions it isimpossible for the patient to keep the parts clean, septic infectionbecomes a prominent feature, the prepuce is œdematous and inflamed, andthere is an abundant discharge of pus from its orifice. It occasionallyhappens that the infection assumes a virulent character and causessloughing of the prepuce--a condition known as _phagedæna_. Thedischarge is then foul and blood-stained, and the prepuce becomes of adusky red or purple colour, and may finally slough, exposing the glans. _Extra-genital or Erratic Chancres_ (Fig. 38). --Erratic chancre is theterm applied by Jonathan Hutchinson to the primary lesion of syphiliswhen it appears on parts of the body other than the genitals. It differsin some respects from the hard chancre as met with on the penis; it isusually larger, the induration is more diffused, and the enlarged glandsare softer and more sensitive. The glands in nearest relation to thesore are those first affected, for example, the epitrochlear or axillaryglands in chancre of the finger; the submaxillary glands in chancre ofthe lip or mouth; or the pre-auricular gland in chancre of the eyelid orforehead. 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 venerealdisease, the true nature of erratic chancres is often overlooked untilthe persistence of the lesion, its want of resemblance to anything else, or the onset of constitutional symptoms, determines the diagnosis ofsyphilis. 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 adjacentglands, is most likely to be the primary lesion of syphilis. [Illustration: FIG.  38. --Primary Lesion on Thumb, with SecondaryEruption on Forearm. [1]] [1] From _A System of Syphilis_, vol. Ii. , edited by D'Arcy Power andJ.  Keogh Murphy, Oxford Medical Publications. #The Soft Sore, Soft Chancre, or Chancroid. #--The differential diagnosisof syphilis necessitates the consideration of the _soft sore_, _softchancre_, or _chancroid_, which is also a common form of venerealdisease, and is due to infection with a virulent pus-forming bacillus, first described by Ducrey in 1889. Ducrey's bacillus occurs in the formof minute oval rods measuring about 1. 5 µ in length, which stain readilywith any basic aniline dye, but are quickly decolorised by Gram'smethod. They are found mixed with other organisms in the purulentdischarge from the sore, and are chiefly arranged in small groups or inshort chains. Soft sores are always contracted by direct contact fromanother individual, and the incubation period is a short one of from twoto five days. They are usually situated in the vicinity of the frænum, and, in women, about the labia minora or fourchette; they probablyoriginate in abrasions in these situations. They appear as pustules, which are rapidly converted into small, acutely inflamed ulcers withsharply cut, irregular margins, which bleed easily and yield an abundantyellow purulent discharge. They are devoid of the induration ofsyphilis, are painful, and nearly always multiple, reproducingthemselves in successive crops by auto-inoculation. Soft sores are oftencomplicated by phimosis and balanitis, and they frequently lead toinfection of the glands in the groin. The resulting bubo is ill-defined, painful, and tender, and suppuration occurs in about one-fourth of thecases. The overlying skin becomes adherent and red, and suppurationtakes place either in the form of separate foci in the interior of theindividual glands, or around them; in the latter case, on incision, theglands are found lying bathed in pus. Ducrey's bacillus is found in pureculture in the pus. Sometimes other pyogenic organisms are superadded. After the bubo has been opened the wound may take on the characters of asoft sore. _Treatment. _--Soft sores heal rapidly when kept clean. If concealedunder a tight prepuce, an incision should be made along the dorsum togive access to the sores. They should be washed with eusol, and dustedwith a mixture of one part iodoform and two parts boracic or salicylicacid, or, when the odour of iodoform is objected to, of equal parts ofboracic acid and carbonate of zinc. Immersion of the penis in a bath ofeusol for some hours daily is useful. The sore is then covered with apiece of gauze kept in position by drawing the prepuce over it, or by afew turns of a narrow bandage. Sublimed sulphur frequently rubbed intothe sore is recommended by C.  H.  Mills. If the sores spread in spite ofthis, they should be painted with cocaine and then cauterised. When theglands 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 byinjection 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 injectedand left in. This is repeated as often as the cavity refills. It issometimes necessary to let the pus out by one or more small incisionsand continue the use of the suction bell. _Diagnosis of Primary Syphilis. _--In cases in which there is a historyof an incubation period of from three to five weeks, when the sore isindurated, persistent, and indolent, and attended with bullet-buboes inthe groin, the diagnosis of primary syphilis is not difficult. Owing, however, to the great importance of instituting treatment at theearliest possible stage of the infection, an effort should be made toestablish the diagnosis without delay by demonstrating the spirochæte. Before any antiseptic is applied, the margin of the suspected sore isrubbed with gauze, and the serum that exudes on pressure is collectedin a capillary tube and sent to a pathologist for microscopicalexamination. A better specimen can sometimes be obtained by puncturingan enlarged lymph gland with a hypodermic needle, injecting a few minimsof sterile saline solution and then aspirating the blood-stained fluid. The Wassermann test must not be relied upon for diagnosis in the earlystage, as it does not appear until the disease has become generalisedand the secondary manifestations are about to begin. The practice ofwaiting in doubtful cases before making a diagnosis until secondarymanifestations appear is to be condemned. Extra-genital chancres, _e. G. _ sores on the fingers of doctors ornurses, are specially liable to be overlooked, if the possibility ofsyphilis is not kept in mind. It is important to bear in mind _the possibility of a patient havingacquired a mixed infection_ with the virus of soft chancre, which willmanifest itself a few days after infection, and the virus of syphilis, which shows itself after an interval of several weeks. This occurrencewas formerly the source of much confusion in diagnosis, and it wasbelieved at one time that syphilis might result from soft sores, but itis now established that syphilis does not follow upon soft sores unlessthe virus of syphilis has been introduced at the same time. Thepractitioner must be on his guard, therefore, when a patient asks hisadvice concerning a venereal sore which has appeared within a few daysof exposure to infection. Such a patient is naturally anxious to knowwhether he has contracted syphilis or not, but neither a positive nor anegative answer can be given--unless the spirochæte can be identified. Syphilis is also to be diagnosed from _epithelioma_, the common form ofcancer of the penis. It is especially in elderly patients with a tightprepuce that the induration of syphilis is liable to be mistaken forthat associated with epithelioma. In difficult cases the prepuce must beslit 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 asa group of vesicles which soon burst and leave shallow ulcers with ayellow floor; these disappear quickly on the use of an antisepticdusting powder. Apprehensive patients who have committed sexual indiscretions are apt toregard as syphilitic any lesion which happens to be located on thepenis--for example, acne pustules, eczema, psoriasis papules, boils, balanitis, or venereal warts. _The local treatment_ of the primary sore consists in attempting todestroy the organisms _in situ_. An ointment made up of calomel 33parts, lanoline 67 parts, and vaseline 10 parts (Metchnikoff's cream) isrubbed into the sore several times a day. If the surface is unbroken, itmay be dusted lightly with a powder composed of equal parts of calomeland carbonate of zinc. A gauze dressing is applied, and the penis andscrotum should be supported against the abdominal wall by a triangularhandkerchief or bathing-drawers; if there is inflammatory œdema thepatient should be confined to bed. In _concealed chancres_ with phimosis, the sac of the prepuce should beslit up along the dorsum to admit of the ointment being applied. Ifphagedæna occurs, the prepuce must be slit open along the dorsum, or ifsloughing, cut away, and the patient should have frequent sitz baths ofweak sublimate lotion. When the chancre is within the meatus, iodoformbougies are inserted into the urethra, and the urine should be renderedbland by drinking large quantities of fluid. General treatment is considered on p. 149. #Secondary Syphilis. #--The following description of secondary syphilisis based on the average course of the disease in untreated cases. Theonset of constitutional symptoms occurs from six to twelve weeks afterinfection, and the manifestations are the result of the entrance of thevirus into the general circulation, and its being carried to all partsof the body. The period during which the patient is liable to sufferfrom secondary symptoms ranges from six months to two years. In some cases the general health is not disturbed; in others the patientis feverish and out of sorts, losing appetite, becoming pale and anæmic, complaining of lassitude, incapacity for exertion, headache, and painsof a rheumatic type referred to the bones. There is a moderate degree ofleucocytosis, but the increase is due not to the polymorpho-nuclearleucocytes but to lymphocytes. In isolated cases the temperature risesto 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, eruptionsappear on the skin and mucous membranes, and the patient may suffer fromsore throat and affections of the eyes. The local lesions are to beregarded as being of the nature of reactions against accumulations ofthe parasite, lymphocytes and plasma cells being the elements chieflyconcerned in the reactive process. _Affections of the Skin_ are among the most constant manifestations. Anevanescent macular rash, not unlike that of measles--_roseola_--is thefirst to appear, usually in from six to eight weeks from the date ofinfection; it is widely diffused over the trunk, and the original dullrose-colour soon fades, leaving brownish stains, which in timedisappear. It is usually followed by a _papular eruption_, theindividual papules being raised above the surface of the skin, smooth orscaly, and as they are due to infiltration of the skin they are morepersistent than the roseoles. They vary in size and distribution, beingsometimes small, hard, polished, and closely aggregated like lichen, sometimes as large as a shilling-piece, with an accumulation of scaleson the surface like that seen in psoriasis. The co-existence of scalypapules and faded roseoles is very suggestive of syphilis. Other types of eruption are less common, and are met with from the thirdmonth onwards. A _pustular_ eruption, not unlike that of acne, issometimes a prominent feature, but is not characteristic of syphilisunless it affects the scalp and forehead and is associated with theremains of the papular eruption. The term _ecthyma_ is applied when thepustules are of large size, and, after breaking on the surface, giverise to superficial ulcers; the discharge from the ulcer often dries upand forms a scab or crust which is continually added to from below asthe ulcer extends in area and depth. The term _rupia_ is applied whenthe crusts are prominent, dark in colour, and conical in shape, roughlyresembling the shell of a limpet. If the crust is detached, a sharplydefined ulcer is exposed, and when this heals it leaves a scar which isusually circular, thin, white, shining like satin, and the surroundingskin is darkly pigmented; in the case of deep ulcers, the scar isdepressed and adherent (Fig. 39). [Illustration: FIG.  39. --Syphilitic Rupia, showing the limpet-shapedcrusts or scabs. ] In the later stages there may occur a form of creeping or _spreadingulceration of the skin_ of the face, groin, or scrotum, healing at oneedge and spreading at another like tuberculous lupus, but distinguishedfrom this by its more rapid progress and by the pigmentation of thescar. _Condylomata_ are more characteristic of syphilis than any other type ofskin lesion. They are papules occurring on those parts of the body wherethe skin is habitually moist, and especially where two skin surfaces arein contact. They are chiefly met with on the external genitals, especially in women, around the anus, beneath large pendulous mammæ, between the toes, and at the angles of the mouth, and in thesesituations their development is greatly favoured by neglect ofcleanliness. They present the appearance of well-defined circular orovoid areas in which the skin is thickened and raised above the surface;they are covered with a white sodden epidermis, and furnish a scanty butvery infective discharge. Under the influence of irritation and want ofrest, as at the anus or at the angle of the mouth, they are apt tobecome fissured and superficially ulcerated, and the discharge thenbecomes abundant and may crust on the surface, forming yellow scabs. Atthe angle of the mouth the condylomatous patches may spread to thecheek, and when they ulcerate may leave fissure-like scars radiatingfrom the mouth--an appearance best seen in inherited syphilis (Fig. 44). _The Appendages of the Skin. _--The _hair_ loses its gloss, becomes dryand brittle, and readily falls out, either as an exaggeration of thenormal shedding of the hair, or in scattered areas over the scalp(_syphilitic alopœcia_). The hair is not re-formed in the scars whichresult from ulcerated lesions of the scalp. The _nail-folds_occasionally present a pustular eruption and superficial ulceration, towhich the name _syphilitic onychia_ has been applied; more commonly thenails 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. Ona mucous surface the papular eruption assumes the form of _mucouspatches_, which are areas with a congested base covered with a thinwhite film of sodden epithelium like wet tissue-paper. They are bestseen on the inner aspect of the cheeks, the soft palate, uvula, pillarsof the fauces, and tonsils. In addition to mucous patches, there may bea number of small, _superficial, kidney-shaped ulcers_, especially alongthe margins of the tongue and on the tonsils. In the absence of mucouspatches and ulcers, the sore throat may be characterised by a bluishtinge of the inflamed mucous membrane and a thin film of shed epitheliumon the surface. Sometimes there is an elongated sinuous film which hasbeen likened to the track of a snail. In the _larynx_ the presence ofcongestion, œdema, and mucous patches may be the cause of persistenthoarseness. The _tongue_ often presents a combination of lesions, including ulcers, patches where the papillæ are absent, fissures, andraised white papules resembling warts, especially towards the centre ofthe dorsum. These lesions are specially apt to occur in those who smoke, drink undiluted alcohol or spirits, or eat hot condiments to excess, orwho have irregular, sharp-cornered teeth. At a later period, and inthose who are broken down in health from intemperance or other cause, the sore throat may take the form of rapidly spreading, penetratingulcers in the soft palate and pillars of the fauces, which may lead toextensive destruction of tissue, with subsequent scars and deformityhighly characteristic of previous syphilis. In the _Bones_, lesions occur which assume the clinical features of anevanescent periostitis, the patient complaining of nocturnal pains overthe frontal bone, sternum, tibiæ, and ulnæ, and localised tenderness ontapping over these bones. In the _Joints_, a serous synovitis or hydrops may occur, chiefly in theknee, on one or on both sides. _The Affections of the Eyes_, although fortunately rare, are of greatimportance because of the serious results which may follow if they arenot recognised and treated. _Iritis_ is the commonest of these, and mayoccur in one or in both eyes, one after the other, from three to eightmonths after infection. The patient complains of impairment of sight andof frontal or supraorbital pain. The eye waters and is hypersensitive, the iris is discoloured and reacts sluggishly to light, and there is azone of ciliary congestion around the cornea. The appearance of minutewhite nodules or flakes of lymph at the margin of the pupil isespecially characteristic of syphilitic iritis. When adhesions haveformed between the iris and the structures in relation to it, the pupildilates irregularly under atropin. Although complete recovery is to beexpected under early and energetic treatment, if neglected, _iritis_ mayresult in occlusion of the pupil and permanent impairment or loss ofsight. The other lesions of the eye are much rarer, and can only be discoveredon ophthalmoscopic examination. The virus of syphilis exerts a special influence upon the _BloodVessels_, exciting a proliferation of the endothelial lining whichresults in narrowing of their lumen, _endarteritis_, and a perivascularinfiltration in the form of accumulations of plasma cells around thevessels and in the lymphatics that accompany them. In the _Brain_, in the later periods of secondary and in tertiarysyphilis, changes occur as a result of the narrowing of the lumen of thearteries, or of their complete obliteration by thrombosis. Byinterfering with the nutrition of those parts of the brain supplied bythe affected arteries, these lesions give rise to clinical features ofwhich severe headache and paralysis are the most prominent. Affections of the _Spinal Cord_ are extremely rare, but paraplegia frommyelitis has been observed. Lastly, attention must be directed to the remarkable variations observedin different patients. Sometimes the virulent character of the diseasecan only be accounted for by an idiosyncrasy of the patient. Constitutional symptoms, particularly pyrexia and anæmia, are most oftenmet with in young women. Patients over forty years of age have greaterdifficulty in overcoming the infection than younger adults. Malarial andother infections, and the conditions attending life in tropicalcountries, from the debility which they cause, tend to aggravate andprolong the disease, which then assumes the characters of what has beencalled _malignant syphilis_. All chronic ailments have a similarinfluence, and alcoholic intemperance is universally regarded as aserious aggravating factor. _Diagnosis of Secondary Syphilis. _--A routine examination should be madeof the parts of the body which are most often affected in thisdisease--the scalp, mouth, throat, posterior cervical glands, and thetrunk, the patient being stripped and examined by daylight. Among the_diagnostic features of the skin affections_ the following may bementioned: They are frequently, and sometimes to a marked degree, symmetrical; more than one type of eruption--papules and pustules, forexample--are present at the same time; there is little itching; they areat first a dull-red colour, but later present a brown pigmentation whichhas been likened to the colour of raw ham; they exhibit a predilectionfor those parts of the forehead and neck which are close to the roots ofthe hair; they tend to pass off spontaneously; and they disappearrapidly under treatment. #Serum Diagnosis--Wassermann Reaction. #--Wassermann found that if anextract of syphilitic liver rich in spirochætes is mixed with the serumfrom a syphilitic patient, a large amount of complement is fixed. Theapplication of the test is highly complicated and can only be carriedout by an expert pathologist. For the purpose he is supplied with from 5c. C. To 10 c. C. Of the patient's blood, withdrawn under asepticconditions from the median basilic vein by means of a serum syringe, andtransferred to a clean and dry glass tube. There is abundant evidencethat the Wassermann test is a reliable means of establishing a diagnosisof syphilis. A definitely positive reaction can usually be obtained between thefifteenth and thirtieth day after the appearance of the primary lesion, and as time goes on it becomes more marked. During the secondary periodthe reaction is practically always positive. In the tertiary stage alsoit is positive except in so far as it is modified by the results oftreatment. In para-syphilitic lesions such as general paralysis andtabes a positive reaction is almost always present. In inheritedsyphilis the reaction is positive in every case. A positive reaction maybe present in other diseases, for example, frambesia, trypanosomiasis, and leprosy. As the presence of the reaction is an evidence of the activity of thespirochætes, repeated applications of the test furnish a valuable meansof estimating the efficacy of treatment. The object aimed at is tochange a persistently positive reaction to a permanently negative one. #Treatment of Syphilis. #--In the treatment of syphilis the two mainobjects are to maintain the general health at the highest possiblestandard, and to introduce into the system therapeutic agents which willinhibit or destroy the invading parasite. The second of these objects has been achieved by the researches ofEhrlich, who, in conjunction with his pupil, Hata, has built up acompound, the dihydrochloride of dioxydiamido-arseno-benzol, popularlyknown 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 equallyefficient. The full dose is 0. 6 grm. All these members of the "606"group form an acid solution when dissolved in water, and must berendered alkaline before being injected. As subcutaneous andintra-muscular injections cause considerable pain, and may causesloughing of the tissues, "606" preparations must be injectedintravenously. Ehrlich has devised a preparation--neo-salvarsan, or"914, " which is more easily prepared and forms a neutral solution. Itcontains from 18 to 20 per cent. Of arsenic. Neo-kharsivan, novo-arseno-billon, and neo-diarsenol belong to the "914" group, thefull dosage of which is 0. 9 grm. As subcutaneous and intra-muscularinjections of the "914" group are not painful, and even more efficientthan 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 orby means of an apparatus which allows the solution to flow in bygravity. The left median basilic vein is selected, and a platino-iridiumneedle with a short point and a bore larger than that of the ordinaryhypodermic syringe is used. The needle is passed for a few millimetresalong the vein, and the solution is then slowly introduced; beforewithdrawing the needle some saline is run in to diminish the risk ofthrombosis. The "914" preparations may be injected either into the subcutaneoustissue of the buttock or into the substance of the gluteus muscle. Thepart is then massaged for a few minutes, and the massage is repeateddaily for a few days. No hard-and-fast rules can be laid down as to what constitutes acomplete course of treatment. Harrison recommends as a _minimum_ courseof one of the "914" preparations in _early primary cases_ an initialdose of 0. 45 grm. Given intra-muscularly or into the deep subcutaneoustissue; the same dose a week later; 0. 6 grm. The following week; thenmiss a week and give 9. 6 grms. On two successive weeks; then miss twoweeks and give 0. 6 grm. On two more successive weeks. When a _positive Wassermann reaction_ is present before treatment iscommenced, the above course is prolonged as follows: for three weeks isgiven a course of potassium iodide, after which four more weeklyinjections of 0. 6 grm. Of "914" are given. With each injection of "914" after the first, throughout the wholecourse 1 grain of mercury is injected intra-muscularly. In the course of a few hours, there is usually some indisposition, witha feeling of chilliness and slight rise of temperature; these symptomspass off within twenty-four hours, and in a few days there is a decidedimprovement of health. Three or four days after an intra-muscularinjection there may be pain and stiffness in the gluteal region. These preparations are the most efficient therapeutic agents that haveyet been employed in the treatment of syphilis. The manifestations of the disease disappear with remarkable rapidity. Observations show that the spirochætes lose their capacity for movementwithin an hour or two of the administration, and usually disappearaltogether in from twenty-four to thirty-six hours. Wassermann'sreaction usually yields a negative result in from three weeks to twomonths, but later may again become positive. Subsequent doses of thearsenical preparation are therefore usually indicated, and should begiven in from 7 to 21 days according to the dose. When syphilis occurs in a _pregnant woman_, she should be given in theearly months an ordinary course of "914, " followed by 10-grain doses ofpotassium iodide twice daily. The injections may be repeated two monthslater, and during the remainder of the pregnancy 2-grain mercury pillsare given twice daily (A.  Campbell). The presence of albumen in theurine 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 eachdose contains nearly three grains of arsenic. Before the administrationthe patient must be overhauled; its administration is contra-indicatedin the presence of disease of the heart and blood vessels, especially acombination of syphilitic aortitis and sclerosis of the coronaryarteries, with degeneration of the heart muscle; in affections of thecentral nervous system, especially advanced paralysis, and in suchdisturbances of metabolism as are associated with diabetes and Bright'sdisease. Its use is not contra-indicated in any lesion of activesyphilis. The administration is controlled by the systematic examination of theurine for arsenic. _The Administration of Mercury. _--The success of the arsenicalpreparations has diminished the importance of mercury in the treatmentof syphilis, but it is still used to supplement the effect of theinjections. The amount of mercury to be given in any case must beproportioned to the idiosyncrasies of the patient, and it is advisable, before commencing the treatment, to test his urine and record hisbody-weight. The small amount of mercury given at the outset isgradually increased. If the body-weight falls, or if the gums becomesore and the breath foul, the mercury should be stopped for a time. Ifsalivation occurs, the drinking of hot water and the taking of hot bathsshould be insisted upon, and half-dram doses of the alkaline sulphatesprescribed. _Methods of Administering Mercury. _--(1) _By the Mouth. _--This was forlong the most popular method in this country, the preparation usuallyemployed being grey powder, in pills or tablets, each of which containsone grain of the powder. Three of these are given daily in the firstinstance, and the daily dose is increased to five or even seven grainstill the standard for the individual patient is arrived at. As the greypowder alone sometimes causes irritation of the bowels, it should becombined 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 theskin an ointment composed of equal parts of 20 per cent. Oleate ofmercury and lanolin. Every night after a hot bath, a dram of theointment (made up by the chemist in paper packets) is rubbed for fifteenminutes into the skin where it is soft and comparatively free fromhairs. When the patient has been brought under the influence of themercury, inunction may be replaced by one of the other methods, ofadministering the drug. (3) _By Intra-muscular Injection. _--This consists in introducing thedrug by means of a hypodermic syringe into the substance of the glutealmuscles. The syringe is made of glass, and has a solid glass piston; theneedle of platino-iridium should be 5 cm. Long and of a larger calibrethan the ordinary hypodermic needle. The preparation usually employedconsists of: metallic mercury or calomel 1 dram, lanolin and olive oileach 2 drams; it must be warmed to allow of its passage through theneedle. Five minims--containing one grain of metallic mercury--representa dose, and this is injected into the muscles above and behind the greattrochanter once a week. The contents of the syringe are slowlyexpressed, and, after withdrawing the needle, gentle massage of thebuttock should be employed. Four courses each of ten injections aregiven the first year, three courses of the same number during the secondand third years, and two courses during the fourth year (Lambkin). _The General Health. _--The patient must lead a regular life andcultivate the fresh-air habit, which is as beneficial in syphilis as intuberculosis. Anæmia, malaria, and other sources of debility mustreceive appropriate treatment. The diet should be simple and easilydigested, and should include a full supply of milk. Alcohol isprohibited. The excretory organs are encouraged to act by the liberaldrinking of hot water between meals, say five or six tumblerfuls in thetwenty-four hours. The functions of the skin are further aided byfrequent hot baths, and by the wearing of warm underclothing. While thepatient should avoid exposure to cold, and taxing his energies by undueexertion, he should be advised to take exercise in the open air. Onaccount of the liability to lesions of the mouth and throat, he shoulduse tobacco in moderation, his teeth should be thoroughly overhauled bythe dentist, and he should brush them after every meal, using anantiseptic tooth powder or wash. The mouth and throat should be rinsedout night and morning with a solution of chlorate of potash and alum, orwith peroxide of hydrogen. _Treatment of the Local Manifestations. _--_The skin lesions_ are treatedon the same lines as similar eruptions of other origin. As localapplications, preparations of mercury are usually selected, notably theointments of the red oxide of mercury, ammoniated mercury, or oleate ofmercury (5 per cent. ), or the mercurial plaster introduced by Unna. Inthe treatment of condylomata the greatest attention must be paid tocleanliness and dryness. After washing and drying the affected patches, they are dusted with a powder consisting of equal parts of calomel andcarbonate of zinc; and apposed skin surfaces, such as the nates orlabia, are separated by sublimate wool. In the ulcers of later secondarysyphilis, crusts are got rid of in the first instance by means of aboracic poultice, after which a piece of lint or gauze cut to the sizeof the ulcer and soaked in black wash is applied and covered withoil-silk. If the ulcer tends to spread in area or in depth, it should bescraped with a sharp spoon, and painted over with acid nitrate ofmercury, or a local hyperæmia may be induced by Klapp's suctionapparatus. _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 tothe ounce--painted on with a brush once daily. If this fails, thelesions may be dusted with calomel the last thing at night. For deepulcers of the throat the patient should gargle frequently with chlorinewater or with perchloride of mercury (1 in 2000); if the ulcer continuesto spread it should be painted with acid nitrate of mercury. In the treatment of _iritis_ the eyes are shaded from the light andcompletely rested, and the pupil is well dilated by atropin to preventadhesions. If there is much pain, a blister may be applied to thetemple. _The Relations of Syphilis to Marriage. _--Before the introduction of theEhrlich-Hata treatment no patient was allowed to marry until three yearshad elapsed after the disappearance of the last manifestation. Whilemarriage might be entered upon under these conditions without risk ofthe husband infecting the wife, the possibility of his conveying thedisease to the offspring cannot be absolutely excluded. It isrecommended, as a precautionary measure, to give a further mercurialcourse of two or three months' duration before marriage, and anintravenous injection of an arsenical preparation. #Intermediate Stage. #--After the dying away of the secondarymanifestations and before the appearance of tertiary lesions, thepatient may present certain symptoms which Hutchinson called_reminders_. These usually consist of relapses of certain of theaffections of the skin, mouth, or throat, already described. In theskin, they may assume the form of peeling patches in the palms, or mayappear as spreading and confluent circles of a scaly papular eruption, which if neglected may lead to the formation of fissures and superficialulcers. Less frequently there is a relapse of the eye affections, or ofparalytic symptoms from disease of the cerebral arteries. #Tertiary Syphilis. #--While the manifestations of primary and secondarysyphilis are common, those of the tertiary period are by comparisonrare, and are observed chiefly in those who have either neglectedtreatment or who have had their powers of resistance lowered byprivation, by alcoholic indulgence, or by tropical disease. It is to be borne in mind that in a certain proportion of men and in alarger proportion of women, the patient has no knowledge of havingsuffered from syphilis. Certain slight but important signs may give theclue in a number of cases, such as irregularity of the pupils or failureto react to light, abnormality of the reflexes, and the discovery ofpatches of leucoplakia on the tongue, cheek, or palate. The _general character of tertiary manifestations_ may be stated asfollows: They attack by preference the tissues derived from themesoblastic 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, orthe liver, and they are rarely symmetrical. They are usually aggressiveand persistent, with little tendency to natural cure, and they may bedangerous to life, because of the destructive changes produced in suchorgans as the brain or the larynx. They are remarkably amenable totreatment if instituted before the stage which is attended withdestruction of tissue is reached. Early tertiary lesions may beinfective, and the disease may be transmitted by the discharges fromthem; but the later the lesions the less is the risk of their containingan infective virus. The most prominent feature of tertiary syphilis consists in theformation of granulation tissue, and this takes place on a scaleconsiderably larger than that observed in lesions of the secondaryperiod. The granulation tissue frequently forms a definite swelling ortumour-like mass (syphiloma), which, from its peculiar elasticconsistence, is known as a _gumma_. In its early stages a gumma is afirm, semi-translucent greyish or greyish-red mass of tissue; later itbecomes opaque, yellow, and caseous, with a tendency to soften andliquefy. The gumma does harm by displacing and replacing the normaltissue elements of the part affected, and by involving these in thedegenerative changes, of the nature of caseation and necrosis, whichproduce the destructive lesions of the skin, mucous membranes, andinternal organs. This is true not only of the circumscribed gumma, butof the condition known as _gummatous infiltration_ or _syphiliticcirrhosis_, in which the granulation tissue is diffused throughout theconnective-tissue framework of such organs as the tongue or liver. Boththe gummatous lesions and the fibrosis of tertiary syphilis are directlyexcited by the spirochætes. The life-history of an untreated gumma varies with its environment. Whenprotected from injury and irritation in the substance of an internalorgan such as the liver, it may become encapsulated by fibrous tissue, and persist in this condition for an indefinite period, or it may beabsorbed and leave in its place a fibrous cicatrix. In the interior of along bone it may replace the rigid framework of the shaft to such anextent as to lead to pathological fracture. If it is near the surface ofthe body--as, for example, in the subcutaneous or submucous cellulartissue, 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 toundergo necrosis, in which the overlying skin or mucous membranefrequently participates, the result being an ulcer--the tertiarysyphilitic ulcer (Figs. 40 and 41). _Tertiary Lesions of the Skin and Subcutaneous Cellular Tissue. _--Theclinical features of a _subcutaneous gumma_ are those of an indolent, painless, elastic swelling, varying in size from a pea to an almond orwalnut. After a variable period it usually softens in the centre, theskin 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, caseatedtissue resembling wash-leather. The caseated tissue of a gumma differsfrom that of a tuberculous lesion in being tough and firm, of a buffcolour like wash-leather, or whitish, like boiled fish. The degeneratedtissue separates slowly and gradually, and in untreated cases may bevisible 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 frequentlymet with on the leg, especially in the region of the knee (Fig. 42) andover the calf. There may be one or more ulcers, and also scars ofantecedent ulcers. The edges are sharply cut, as if punched out; themargins are rounded in outline, firm, and congested; the base isoccupied by gummatous tissue, or, if this has already separated andsloughed out, by unhealthy granulations and a thick purulent discharge. When the ulcer has healed it leaves a scar which is depressed, and ifover a bone, is adherent to it. The features of the tertiary ulcer, however, are not always so characteristic as the above description wouldimply. It is to be diagnosed from the "leg ulcer, " which occurs almostexclusively 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 alesion, met with chiefly on the face and in the region of the externalgenitals, in which the skin becomes infiltrated with granulation tissueso that it is thickened, raised above the surface, and of a brownish-redcolour. It appears as isolated nodules, which may fuse together; theepidermis becomes scaly and is shed, giving rise to superficial ulcerswhich are usually covered by crusted discharge. The disease tends tospread, creeping over the skin with a serpiginous, crescentic, orhorse-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 themargin, it may resemble tuberculous disease of the skin. It can usuallybe differentiated by observing that the infiltration is on a largerscale; the progress is much more rapid, involving in the course ofmonths an area which in the case of tuberculosis would require as manyyears; 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 durationin a woman æt.  24, the subject of inherited syphilis, showing activeulceration, cicatricial contraction, and sabre-blade deformity oftibiæ. ] _Tertiary lesions of mucous membrane and of the submucous cellulartissue_ are met with chiefly in the tongue, nose, throat, larynx, andrectum. They originate as gummata or as gummatous infiltrations, whichare liable to break down and lead to the formation of ulcers which mayprove locally destructive, and, in such situations as the larynx, evendangerous to life. In the tongue the tertiary ulcer may prove thestarting-point of cancer; and in the larynx or rectum the healing of theulcer 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 playedby syphilis in the production of disease of arteries and of aneurysmwill be referred to along with diseases of blood vessels. [Illustration: FIG.  42. --Tertiary Syphilitic Ulceration in region ofKnee and on both Thumbs of woman æt.  37. ] _Treatment. _--The most valuable drugs for the treatment of themanifestations of the tertiary period are the arsenical preparations andthe iodides of sodium and potassium. On account of their depressingeffects, the latter are frequently prescribed along with carbonate ofammonium. The dose is usually a matter of experiment in each individualcase; 5 grains three times a day may suffice, or it may be necessary toincrease each dose to 20 or 25 grains. The symptoms of iodism which mayfollow from the smaller doses usually disappear on giving a largeramount of the drug. It should be taken after meals, with abundant wateror other fluid, especially if given in tablet form. It is advisable tocontinue the iodides for from one to three months after the lesions forwhich they are given have cleared up. If the potassium salt is nottolerated, it may be replaced by the ammonium or sodium iodide. _Local Treatment. _--The absorption of a subcutaneous gumma is oftenhastened by the application of a fly-blister. When a gumma has broken onthe surface and caused an ulcer, this is treated on general principles, with a preference, however, for applications containing mercury oriodine, or both. If a wet dressing is required to cleanse the ulcer, black wash may be used; if a powder to promote dryness, one containingiodoform; if an ointment is indicated, the choice lies between the redoxide of mercury or the dilute nitrate of mercury ointment, and oneconsisting of equal parts of lanolin and vaselin with 2 per cent. Ofiodine. Deep ulcers, and obstinate lesions of the bones, larynx, andother parts may be treated by excision or scraping with the sharp spoon. #Second Attacks of Syphilis. #--Instances of re-infection of syphilishave been recorded with greater frequency since the more generalintroduction of arsenical treatment. A remarkable feature in such casesis the shortness of the interval between the original infection and thealleged re-infection; in a recent series of twenty-eight cases, thisinterval was less than a year. Another feature of interest is that whenpatients in the tertiary stage of syphilis are inoculated with the virusfrom lesions from these in the primary and secondary stage lesions ofthe 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 ofdifficulty in diagnosis. A patient who has had an infecting chancre oneor more years before, may present a slightly raised induration on thepenis at or close to the site of his original sore. This relapsedinduration is often so like that of a primary chancre that it isimpossible to distinguish between them, except by the history. If therehas been a recent exposure to venereal infection, it is liable to beregarded as the primary lesion of a second attack of syphilis, but thefurther progress shows that neither bullet-buboes nor secondarymanifestations develop. These facts, together with the disappearance ofthe induration under treatment, make it very likely that the lesion isreally gummatous in character. INHERITED SYPHILIS One of the most striking features of syphilis is that it may betransmitted from infected parents to their offspring, the childrenexhibiting the manifestations that characterise the acquired form of thedisease. The more recent the syphilis in the parent, the greater is the risk ofthe disease being communicated to the offspring; so that if eitherparent suffers from secondary syphilis the infection is almostinevitably transmitted. While it is certain that either parent may be responsible fortransmitting the disease to the next generation, the method oftransmission is not known. In the case of a syphilitic mother it is mostprobable that the infection is conveyed to the fœtus by the placentalcirculation. In the case of a syphilitic father, it is commonly believedthat the infection is conveyed to the ovum through the seminal fluid atthe moment of conception. If a series of children, one after the other, suffer from inherited syphilis, it is almost invariably the case thatthe mother has been infected. In contrast to the acquired form, inherited syphilis is remarkable forthe absence of any primary stage, the infection being a general one fromthe outset. The spirochæte is demonstrated in incredible numbers in theliver, spleen, lung, and other organs, and in the nasal secretion, and, from any of these, successful inoculations in monkeys can readily bemade. The manifestations differ in degree rather than in kind from thoseof the acquired disease; the difference is partly due to the fact thatthe virus is attacking developing instead of fully formed tissues. The virus exercises an injurious influence on the fœtus, which in manycases dies during the early months of intra-uterine life, so thatmiscarriage results, and this may take place in repeated pregnancies, the date at which the miscarriage occurs becoming later as the virus inthe mother becomes attenuated. Eventually a child is carried to fullterm, and it may be still-born, or, if born alive, may suffer fromsyphilitic manifestations. It is difficult to explain such vagaries ofsyphilitic inheritance as the infection of one twin and the escape ofthe other. _Clinical Features. _--We are not here concerned with the severe forms ofthe disease which prove fatal, but with the milder forms in which theinfant is apparently healthy when born, but after from two to six weeksbegins to show evidence of the syphilitic taint. The usual phenomena are that the child ceases to thrive, becomes thinand sallow, and suffers from eruptions on the skin and mucous membranes. There is frequently a condition known as _snuffles_, in which the nasalpassages are obstructed by an accumulation of thin muco-purulentdischarge which causes the breathing to be noisy. It usually beginswithin a month after birth and before the eruptions on the skin appear. When long continued it is liable to interfere with the development ofthe nasal bones, so that when the child grows up there results acondition 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 metwith in the inherited disease, the most important is a _papular_eruption, the papules being of large size, with a smooth shining top andof a reddish-brown colour. It affects chiefly the buttocks and thighs, the genitals, and other parts which are constantly moist. It isnecessary to distinguish this specific eruption from a form of eczemawhich occurs in these situations in non-syphilitic children, the pointsthat characterise the syphilitic condition being the infiltration of theskin and the coppery colour of the eruption. At the anus the papulesacquire the characters of _condylomata_, also at the angles of themouth, where they often ulcerate and leave radiating scars. _Affections of the Mucous Membranes. _--The inflammation of the nasalmucous membrane that causes snuffles has already been referred to. Theremay be mucous patches in the mouth, or a stomatitis which is ofimportance, because it results in interference with the development ofthe permanent teeth. The mucous membrane of the larynx may be the seatof mucous patches or of catarrh, and as a result the child's cry ishoarse. _Affections of the Bones. _--Swellings at the ends of the long bones, dueto inflammation at the epiphysial junctions, are most often observed atthe upper end of the humerus and in the bones in the region of theelbow. Partial displacement and mobility at the ossifying junction maybe observed. The infant cries when the part is touched; and as it doesnot move the limb voluntarily, the condition is spoken of as _thepseudo-paralysis of syphilis_. Recovery takes place underanti-syphilitic treatment and immobilisation of the limb. Diffuse thickening of the shafts of the long bones, due to a deposit ofnew 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, andcraniotabes, were formerly believed to be characteristic of inheritedsyphilis, but they are now known to occur, particularly in ricketychildren, from other causes. The _bosses_ result from the heaping up ofnew spongy bone beneath the pericranium, and they may be groupedsymmetrically around the anterior fontanelle, or may extend along eitherside of the sagittal suture, which appears as a deep groove--the"natiform skull. " The bosses disappear in time, but the skull may remainpermanently altered in shape, the frontal and parietal eminencesappearing unduly prominent. The term _craniotabes_ is applied when thebone becomes thin and soft, reverting to its original membranouscondition, so that the affected areas dimple under the finger likeparchment or thin cardboard; its localisation in the posterior parts ofthe skull suggests that the disappearance of the osseous tissue isinfluenced by the pressure of the head on the pillow. Craniotabes isrecovered from as the child improves in health. Between the ages of three and six months, certain other phenomena may bemet with, such as _effusion into the joints_, especially the knees;_iritis_, in one or in both eyes, and enlargement of the spleen andliver. In the majority of cases the child recovers from these earlymanifestations, especially when efficiently treated, and may enjoy anindefinite period of good health. On the other hand, when it attains theage of from two to four years, it may begin to manifest lesions whichcorrespond to those of the tertiary period of acquired syphilis. #Later Lesions. #--In the skin and subcutaneous tissue, the latermanifestations may take the form of localised gummata, which tend tobreak down and form ulcers, on the leg for example, or of a spreadinggummatous infiltration which is also liable to ulcerate, leavingdisfiguring scars, especially on the face. The palate and fauces may bedestroyed by ulceration. In the nose, especially when the ulcerativeprocess is associated with a putrid discharge--ozæna--the destruction oftissue may be considerable and result in unsightly deformity. The entirepalatal portions of the upper jaws, the vomer, turbinate, and otherbones bounding the nasal and oral cavities, may disappear, so that onlooking into the mouth the base of the skull is readily seen. Gummatousdisease is frequently observed also in the flat bones of the skull, inthe bones of the hand, as syphilitic dactylitis, and in the bones of theforearm and leg. When the tibia is affected the disease is frequentlybilateral, and may assume the form of gummatous ulcers and sinuses. Inlater years the tibia may present alterations in shape resulting fromantecedent gummatous disease--for example, nodular thickenings of theshaft, flattening of the crest, or a more uniform increase in thicknessand length of the shaft of the bone, which, when it is curved inaddition, is described as the "sabre-blade" deformity. Among lesions ofthe viscera, mention should be made of gumma of the testis, which causesthe organ to become enlarged, uneven, and indurated. This has even beenobserved in infants a few months old. Occasionally a syphilitic child suffers from a succession of thesegummatous lesions with resulting ill-health, and, it may be, waxydisease of the internal organs; on the other hand, it may recover andpresent no further manifestations of the inherited taint. _Affections of the Eyes. _--At or near puberty there is frequentlyobserved an affection of the eyes, known as _chronic interstitialkeratitis_, the relationship of which to inherited syphilis was firstestablished by Hutchinson. It occurs between the ages of six and sixteenyears, and usually affects one eye before the other. It commences as adiffuse haziness or steaminess near the centre of the cornea, and as itspreads the entire cornea assumes the appearance of ground glass. Thechief complaint is of dimness of sight, which may almost amount toblindness, but there is little pain or photophobia; a certain amount ofconjunctival and ciliary congestion is usually present, and there may be_iritis_ in addition. The cornea, or parts of it, may become of a deeppink or salmon colour from the formation in it of new blood vessels. Theaffection may last for from eighteen months to two years. Completerecovery usually takes place, but slight opacities, especially in thesite of former salmon patches, may persist, and the disease occasionallyrelapses. _Choroiditis_ and _retinitis_ may also occur, and leavepermanent changes easily recognised on examination with theophthalmoscope. Among the rarer and more serious lesions of the inherited disease may bementioned gummatous disease in the _larynx and trachea_, attended withulceration and resulting in stenosis; and lesions of the _nervoussystem_ which may result in convulsions, paralysis, or dementia. In a limited number of cases, about the period of puberty there maydevelop _deafness_, which is usually bilateral and may become absolute. _Changes in the Permanent Teeth. _--These affect specially the uppercentral incisors, which are dwarfed and stand somewhat apart in the gum, with their free edges converging towards one another. They are taperingor peg-shaped, and present at their cutting margin a deep semilunarnotch. These appearances are commonly associated with the name ofHutchinson, who first described them. Affecting as they do thepermanent teeth, they are not available for diagnosis until the child isover eight years of age. Henry Moon drew attention to a change in thefirst molars; these are reduced in size and dome-shaped through dwarfingof the central tubercle of each cusp. #Diagnosis of Inherited Syphilis. #--When there is a typical eruption onthe buttocks and snuffles there is no difficulty in recognising thedisease. When, however, the rash is scanty or is obscured by co-existingeczema, most reliance should be placed on the distribution of theeruption, on the brown stains which are left after it has passed off, onthe presence of condylomata, and of fissuring and scarring at the anglesof the mouth. The history of the mother relative to repeatedmiscarriages and still-born children may afford confirmatory evidence. In doubtful cases, the diagnosis may be aided by the Wassermann test andby noting the therapeutic effects of grey powder, which, in syphiliticinfants, usually effects a marked and rapid improvement both in thesymptoms and in the general health. While a considerable number of syphilitic children grow up withoutshowing any trace of their syphilitic inheritance, the majority retainthroughout life one or more of the following characteristics, which maytherefore be described as _permanent signs of the inherited disease_:Dwarfing of stature from interference with growth at the epiphysialjunctions; the forehead low and vertical, and the parietal and frontaleminences unduly prominent; the bridge of the nose sunken and rounded;radiating scars at the angles of the mouth; perforation or destructionof the hard palate; Hutchinson's teeth; opacities of the cornea fromantecedent 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 tibiæ. #The Contagiousness of Inherited Syphilis. #--In 1837, Colles of Dublinstated his belief that, while a syphilitic infant may convey the diseaseto a healthy wet nurse, it is incapable of infecting its own mother ifnursed by her, even although she may never have shown symptoms of thedisease. This doctrine, which is known as _Colles' law_, is generallyaccepted in spite of the alleged occurrence of occasional exceptions. The older the child, the less risk there is of its communicating thedisease to others, until eventually the tendency dies out altogether, asit does in the tertiary period of acquired syphilis. It should beadded, however, that the contagiousness of inherited syphilis is deniedby some observers, who affirm that, when syphilitic infants proveinfective, the disease has been really acquired at or soon after birth. There is general agreement that the subjects of inherited syphiliscannot transmit the disease by inheritance to their offspring, and that, although they very rarely acquire the disease _de novo_, it is possiblefor them to do so. #Prognosis of Inherited Syphilis. #--Although inherited syphilis isresponsible for a large but apparently diminishing mortality in infancy, the subjects of this disease may grow up to be as strong and healthy astheir neighbours. Hutchinson insisted on the fact that there is littlebad health in the general community that can be attributed to inheritedsyphilis. #Treatment. #--Arsenical injections are as beneficial in the inherited asin the acquired disease. An infant the subject of inherited syphilisshould, if possible, be nursed by its mother, and failing this it shouldbe fed by hand. In infants at the breast, the drug may be given to themother; in others, it is administered in the same manner as alreadydescribed--only in smaller doses. On the first appearance of syphiliticmanifestations it should be given 0. 05 grm, novarsenbillon, injectedinto the deep subcutaneous tissues every week for six weeks, followed byone year's mercurial inunction--a piece of mercurial ointment the sizeof a pea being inserted under the infant's binder. In older children thedose is proportionately increased. The general health should be improvedin every possible direction; considerable benefit may be derived fromthe use of cod-liver oil, and from preparations containing iron andcalcium. Surgical interference may be required in the destructivegummatous lesions of the nose, throat, larynx, and bones, either withthe object of arresting the spread of the disease, or of removing oralleviating the resulting deformities. In children suffering fromkeratitis, the eyes should be protected from the light by smoked orcoloured glasses, and the pupils should be dilated with atropin fromtime to time, especially in cases complicated with iritis. #Acquired Syphilis in Infants and Young Children. #--When syphilis is metwith in infants and young children, it is apt to be taken for grantedthat the disease has been inherited. It is possible, however, for themto acquire the disease--as, for example, while passing through thematernal passages during birth, through being nursed or kissed byinfected women, or through the rite of circumcision. The risk ofinfection which formerly existed by the arm-to-arm method ofvaccination has been abolished by the use of calf lymph. The clinical features of the acquired disease in infants and youngchildren are similar to those observed in the adult, with a tendency, however, to be more severe, probably because the disease is often latein 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-bookof pathology. A tumour or neoplasm is a localised swelling composed of newly formedtissue which fulfils no physiological function. Tumours increase in sizequite independently of the growth of the body, and there is no naturaltermination to their growth. They are to be distinguished from suchover-growths as are of the nature of simple hypertrophy or localgiantism, and also from inflammatory swellings, which usually developunder the influence of a definite cause, have a natural termination, andtend 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 theirdevelopment. Certain tumours, for example, are the result of somecongenital malformation of the particular tissue from which they takeorigin. This would appear to be the case in many tumours of bloodvessels (angioma), of cartilage (chondroma), of bone (osteoma), and ofsecreting gland tissue (adenoma). The theory that tumours originate fromfœtal residues or "rests, " is associated with the name of Cohnheim. These rests are supposed to be undifferentiated embryonic cells whichremain embedded amongst fully formed tissue elements, and lie dormantuntil they are excited into active growth and give rise to a tumour. This mode of origin is illustrated by the development of dermoids fromsequestrated portions of epidermis. Among the local factors concerned in the development of tumours, reference must be made to the influence of irritation. This is probablyan important agent in the causation of many of the tumours met with inthe skin and in mucous membranes--for example, cancer of the skin, ofthe lip, and of the tongue. The part played by injury is doubtful. Itnot infrequently happens that the development of a tumour is preceded byan injury of the part in which it grows, but it does not necessarilyfollow that the injury and the tumour are related as cause and effect. It is possible that an injury may stimulate into active growthundifferentiated tissue elements or "rests, " and so determine the growthof a tumour, or that it may alter the characters of a tumour whichalready exists, causing it to grow more rapidly. The popular belief that there is some constitutional peculiarityconcerned in the causation of tumours is largely based on the fact thatcertain forms of new growth--for example, cancer--are known to occurwith undue frequency in certain families. The same influence is morestriking in the case of certain innocent tumours--particularly multipleosteomas and lipomas--which are hereditary in the same sense assupernumerary or webbed fingers, and appear in members of the samefamily through several generations. INNOCENT AND MALIGNANT TUMOURS For clinical purposes, tumours are arbitrarily divided into twoclasses--the innocent and the malignant. The outstanding differencebetween them is, that while the evil effects of innocent tumours areentirely local and depend for their severity on the environment of thegrowth, malignant tumours wherever situated, in addition to producingsimilar local effects, injure the general health and ultimately causedeath. _Innocent_, benign, or simple tumours present a close structuralresemblance to the normal tissues of the body. They grow slowly, and areusually definitely circumscribed by a fibrous capsule, from which theyare easily enucleated, and they do not tend to recur after removal. Intheir growth they merely push aside and compress adjacent parts, andthey present no tendency to ulcerate and bleed unless the overlying skinor mucous membrane is injured. Although usually solitary, some aremultiple from the outset--for example, fatty, fibrous, and bony tumours, warts, and fibroid tumours of the uterus. They produce no constitutionaldisturbance. They only threaten life when growing in the vicinity ofvital organs, and then only in virtue of their situation--for example, death may result from an innocent tumour in the air-passage causingsuffocation, in the intestine causing obstruction of the bowels, or inthe vertebral canal causing pressure on the spinal medulla. _Malignant tumours_ usually show a marked departure from the structureand arrangement of the normal tissues of the body. Although the cells ofwhich they are composed are derived from normal tissue cells, they tendto take on a lower, more vegetative form; they may be regarded asparasites living at the expense of the organism, multiplyingindefinitely and destroying everything with which they come in contact. Malignant tumours grow more rapidly than innocent tumours, and tend toinfiltrate their surroundings by sending out prolongations or offshoots;they are therefore liable to recur after an operation which isrestricted to the removal of the main tumour. They are not encapsulated, although they may appear to be circumscribed by condensation of thesurrounding tissues; they are rarely multiple at the outset, but show amarked tendency to spread to other parts of the body. Fragments of theparent tumour may become separated and be carried off in the lymph orblood-stream and deposited in other parts of the body, where they giverise to secondary growths. Malignant tumours tend to invade and destroythe overlying skin or mucous membrane, and thus give rise to bleedingulcers; if the tumour tissue protrudes through the gap in the skin, itis said to _fungate_. In course of time they give rise to a condition ofill-health or _cachexia_, the patient becoming pale, sallow, feverish, and emaciated, probably as a result of chronic poisoning from theabsorption of toxic products from the tumour. They ultimately destroylife, it may be by their local effects, such as ulceration andhæmorrhage, by favouring the entrance of septic infection, byinterfering with the function of organs which are essential to life, bycachexia, or by a combination of these effects. The situation of a malignant tumour exercises considerable influence onthe rapidity, as well as on the mode, in which it causes death. Somecancers, such as that known as "rodent, " show malignant features whichare entirely local, while others, such as melanotic cancer, exhibit amalignancy characterised by rapid generalisation of growths throughoutthe body. Tumours that are structurally alike may show variations inmalignancy, 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 ormalignancy of any tumour, too much reliance must not be placed on itshistological features; its situation, rate of growth, and other clinicalfeatures must also be taken into consideration. It cannot be tooemphatically stated that there is no hard-and-fast line between innocentand malignant growths; there is an indefinite transition from one to theother. The possibility of the transformation of a benign into amalignant tumour must be admitted. Such a transformation implies achange in the structure of the growth, and has been observed especiallyin fibrous and cartilaginous tumours, in tumours of the thyreoid gland, and in uterine fibroids. The alteration in character may take placeunder the influence of injury, prolonged or repeated irritation, incomplete removal of the benign tumour by operation, or the alteredphysiological conditions of the tissues which attend upon advancingyears. After a tumour has been removed by operation it should as a routinemeasure be subjected to microscopical examination; the results are ofteninstructive and sometimes other than what was expected. #Varieties of Tumours. #--In the following description, tumours areclassified on an anatomical basis, taking in order first theconnective-tissue group and subsequently those that originate inepithelium. INNOCENT CONNECTIVE-TISSUE TUMOURS #Lipoma. #--A lipoma is composed of fat resembling that normally presentin the body. The commonest variety is the _subcutaneous lipoma_, whichgrows from the subcutaneous fat, and forms a soft, irregularly lobulatedtumour (Fig. 45). The fat is arranged in lobules separated byconnective-tissue septa, which are continuous with the capsulesurrounding the tumour and with the overlying skin, which becomesdimpled or puckered when an attempt is made to pinch it up. As the fatis almost fluid at the body temperature, fluctuation can usually bedetected. These tumours vary greatly in size, occur at all ages, growslowly, and, while generally solitary, are sometimes multiple. They aremost commonly met with on the shoulder, buttock, or back. In certainsituations, such as the thigh and perineum, they tend to becomepedunculated (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 anddimpling of the overlying skin, the lobulation of the tumour, which isrecognised when it is pressed upon with the flat of the hand, and, morereliable than either of these, the mobility, the tumour slipping awaywhen pressed upon at its margin. [Illustration: FIG.  45. --Subcutaneous Lipoma showing lobulation. ] The prognosis is more favourable than in any other tumour as it neverchanges its characters; the only reasons for its removal by operationare its unsightliness and its probable increase in size in the course ofyears. The operation consists in dividing the skin and capsule over thetumour and shelling it out. Care must be taken that none of the outlyinglobules are left behind. If the overlying skin is damaged or closelyadherent, it should be removed along with the tumour. [Illustration: FIG.  46. --Pedunculated Lipoma of Buttock of forty years'duration in a woman æt.  68. ] _Multiple subcutaneous lipomas_ are frequently symmetrical, and in acertain group of cases, met with chiefly in women, pain is a prominentsymptom, hence the term _adiposis dolorosa_ (Dercum). These multipletumours show little or no tendency to increase in size, and the painwhich attends their development does not persist. In the neck, axilla, and pubes a diffuse overgrowth of the subcutaneousfat is sometimes met with, forming symmetrical tumour-like masses, knownas _diffuse lipoma_. As this is not, strictly speaking, a tumour, theterm _diffuse lipomatosis_ is to be preferred. A similar condition wasdescribed by Jonathan Hutchinson as being met with in the domesticanimals. If causing disfigurement, the mass of fat may be removed byoperation. [Illustration: FIG.  47. --Diffuse Lipomatosis of Neck. ] _Lipoma in other Situations. _--The _periosteal lipoma_ is usuallycongenital, and is most often met with in the hand; it forms aprojecting lobulated tumour, which, when situated in the palm, resemblesan angioma or a lymphangioma. The _subserous lipoma_ arises from theextra-peritoneal fat in the posterior abdominal wall, in which case ittends to grow forwards between the layers of the mesentery and to giverise to an abdominal tumour; or it may grow from the extra-peritonealfat in the anterior abdominal wall and protrude from one of the hernialopenings or through an abnormal opening in the parietes, constituting a_fatty hernia_. A _subsynovial lipoma_ grows from the fat surroundingthe synovial membrane of a joint, and projects into its interior, givingrise to the symptoms of loose body. Lipomas are also met with growingfrom the adipose connective tissue _between or in the substance ofmuscles_, and, when situated beneath the deep fascia, such as the fascialata of the thigh, the characteristic signs are obscured and adifferential diagnosis is difficult. It may be differentiated from acold abscess by puncture with an exploring needle. [Illustration: FIG.  48. --Zanthoma of Hands in a girl æt.  14, showingmultiple subcutaneous tumours (cf. Fig. 49). (Sir H.  J.  Stiles' case. )] #Zanthoma# is a rare but interesting form of tumour, composed of afibrous and fatty tissue, containing a granular orange-yellow pigment, resembling that of the corpus luteum. It originates in the corium andpresents two clinical varieties. In the first of these, it occurs in theform of raised yellow patches, usually in the skin of the eyelids ofpersons after middle life, and in many instances is associated withchronic jaundice; the patches are often symmetrical, and as theyincrease in size they tend to fuse with another. The second form occurs in children and adolescents; it may affectseveral generations of the same family, and is often multiple, therebeing a combination of thickened yellow patches of skin and projectingtumours, some of which may attain a considerable size (Figs. 48 and 49). On section, the tumour tissue presents a brilliant orange or saffroncolour. There is no indication for removing the tumours unless for the deformitywhich they cause; exposure to the X-rays is to be preferred tooperation. [Illustration: FIG.  49. --Zanthoma showing Subcutaneous Tumours onButtocks. From same patient as Fig. 48. ] #Chondroma. #--A chondroma is mainly composed of cartilage. Processes ofvascular connective tissue pass in between the nodules of cartilagecomposing the tumour from the fibrous capsule which surrounds it. Onsection it is of a greyish-blue colour and semi-translucent. The tumouris firm and elastic in consistence, but certain portions may be denselyhard from calcification or ossification, while other portions may besoft and fluctuating as a result of myxomatous degeneration andliquefaction. These tumours grow slowly and painlessly, and may surroundnerves and arteries without injuring them. They may cause a deep hollowin the bone from which they originate. All intermediate forms betweenthe innocent chondroma and the malignant chondro-sarcoma are met with. Chondroma may occur in a multiple form, especially in relation to thephalanges and metacarpal bones. When growing in the interior of a boneit causes a spindle-shaped enlargement of the shaft, which in the caseof a phalanx or metacarpal bone may resemble the dactylitis resultingfrom tubercle or syphilis. A chondroma appears as a clear area in askiagram. A _skiagram_ of a bone in which there is a chondroma shows a clearrounded area in the position of the tumour, which must be differentiatedfrom similar clear areas due to other kinds of tumour, especially themyeloma; when it has undergone calcification or ossification, it gives ashadow as dark as bone. [Illustration: FIG.  50. --Chondroma growing from infraspinous fossa ofScapula. ] [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 assoon as it is recognised. In those projecting from the surface of abone, both the tumour and its capsule should be removed. If in theinterior, a sufficient amount of the cortex should be removed to allowof the tumour being scraped out, and care must be taken that no nodulesof cartilage are left behind. In multiple chondromas of the hand, whenthe fingers are crippled and useless, exposure to the X-rays should begiven a trial, and in extreme cases the question of amputation may haveto be considered. When a cartilaginous tumour takes on active growth, itmust be treated as malignant. The chondromas that are met with at the ends of the long bones inchildren and young adults form a group by themselves. They are usuallyrelated to the epiphysial cartilage, and it was suggested by Virchowthat they take origin from islands of cartilage which have not been usedup in the process of ossification. They are believed to occur morefrequently in those who have suffered from rickets. They have nomalignant tendencies and tend to undergo ossification concurrently withthe epiphysial cartilage from which they take origin, and constitutewhat are known as _cartilaginous exostoses_. These are sometimes metwith in a multiple form, and may occur in several generations of thesame family. They are considered in greater detail in the chapterdealing with tumours of bone. Minute nodules of cartilage sometimes form in the synovial membrane ofjoints and lining of tendon sheaths and bursæ: they tend to becomedetached from the membrane and constitute loose bodies; they alsoundergo a variable amount of calcification and ossification, so as to bevisible in skiagrams. They are further considered with loose bodies injoints. Cartilaginous tumours in the parotid, submaxillary gland, and testiclebelong to a class of "mixed tumours" that will be referred to later. #Osteoma. #--The true osteoma is composed of bony tissue, and originatesfrom the skeleton. Two varieties are recognised--the spongy orcancellous, and the ivory or compact. The _spongy_ or _cancellousosteoma_ is really an ossified chondroma, and is met with at the ends ofthe long bones (Fig. 52). From the fact that it projects from thesurface of the bone it is often spoken of as an _exostosis_. It growsslowly, and rarely causes any discomfort unless it presses upon anerve-trunk or upon a bursa which has developed over it. The Röntgenrays show a dark shadow corresponding to the ossified portion of thetumour, and continuous with that of the bone from which it is growing(Fig. 138). Operative interference is only indicated when the tumour isgiving rise to inconvenience. It is then removed, its base or neck beingdivided by means of the chisel. The multiple variety of osteoma isconsidered with the diseases of bone. The bony outgrowth from the terminal phalanx of the great toe--known asthe _subungual exostosis_--is described and figured on p. 404. Bonyprojections or "spurs" sometimes occur on the under surface of thecalcaneus, and, projecting downwards and forwards from the greaterprocess, 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 usuallygrows from the skull. It is generally sessile and solitary, and may growinto the interior of the skull, into the frontal sinus, into the cavityof 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 theirpoints 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 varyingproportions and different degrees of development, arising fromtooth-germs or from teeth still in process of growth (Bland Sutton). Odontomas resemble teeth in so far that during their development theyremain hidden below the mucous membrane and give no evidence of theirexistence. There then succeeds, usually between the twentieth andtwenty-fifth years, an eruptive stage, which is often attended withsuppuration, and this may be the means of drawing attention to thetumour. Following Bland Sutton, several varieties of odontoma may bedistinguished according to the part of the tooth-germ concerned in theirformation. The _epithelial odontoma_ is derived from persistent portions of theepithelium of the enamel organ, and constitutes a multilocular cystictumour which is chiefly met with in the mandible. The cystic spaces ofthe tumour contain a brownish glairy fluid. These tumours have beendescribed by Eve under the name of multilocular cystic epithelialtumours of the jaw. The _follicular odontoma_, also known as a _dentigerous cyst_, isderived from the distension of a tooth follicle. It constitutes a cystcontaining a viscid fluid, and an imperfectly formed tooth is oftenfound embedded in its wall. The cyst usually forms in relation to one ofthe permanent molars, and may attain considerable dimensions. The _fibrous odontoma_ is the result of an overgrowth of fibrous tissuesurrounding the tooth sac, which encapsulates the tooth and prevents itseruption. The thickened tooth sac is usually mistaken for a fibroustumour, until, after removal, the tooth is recognised in its interior. _Composite Odontoma. _--This is a convenient term to apply to certainhard dental tumours which are met with in the jaws, and consist ofenamel, dentine, and cement. The tumour is to be regarded as beingderived from an abnormal growth of all the elements of a tooth germ, orof two or more tooth germs, indiscriminately fused with one another. Itmay appear in childhood, and form a smooth unyielding tumour, often ofconsiderable size, replacing the corresponding permanent tooth. It maycause a purulent discharge, and in some cases it has been extruded aftersloughing of the overlying soft parts. Many examples of this variety ofodontoma, growing in the nasal cavity or in the maxillary sinus, havebeen erroneously regarded as osteomas even after removal. On section, the tumour is usually laminated, and is seen to consistmainly of dentine with a partial covering of enamel and cement. _Diagnosis. _--Odontomas are often only diagnosed after removal. Whenattended with suppuration, the condition has been mistaken for diseaseof the jaw. Fibrous odontomas have been mistaken for sarcoma, andportions of the maxilla removed unnecessarily. Any circumscribed tumourof the jaw, particularly when met with in a young adult, should suggestthe possibility of an odontoma. Skiagrams often give useful informationboth for diagnosis and for treatment. _Treatment. _--The solid varieties of odontoma can usually be shelled outafter dividing the overlying soft parts. In the follicular variety, itis usually sufficient to excise a portion of the wall, scrape out theinterior, and remove any tooth that may be present. The cavity is thenpacked 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 iscomparatively rich in cells and blood vessels, and in which the fibresare arranged loosely; and the _hard fibroma_, which is composed ofclosely packed bundles of fibres often arranged in a concentric fashionaround the blood vessels. The cut surface of the soft fibroma presents apinkish-white, fleshy appearance, resembling the slowly growing forms ofsarcoma; that of a hard fibroma presents a dry, glistening appearance, aptly compared to watered silk. The soft variety grows much more rapidlythan the hard. In certain fibromas--in those, for example, which growfrom the periosteum of the base of the skull and project into thenaso-pharynx--the blood vessels are dilated into sinuses and have noproper sheaths; they therefore tend to remain open when divided, and tobleed excessively. Transition forms between soft fibroma and sarcoma aremet with, so that in operating for their removal it is safer to takeaway the capsule along with the tumour, and the patient should be keptunder observation in view of the risk of recurrence. The skin--especially the skin of the buttock--is one of the favouriteseats of fibroma, and it may occur in a multiple form. It is met withalso in the subcutaneous and intermuscular cellular tissue, and in theabdominal wall, where it sometimes attains considerable dimensions. Various forms of fibroma are met with in the mamma and are describedwith diseases of that organ. The fibrous overgrowths in the skin, knownas _keloid_ and _molluscum fibrosum_, and those met with in the _sheathsof nerves_, are described elsewhere. Fibroid tumours of the uterus aredescribed with myoma. _Diffuse fibroma_ or _Fibromatosis_, analogous to lipomatosis, is metwith in the connective tissue of the skin and sheaths of nerves, andconstitutes one form of neuro-fibromatosis; a similar change is also metwith in the stomach and colon. #Myxoma. #--A myxoma is composed of tissue of a soft gelatinous, semifluid consistence. The pure myxoma is extremely rare, andclinically resembles the lipoma. Myxomatous tissue is, however, frequently found in other connective-tissue tumours as a result ofdegeneration, for example, in cartilaginous tumours and in sarcomas. Myxomatous tissue is also a prominent constituent of the "innocentparotid tumour. " Mucous polypus of the nose, which is often described asa myxoma, is merely a pendulous process of œdematous mucous membrane. [Illustration: FIG.  53. --Myeloma of Shaft of Humerus, causingpathological 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 cellssurrounded by round and spindle cells. The cut surface of the tumourpresents a deep red or maroon colour. While occasionally met with intendon sheaths and bursæ, and is then of an orange-yellow colour, themyeloma occurs most frequently in the cancellous tissue at the ends ofthe long bones, its favourite site being the upper end of the tibia. Although formerly classified as a sarcoma, it is the exception for it topresent malignant features, and it can usually be extirpated by localmeasures 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, inassociation with an unusual form of protein in the urine (Bence Jones). #Myoma. #--A myoma is composed of non-striped muscle fibres. A pure myomais very rare, and is met with in organs possessed of non-striped muscle, such as the stomach, intestine, urinary bladder, and prostate. In theuterus, which is the most common situation, these tumours contain aconsiderable admixture of fibrous tissue, and are known as _fibroids_ or_fibro-myomas_. They present on section a fasciculated appearance, whichmay resemble that of a section of balls of cotton (Fig. 54). They areencapsulated and vascular, frequently attain a large size, and may besingle or multiple. While they may occasion neither inconvenience norsuffering, they frequently give rise to profuse hæmorrhage from theuterus, and may cause serious symptoms by pressing injuriously on theureters or the intestine, or by complicating pregnancy and parturition. The #Rhabdomyoma# is an extremely rare form of tumour, met with in thekidney, uterus, and testicle. It contains striped muscle fibres, and issupposed to originate from a residue of muscular tissue which has becomesequestrated 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 withexclusively in the central nervous system, retina, and optic nerve. Itis a slowly growing, soft, ill-defined tumour, which displaces theadjacent nerve centres and nerve tracts, and is liable to become theseat of hæmorrhage and thus to give rise to pressure symptoms resemblingapoplexy. The glioma of the retina tends to grow into the vitreoushumour and to perforate the globe. It is usually of the nature of aglio-sarcoma and is highly malignant. #Endotheliomas# take origin from the endothelium of lymph vessels andblood vessels, and serous cavities. They show great variation in type, partly because of the number of different kinds of endothelium fromwhich they are derived, and partly because the new connective tissuewhich 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, althoughrecurrence has been occasionally observed. Cases of multipleendotheliomata of the skin have recently been described by Wise. _Angioma_, _lymphangioma_, and _neuroma_ are described with the diseaseof the individual tissues. MALIGNANT CONNECTIVE-TISSUE TUMOURS--SARCOMA The term sarcoma is applied to any connective-tissue tumour whichexhibits malignant characters. The essential structural feature is thepredominance of the cellular elements over the intercellular substanceor stroma, in which respect a sarcoma resembles the connective tissue ofthe embryo. The typical sarcoma consists chiefly of immature orembryonic connective tissue. It most frequently originates from fascia, intermuscular connective tissue, periosteum, bone-marrow, and skin, andforms 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 tumourdepends on the nature and amount of the stroma, and on the presence ofdegenerative changes. The softer medullary forms are composed almostexclusively of cells; while the harder forms--such as the fibro-, chondro-, and osteo-sarcoma--are provided with an abundant stroma andare relatively poor in cells. Degenerative changes may produce areas ofsoftening or liquefaction which result in the formation of cysticcavities in the interior of the tumour. The colour depends on the amountof blood in the tumour, and on the presence of the products ofdegeneration. The blood vessels are usually represented by mere chinks or spacesbetween the cells. This peculiarity accounts for the facility with whichhæmorrhage takes place into the substance of the tumour, the persistenceof the bleeding when it is incised or ulcerates through the skin, andthe readiness with which the sarcomatous cells are carried off andinfect distant parts through the blood-stream. Sarcomas are devoid oflymphatics, and unless originating in lymphatic structures--for example, in the tonsil--they rarely infect the lymph glands. Minute portions ofthe tumour grow into the small veins, and, becoming detached, aretransported by the blood-current to distant organs, where they arearrested in the capillaries and give rise to secondary growths. Theseare most frequently situated in the lungs, except when the primarygrowth lies within the territory of the portal circulation, in whichcase they occur in the liver. The secondary growths closely resemble theparent tumour. Sarcoma may invade an adjacent vein on such a scale thatif the invading portion becomes detached it may constitute a dangerousembolus. This may be observed in sarcoma of the kidney, the growthtaking place along the renal vein until it projects into the vena cava. [Illustration: FIG.  55. --Recurrent Sarcoma of Sciatic Nerve in a womanæt.  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 frompressure. Inflammatory and suppurative changes may take place as aresult of pyogenic infection following upon sloughing of the overlyingskin or upon an exploratory incision. Once the skin is broken the tumourfungates through the opening. Sarcomas vary in malignancy, especially asregards rapidity of growth and capacity for dissemination. Certain ofthem, such as the so-called "recurrent fibroid of Paget, " growcomparatively slowly, and are only malignant in the sense that they tendto recur locally after removal; others--especially the more cellularones--grow with extreme rapidity, and are early disseminated throughoutthe body, resembling in these respects the most malignant forms ofcancer. They are usually solitary in the first instance, althoughprimary multiple growths are occasionally met with in the skin and inthe bones. Many varieties of sarcoma are recognised, according to its structuralpeculiarities. 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 structuresimilar to that of lymph-follicular tissue, and the _alveolar sarcoma_an arrangement of cells in alveoli resembling that seen in cancers. Whenthere is a considerable amount of intercellular fibrous tissue, thetumour 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 tumourare derived from the endothelium of lymph spaces and vessels. The_angio-sarcomas_ are those in which blood vessels form a prominentelement in the structure of the tumour. They are sometimes derived frominnocent angiomas, and they may be so vascular as to pulsate and onauscultation yield a blowing murmur like an aneurysm. The_glio-sarcoma_, _myxo-sarcoma_, _chondro-sarcoma_, and _myo-sarcoma_ aremixed 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 ofmarrow. The _osteoid sarcoma_ is characterised by the formation of atissue resembling bone but deficient in lime salts, and the _petrifyingsarcoma_ by the formation of calcified areas in the stroma. Thesevarieties, although met with chiefly in the bones, may occur in softtissues such as muscle, and in such organs as the mamma. The pigmentedvarieties include the _chloroma_, which is of a light-green colour, andthe _melanotic sarcoma_, which is brown or black. The _psammoma_ is asarcoma containing a material resembling sand; it is chiefly met with inthe membranes of the brain. The _chordoma_ is a rare form of tumouroriginating from the remains of the notochord in the region of thespheno-occipital synchondrosis or in the sacro-coccygeal region. _Diagnosis of Sarcoma. _--A sarcoma is to be differentiated from aninflammatory swelling such as results from tubercle, actinomycosis, orsyphilis, from an innocent tumour, and from a cancer. The points onwhich the diagnosis is founded are discussed with the different tissuesand organs. _Treatment. _--The removal of the tumour by operation is the mostreliable method of treatment; in order to be successful it must beundertaken before dissemination has taken place, and a considerable areaof healthy tissue beyond the apparent margin of the growth must beremoved, and in tumours near the surface of the body, the overlying skinalso. In order to prevent recurrence, a tube of _radium_, to which a silkthread is attached, is inserted into the space from which the tumour wasremoved; the thread is brought out at the drain-opening, and at the endof a week or ten days the tube of radium is removed by pulling on thethread. Radium causes a reaction in the tissues attended with exudationfrom the vessels, for the escape of which provision must be made. Ifradium is not available, the affected area is repeatedly exposed to theaction of the _X-rays_ as soon as the wound has healed. The employmentof these measures has diminished to a remarkable degree the recurrenceof sarcoma after operation. It will readily be understood that the less thoroughly or radically thegrowth has been removed, the more do we depend upon radium or the X-raysfor bringing about a permanent cure, and that in advanced cases ofsarcoma and in cases in which, on account of their anatomical situation, removal by operation is necessarily incomplete, the prospect of cure isstill more dependent on the use of radium or of the X-rays. Finally, there are cases in which removal by operation is impossible, theso-called _inoperable sarcoma_; a tube of radium, to which a silk threadis attached, is inserted into the substance of the tumour, eitherthrough an opening made by a large trocar, or, when necessary, by opendissection. A second tube of radium is placed upon the skin over thetumour and is secured there by a stitch or by a strip of plaster, thussecuring a cross-fire action of the radium rays, both from within andwithout, as this is found to be much more efficacious in destroying orinhibiting the cellular elements of the growth. The tubes of radium areleft _in situ_ for from eight to fourteen days, according to the powerof the radium employed, but are moved about every second day or so inorder that every part of the tumour may be efficiently radiated. If thetumour shrinks in size after the use of radium and becomes operable, itshould be removed before time is given it to resume its growth. It willdepend upon the subsequent course of the disease, whether or not asecond, or it may be even a third, application of radium will berequired. Where neither radium nor X-rays is available or applicable, recourse maybe had to the injection of Coley's fluid, a preparation containing themixed toxins of the streptococcus of erysipelas and the bacillusprodigiosus; or of selenium. EPITHELIAL TUMOURS An excessive and erratic growth of epithelium is the essential anddistinguishing feature of these tumours. The innocent forms are thepapilloma and the adenoma; the malignant, the carcinoma or cancer. #Papilloma. #--A papilloma is a tumour which projects from a cutaneous ormucous surface, and consists of a central axis of vascular fibroustissue with a covering of epithelium resembling that of the surface fromwhich the tumour grows. In the papillomas of the skin--commonly known as_warts_--the covering consists of epidermis; in those growing frommucous surfaces it consists of the epithelium covering the mucousmembrane. When the surface epithelium projects as filiform processes, the tumour is called a _villous papilloma_, the best-known example ofwhich is met with in the urinary bladder. Papillomatous growths arealso met with in the larynx, in the ducts of the breast, and in theinterior of certain cystic tumours of the breast and of the ovary. Although papillomas are primarily innocent, they may become thestarting-point of cancer, especially in persons past middle life and ifthe papilloma has been subjected to irritation and has ulcerated. Theclinical features and treatment of the various forms of papilloma areconsidered with the individual tissues and organs. #Adenoma. #--An adenoma is a tumour constructed on the type of, andgrowing in connection with, a secreting gland. In the substance of suchglands as the mamma, parotid, thyreoid, and prostate, adenomas are metwith as encapsulated tumours. When they originate from the glands of theskin or of a mucous membrane, they tend to project from the surface, andform pedunculated tumours or polypi. Adenomas may be single or multiple, and they vary greatly in size. Thetumour is seldom composed entirely of gland tissue; it usually containsa 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 distendedwith accumulated secretion, a _cystic adenoma_, the best examples ofwhich are met with in the mamma and ovary. A characteristic feature ofthe cystic variety is the tendency the tumour tissue exhibits to projectinto the interior of the cysts, constituting what are known as_intracystic growths_. They are essentially innocent, but intracysticgrowths, especially in the mamma of women over fifty, should be regardedwith suspicion and therefore should be removed on radical lines. Transition forms between adenoma and carcinoma are also met with in therectum and large intestine, and these should be treated on the samelines as cancer. CARCINOMA OR CANCER A cancer is a malignant tumour which originates in epithelium. Thecancer cells are derived by proliferation from already existingepithelium, and they invade the sub-epithelial connective tissue in theform of simple or branching columns. These columns are enclosed inspaces--termed alveoli--which are probably dilated lymph spaces, andwhich communicate freely with the lymph vessels. The cells composing thecolumns and filling the alveoli vary with the character of theepithelium in which the cancer originates. The malignancy of cancerdepends on the tendency which the epithelium has of invading the tissuesin its neighbourhood, and on the capacity of the cells, whentransported elsewhere by the lymph or blood-stream, of giving rise tosecondary growths. Cancer may arise on any surface covered by epithelium or in any of thesecreting glands of the body, but it is much more common in somesituations than in others. It is frequently met with, for example, inthe 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 attainedmaturity, they enter upon the phase of decadence or involution, and thisphase is reached by different tissues at different periods. It is not somuch, therefore, the age of the person in whom it occurs, as the age ofthe tissue in which it arises, that determines the maximum incidence ofcancer. Cancer of the stomach appears and attains a maximum frequencyearlier than cancer of the skin; cancer of the uterus and mamma is morefrequent towards the decline of reproductive activity than in the lateryears of life; rectal cancer is not infrequently met with during thesecond and third decades. There is evidence that the irritation causedby alcohol and tobacco plays a part in the causation of cancer, in thefact that a large proportion of those who become the subjects of cancerof 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 ofa tubular organ such as the stomach or intestine. The absence ofdefinition in cancerous tumours explains the difficulty of completelyremoving them by surgical measures, and has led to the practice ofcomplete extirpation of cancerous organs wherever this is possible. Theboundaries of the affected organ, moreover, are frequently transgressedby the disease, and the epithelial infiltration implicates thesurrounding parts. In cancer of the breast, for example, the diseaseoften extends to the adjacent skin, fat, and muscle; in cancer of thelip or tongue, to the mandible; in cancer of the uterus or intestine, tothe investing peritoneum. In addition to its tendency to infiltrate adjacent tissues and organs, cancer is also liable to give rise to _secondary growths_. These aremost often met with in the nearest lymph glands; those in the neck, forexample, becoming infected from cancer of the lip, tongue, or throat;those in the axilla, from cancer of the breast; those along thecurvatures of the stomach, from cancer of the pylorus; and those in thegroin, from cancer of the external genitals. In lymph vessels the cancercells may merely accumulate so as to fill the lumen and form induratedcords, or they may proliferate and give rise to secondary nodules alongthe course of the vessels. When the lymphatic network in the skin isdiffusely infected, the appearance is either that of a multitude ofsecondary nodules or of a diffuse thickening, so that the skin comes toresemble coarse leather. On the wall of the chest this condition isknown as _cancer en cuirasse_. Although the cancer cells constantlyattack the walls of the adjacent veins and spread into their interior ata comparatively early period, secondary growths due to dissemination bythe blood-stream rarely show themselves clinically until late in thecourse of the disease. It is probable that many of the cancer cellswhich are carried away in the blood or lymph stream undergo necrosis andfail to give rise to secondary growths. Secondary growths present afaithful reproduction of the structure of the primary tumour. Apart fromthe 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 thatdevelop at a distance from the primary tumour, those, for example, inthe medullary canal of the femur or in the diploë of the skull occurringin advanced cases of cancer of the breast, are the result ofdissemination of cancer cells by way of the blood-stream and are to beregarded as emboli. Sampson Handley disagrees with this view; hebelieves that the dissemination is accomplished in a more subtle way, namely, by the actual growth of cancer cells along the finer vessels ofthe lymph plexuses that ramify in the deep fascia, a method of spreadwhich he calls _permeation_. It is maintained also that permeationoccurs as readily against the lymph stream as with it. He compares thespread of cancer to that of an invisible annular ringworm. The growingedge extends in a wider and wider circle, within which a healing processmay 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 thenatural process of healing may fail at isolated points, nodules ofcancer appear, which, although apparently separate from the primarygrowth, have developed in continuity with it, peri-lymphatic fibrosishaving destroyed the cancer chain connecting the nodule with the primarygrowth. This centrifugal spread of cancer is clearly seen in thedistribution of the subcutaneous secondary nodules so frequently metwith in the late stages of mammary cancer. The area within which thesecondary nodules occur is a circle of continually increasing diameterwith the primary growth in the centre. In the rare cases in which the skin of the greater part of the body isaffected, the nodules rarely appear below the level of the deltoid orthe middle third of the thigh, the patient dying before the spread canreach the distal portions of the limbs. Handley argues against the embolic origin of the metastases in the bonesbecause of the rarity of these in the bones of the distal parts of thelimbs, because of the fact that secondary cancer of the femur nearlyalways commences in the upper third of the shaft, which harmonises withthe intimate connection of the deep fascia with the periosteum over thegreat trochanter, thus favouring invasion of the bone marrow whenpermeation has spread thus far. He claims support for the permeationtheory from the fact that the humerus is rarely involved below theinsertion of the deltoid, and that spontaneous fracture of the femur isthree times more common on the side on which the breast cancer issituated. The tumour tissue may undergo necrosis, and when the overlying skin ormucous membrane gives way an ulcer is formed. The margins of a_cancerous ulcer_ (Fig. 57) are made up of tumour tissue which has notbroken down. Usually they are irregular, nodularly thickened orindurated; sometimes they are raised and crater-like. The floor of theulcer is smooth and glazed, or occupied by necrosed tissue, and thedischarge is watery and blood-stained, and as a result of putrefactivechanges may become offensive. Hæmorrhage is rarely a prominent feature, but discharge of blood may constitute a symptom of considerablediagnostic 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 recordin which a cancer appears to have been transferred by contact, as fromthe lower to the upper lip, from one labium majus to the other, from thetongue to the cheek, and from one vocal cord to the other; these beingall examples of cancer involving surfaces which are constantly orfrequently in contact. The transference of cancer from one human beingto another, whether by accident, as in the case of a surgeon woundinghis finger while operating for cancer, or by the deliberate introductionof a portion of cancerous tumour into the tissues, has never been knownto occur. It is by no means infrequent, however, that when recurrencetakes place after an operation for the removal of cancer, the recurrentnodules make their appearance in the main scar or in the scars ofstitches in its neighbourhood. In the lower animals the grafting ofcancer only succeeds in animals of the same species; for example, acancer taken from a mouse will not grow in the tissues of a rat, butonly in a mouse of the same variety as that from which the graft wastaken. While cancer cannot be regarded as either contagious or infectious, itis important to bear in mind the possibility of infection of a woundwith cancer when operating for the disease. A cancer should not be cutinto unless this is essential for purposes of diagnosis, and the woundmade for exploration should be tightly closed by stitches before thecurative operation is proceeded with; the instruments used for theexploration must not be used again until they have been boiled. Thegreatest care should be taken that a cancer which has softened or brokendown is not opened into during the operation. Investigations regarding the cause of cancer have been prosecuted withgreat energy during recent years, but as yet without positive result. Itis recognised that there are a number of conditions which favour thedevelopment of cancer, such as prolonged irritation, and a considerablenumber of cases have been recorded in which cancer of the skin of thehands has followed prolonged and repeated exposure to the Röntgen rays. _The Alleged Increase of Cancer. _--Regarding the alleged increase ofcancer, it may be pointed out that it is impossible to ascertain howmuch of the apparent increase is due to more accurate diagnosis andimproved registration. It is probable also that some increase has takenplace in consequence of the increased average duration of life; a largerproportion of persons now reach the age at which cancer is frequent. _The prognosis_ largely depends on the variety of cancer and on itssituation. Certain varieties--such as the atrophic cancer of the breastwhich occurs in old people, and some forms of cancer in the rectum--areso indolent in their progress that they can scarcely be said to shortenlife; while others--such as the softer varieties of mammary canceroccurring in young women--are among the most malignant of tumours. Themode in which cancer causes death depends to a large extent upon itssituation. In the gullet, for example, it usually causes death bystarvation; in the larynx or thyreoid, by suffocation; in the intestine, by obstruction of the bowels; in the uterus, prostate, and bladder, byhæmorrhage or by implication of the ureters and kidneys. Independentlyof their situation, however, cancers frequently cause death by givingrise to a progressive impairment of health known as the _cancerouscachexia_, a condition which is due to the continued absorption ofpoisonous products from the tumour. The patient loses appetite, becomesemaciated, pale, and feverish, and gradually loses strength until hedies. In many cases, especially those in which ulceration has occurred, the addition of pyogenic infection may also be concerned in the failureof health. _Treatment. _--Removal by surgical means affords the best prospect ofcure. If carcinomatous disease is to be rooted out, its mode of spreadby means of the lymph vessels must be borne in mind, and as this occursat an early stage, and is not evident on examination, a wide area mustbe included in the operation. The organ from which the original growthsprings should, if practicable, be altogether removed, because its lymphvessels generally communicate freely with each other, and secondarydeposits have probably already taken place in various parts of it. Inaddition, the nearest chain of lymph glands must also be removed, eventhough they may not be noticeably enlarged, and in some cases--in cancerof the breast, for example--the intervening lymph vessels should beremoved at the same time. The treatment of cancer by other than operative methods has received agreat deal of attention within recent years, and many agents have beenput to the test, _e. G. _ colloidal suspensions of selenium, but withoutany positive results. Most benefit has resulted from the use of radiumand of the X-rays, and one or other should be employed as a routinemeasure after every operation for cancer. It has been demonstrated that cancer cells are more sensitive to radiumand to the Röntgen rays than the normal cells of the body, and are moreeasily killed. The effect varies a good deal with the nature and seat ofthe tumour. In rodent cancers of the skin, for example, both radium andX-ray treatment are very successful, and are to be preferred tooperation because they yield a better cosmetic result. While smallepitheliomas of the skin may be cured by means of the rays, they are notso amenable as rodent cancers. Cancers of mucous membranes are less amenable to ray treatment becausethey are less circumscribed and are difficult of access. In cancersunder the skin, the Röntgen rays are less efficient; if radium isemployed, the tube containing it should be inserted into the substanceof the tumour after the method described in connection with sarcoma--andanother 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 therays, but to avoid damage to the adjacent and overlying tissues. Ray treatment is not to be looked upon as a rival but as a powerfulsupplement to the operative treatment of cancer. VARIETIES OF CANCER The varieties of cancer are distinguished according to the character andarrangement of the epithelial cells. The _squamous epithelial cancer_ or _epithelioma_ originates from asurface covered by squamous epithelium, such as the skin, or the mucousmembrane of the mouth, gullet, or larynx. The cancer cells retain thecharacters of squamous epithelium, and, being confined within the lymphspaces of the sub-epithelial connective tissue, become compressed andundergo a horny change. This results in the formation of concentricallylaminated 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 ofthe edges and floor of the ulcer, and its surface is often covered withwarty or cauliflower-like outgrowths (Fig. 58). The infection of thelymph glands is early and constant, and constitutes the most dangerousfeature of the disease; the secondary growths in the glands exhibit thecharacteristic induration, and may themselves break down and lead to theformation 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 andsequestration of epithelial cells during the process of cicatrisation. The _columnar epithelial cancer_ or _columnar epithelioma_ originates inmucous membranes covered with columnar epithelium, and is chiefly metwith in the stomach and intestine. As it resembles an adenoma instructure it is sometimes described as a _malignant adenoma_. Itsmalignancy is shown by the proliferating epithelium invading the othercoats of the stomach or intestine, and by the development of secondarygrowths. _Glandular carcinoma_ originates in organs such as the breast, and inthe glands of mucous membranes and skin. The epithelial cells are notarranged on any definite plan, but are closely packed in irregularlyshaped alveoli. If the alveoli are large and the intervening stroma isscanty and delicate, the tumour is soft and brain-like, and is describedas a _medullary_ or _encephaloid cancer_. If the alveoli are small andthe intervening stroma is abundant and composed of dense fibrous tissue, the tumour is hard, and is known as a _scirrhous cancer_--a form whichis most frequently met with in the breast. If the cells undergodegeneration and absorption and the stroma contracts, the tumour becomesstill 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 cellsof the tumour undergo colloid degeneration, a _colloid cancer_ results;if the degeneration is complete, as may occur in the breast, themalignancy is thereby greatly diminished; if only partial, as is morecommon in rectal cancer, the malignancy is not appreciably affected. Melanin pigment is formed in relation to the cells and stroma of certainepithelial tumours, giving rise to _melanotic cancer_, one of the mostmalignant of all new growths. Cyst-like spaces may form in the tumour bythe accumulation of the secretion of the epithelial cells, or as aresult of their degeneration--_cystic carcinoma_. This is met withchiefly in the breast and ovary, and the tumour resembles the cysticadenoma, but it tends to infect its surroundings and gives rise tosecondary growths. _Rodent cancer_ originates in the glands of the skin, and presents aspecial tendency to break down and ulcerate on the surface (Figs. 102and 103). It almost never infects the lymph glands. DERMOIDS A dermoid is a tumour containing skin or mucous membrane, occurring in asituation 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 duringthe process of coalescence of two cutaneous surfaces in development. This form is therefore most frequently met with on the face and neck inthe situations which correspond to the various clefts and fissures ofthe embryo. It occurs also on the trunk in situations where the lateralhalves of the body coalesce during development. Such a dermoid usuallytakes the form of a globular cyst, the wall of which consists of skin, and the contents of turbid fluid containing desquamated epithelium, fatdroplets, cholestrol crystals, and detached hairs. Delicate hairs mayalso be found projecting from the epithelial lining of the cyst. Faulty coalescence of the cutaneous covering of the back occurs mostfrequently over the lower sacral vertebræ, giving rise to smallcongenital 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 arenormally obliterated at birth, for example, _lingual dermoids_ developin relation to the thyreo-glossal duct; _rectal and post-rectal_dermoids to the post-anal gut; and _branchial dermoids_ in relation tothe branchial clefts. Tubulo-dermoids present the same structure as skindermoids, save that mucous membrane takes the place of skin in the wallof the cyst, and the contents consist of the pent-up secretion of mucousglands. _Clinical Features. _--Although dermoids are of congenital origin, theyare rarely evident at birth, and may not give rise to visible tumoursuntil puberty, when the skin and its appendages become more active, ornot till adult life. Superficial dermoids, such as those met with at theouter angle of the orbit, form rounded, definitely limited tumours overwhich the skin is freely movable. They are usually adherent to thedeeper parts, and when situated over the skull may be lodged in adepression or actual gap in the bone. Sometimes the cyst becomesinfected and suppurates, and finally ruptures on the surface. This maylead to a natural cure, or a persistent sinus may form. Dermoids moredeeply placed, such as those within the thorax, or those situatedbetween the rectum and sacrum, give rise to difficulty in diagnosis, even with the help of the X-rays, and their nature is seldom recogniseduntil the escape of the contents--particularly hairs--supplies the clue. The literature of dermoid cysts is full of accounts of puzzling tumoursmet with in all sorts of situations. The treatment is to remove the cyst. When it is impossible to remove thewhole of the lining membrane by dissection, the portion that is leftshould 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, thewall of which contains skin, mucous membrane, hair follicles, sebaceous, sweat, and mucous glands, nails, teeth, nipples, and mammary glands. Thecavity of the cyst usually contains a pultaceous mixture of shedepithelium, fluid fat, and hair. If the cyst ruptures, the epithelialelements are diffused over the peritoneum, and may give rise tosecondary dermoids. [Illustration: FIG.  59. --Dermoid Cyst of Ovary showing Teeth in itsinterior. ] The ovarian dermoid appears clinically as an abdominal or pelvic tumourprovided with a pedicle; if the pedicle becomes twisted, the tumourundergoes strangulation, an event which is attended with urgentsymptoms, 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 orcleavage of the trunk axis of the embryo, and is found exclusively inconnection with the skull and vertebral column. It may take the form ofa monstrosity such as conjoined twins or a parasitic fœtus, but morecommonly it is met with as an irregularly shaped tumour, usually growingfrom the sacrum. On dissection, such a tumour is found to contain acurious mixture of tissues--bones, skin, and portions of viscera, suchas the intestine or liver. The question of the removal of the tumourrequires to be considered in relation to the conditions present in eachindividual case. CYSTS[3] [3] Cysts which form in relation to new-growths have been consideredwith tumours. Cysts are rounded sacs, the wall being composed of fibrous tissue linedby epithelium or endothelium; the contents are fluid or semi-solid, andvary in character according to the tissue in which the cyst hasoriginated. _Retention and Exudation Cysts. _--_Retention cysts_ develop when theduct of a secreting gland is partly obstructed; the secretionaccumulates, and the gland and its duct become distended into a cyst. They are met with in the mamma and in the salivary glands. Sebaceouscysts or wens are described with diseases of the skin. _Exudation cysts_arise from the distension of cavities which are not provided withexcretory ducts, such as those in the thyreoid. _Implantation cysts_ are caused by the accidental transference ofportions of the epidermis into the underlying connective tissue, as mayoccur in wounds by needles, awls, forks, or thorns. The implantedepidermis proliferates and forms a small cyst. They are met with chieflyon the palmar aspect of the fingers, and vary in size from a split peato a cherry. The treatment consists in removing them by dissection. _Parasitic cysts_ are produced by the growth within the tissues ofcyst-forming parasites, the best known being the tænia echinococcus, which gives rise to the _hydatid cyst_. The liver is by far the mostcommon site of hydatid cysts in the human subject. With regard to the further life-history of hydatids, the living elementsof the cyst may die and degenerate, or the cyst may increase in sizeuntil it ruptures. As a result of pyogenic infection the cyst may beconverted into an abscess. The _clinical features_ of hydatids vary so much with their situationand size, that they are best discussed with the individual organs. Ingeneral it may be said that there is a slow formation of a globular, elastic, fluctuating, painless swelling. Fluctuation is detected whenthe cyst approaches the surface, and it is then also that percussionmay elicit the "hydatid thrill" or fremitus. This thrill is not oftenobtainable, and in any case is not pathognomonic of hydatids, as it maybe elicited in ascites and in other abdominal cysts. Pressure of thecyst upon adjacent structures, and the occurrence of suppuration, areattended with characteristic clinical features. The _diagnosis_ of hydatids will be considered with the individualorgans. The disease is more common in certain parts of Australia and inShetland and Iceland than in countries where the association of dogs inthe domestic life of the inhabitants is less intimate. Pfeiler, who hasworked at the _serum diagnosis of hydatid disease_, regards thecomplement deviation method as the most reliable; he believes that apositive reaction may almost be regarded as absolutely diagnostic of anechinococcal lesion. The _treatment_ is to excise the cyst completely, or to inject into it a1 per cent. Solution of formalin. In operating upon hydatids the utmostcare must be taken to avoid leakage of the contents of the cyst, asthese may readily disseminate the infection. A _blood cyst_ or hæmatoma results from the encapsulation ofextravasated blood in the tissues, from hæmorrhage taking place into apreformed cyst, or from the saccular pouching of a varicose vein. A _lymph cyst_ usually results from a contusion in which the skin isforcibly displaced from the subjacent tissues, and lymph vessels arethereby torn across. The cyst is usually situated between the skin andfascia, and contains clear or blood-stained serum. At first it is laxand fluctuates readily, later it becomes larger and more tense. Thetreatment consists in drawing off the contents through a hollow needleand applying firm pressure. Apart from injury, lymph cysts are met withas the result of the distension of lymph spaces and vessels(_lymphangiectasis_); and in lymphangiomas, of which the best-knownexample is the cystic hygroma or hydrocele of the neck. GANGLION This term is applied to a cyst filled with a clear colourless jelly orcolloid material, met with in the vicinity of a joint or tendon sheath. The commonest variety--the _carpal ganglion_--popularly known as asprained sinew--is met with as a smooth, rounded, or oval swelling onthe dorsal aspect of the carpus, usually towards its radial side (Fig. 60). It is situated over one of the intercarpal or other joints in thisregion, 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 sizefrom a pea to a pigeon's egg, and usually attains its maximum sizewithin a few months and then remains stationary. It becomes tense andprominent when the hand is flexed towards the palm. Its appearance isusually ascribed to some strain of the wrist--for example, in girlslearning gymnastics. It may cause no symptoms or it may interfere withthe use of the hand, especially in grasping movements and when the handis dorsiflexed. In girls it may give rise to pain which shoots up thearm. Ganglia are also met with on the dorsum of the metacarpus and onthe palmar aspect of the wrist. [Illustration: FIG.  60. --Carpal Ganglion in a woman æt.  25. ] The _tarsal ganglion_ is situated on the dorsum of the foot over one orother of the intertarsal joints. It is usually smaller, flatter, andmore tense than that met with over the wrist, so that it is sometimesmistaken for a bony tumour. It rarely causes symptoms, unless sosituated as to be pressed upon by the boot. _Ganglia in the region of the knee_ are usually situated over theinterval between the femur and tibia, most often on the lateral aspectof the joint in front of the tendon of the biceps (Fig. 61). Theswelling, which may attain the size of half a walnut, is tense and hardwhen the knee is extended, and becomes softer and more prominent when itis flexed. They are met with in young adults who follow laboriousoccupations or who indulge in athletics, and they cause stiffness, discomfort, and impairment of the use of the limb. A ganglion issometimes met with on the median aspect of the head of the metatarsalbone of the great toe and may be the cause of considerable suffering; itis indistinguishable from the thickened and enlarged bursa so commonlypresent in this situation in the condition known as bunion. [Illustration: FIG.  61. --Ganglion on lateral aspect of Knee in a youngwoman. ] 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 bursæ, synovial cysts, and new-growths are the swellings mostlikely to be mistaken for them. The diagnosis is sometimes only clearedup by withdrawing the clear, jelly-like contents through a hollowneedle. _Pathological Anatomy. _--The wall of the cyst is composed of fibroustissue closely adherent to or fused with the surrounding tissues, sothat it cannot be shelled out. There is no endothelial lining, and thefibrous tissue of the wall is in immediate contact with the colloidmaterial in the interior, which appears to be derived by a process ofdegeneration from the surrounding connective tissue. In the region ofthe knee the ganglion is usually multilocular, and consists of ameshwork of fibrous tissue, the meshes of which are occupied by colloidmaterial. It is often stated that a ganglion originates from a hernial protrusionof the synovial membrane of a joint or tendon sheath. We have not beenable to demonstrate any communication between the cavity of the cystand that of an adjacent tendon sheath or joint. It is possible, however, that the cyst may originate from a minute portion of synovial membranebeing protruded and strangulated so that it becomes disconnected fromthat to which it originally belonged; it may then degenerate and giverise to colloid material, which accumulates and forms a cyst. Ledderhoseand others regard ganglia as entirely new formations in theperi-articular tissues, resulting from colloid degeneration of thefibrous tissue of the capsular ligament, occurring at first in numeroussmall areas which later coalesce. Ganglia are probably, therefore, ofthe nature of degeneration cysts arising in the capsule of joints, intendons, and in their sheaths. _Treatment. _--A ganglion can usually be got rid of by a modification ofthe old-fashioned seton. The skin and cyst wall are transfixed by astout needle carrying a double thread of silkworm gut; some of thecolourless jelly escapes from the punctures; the ends of the thread aretied and cut short, and a dressing is applied. A week later the threadsare removed and the minute punctures are sealed with collodion. Theaction of the threads is to convert the cyst wall into granulationtissue, which undergoes the usual conversion into scar tissue. If thecyst re-forms, it should be removed by open dissection under localanæsthesia. 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 onthe observation that the small tumour is cystic, and that it follows themovements of the tendon. The cyst is at first multiple, but thepartitions disappear, and the spaces are thrown into one. The tendon isso weakened that it readily ruptures. The best treatment is to resectthe affected segment of tendon. The so-called "compound palmar ganglion" is a tuberculous disease of thetendon 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 givesway at the same time, a _contused-wound_ results. Bruising occurs whenforce is applied to a part by means of a blunt object, whether as adirect blow, a crush, or a grazing form of violence. If the force actsat right angles to the part, it tends to produce localised lesions whichextend deeply; while, if it acts obliquely, it gives rise to lesionswhich are more diffuse, but comparatively superficial. It is well toremember that those who suffer from scurvy, or hæmophilia (bleeders), and fat and anæmic females, are liable to be bruised by comparativelytrivial injuries. _Clinical Features. _--The less severe forms of contusion are associatedwith _ecchymosis_, numerous minute and discrete punctate hæmorrhagesbeing scattered through the superficial layers of the skin, which isslightly œdematous. The effused blood is soon reabsorbed. The more severe forms are attended with _extravasation_, theextravasated blood being widely diffused through the cellular tissue ofthe part, especially where this is loose and lax, as in the region ofthe orbit, the scrotum and perineum, and on the chest wall. A blue orbluish-black discoloration occurs in patches, varying in size and depthwith the degree of force which produced the injury, and in shape withthe instrument employed. It is most intense in regions where the skin isnaturally thin and pigmented. In parts where the extravasated blood isonly separated from the oxygen of the air by a thin layer of epidermisor by a mucous membrane, it retains its bright arterial colour. Thesepoints are often well illustrated in cases of black eye, where the bloodeffused under the conjunctiva is bright red, while that in the eyelidsis almost black. In severe contusions associated with great tension ofthe skin--for example, over the front of the tibia or around theankle--blisters often form on the surface and constitute a possibleavenue of infection. When deeply situated, the blood tends to spreadalong the lines of least resistance, partly under the influence ofgravity, passing under fasciæ, between muscles, along the sheaths ofvessels, or in connective-tissue spaces, so that it may only reach thesurface after some time, and at a considerable distance from the seat ofinjury. This fact is sometimes of importance in diagnosis, as, forexample, in certain fractures of the base of the skull, wherediscoloration appears under the conjunctiva or behind the mastoidprocess 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 deeppalpation a peculiar sensation, not unlike the crepitus of fracture. It frequently happens that, from the tearing of lymph vessels, serousfluid is extravasated, and a _lymphatic_ or _serous cyst_ may form. In all contusions accompanied by extravasation, there is marked swellingof the area involved, as well as pain and tenderness. The temperaturemay rise to 101° F. , or, in the large extravasations that occur inbleeders, even higher--a form of aseptic fever. The degree of shock isvariable, but sudden syncope frequently results from severe bruises ofthe testicle, abdomen, or head, and occasionally marked nervousdepression 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 toensue in bruised parts, infection taking place from cocci circulating inthe blood, or through the overlying skin. _Terminations of Contusions. _--The usual termination is a completereturn to the normal, some of the extravasated blood being organised, but most of it being reabsorbed. During the process characteristicalterations in the colour of the effused blood take place as a result ofchanges in the blood pigment. In from twenty-four to forty-eight hoursthe margins of the blue area become of a violet hue, and as time goes onthe discoloured area increases in size, and becomes successively green, yellow, and lemon-coloured at its margins, the central part being thelast to change. The rate at which this play of colours proceeds is sovariable, and depends on so many circumstances, that no time-limits canbe laid down. During the disintegration of the effused blood theadjacent lymph glands may become enlarged, and on dissection may befound to be pigmented. Sometimes the blood persists as a collection offluid with a newly formed connective-tissue capsule, constituting a_hæmatoma_ or _blood cyst_, more often met with in the scalp than inother parts. The impairment of the blood supply of the skin may lead to the formationof _blisters_, or to _necrosis_. Death of skin is more liable to occurin bleeders, and when the slough separates the blood-clot is exposed andthe reparative changes go on extremely slowly. _Suppuration_ may occurand lead to the formation of an abscess as a result of direct infectionfrom 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 padof cotton wool and an elastic bandage, are useful in preventing effusionof 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 leadto necrosis of the skin. When extravasation has already taken place, massage is the most speedyand efficacious means of dispersing the effused blood. The part shouldbe massaged several times a day, unless the presence of blebs orabrasions of the skin prevents this being done. When this is the case, the use of antiseptic dressings is called for to prevent infection andto promote healing, after which massage is employed. When the tension caused by the extravasated blood threatens the vitalityof the skin, incisions may be made, if asepsis can be assured. The bloodfrom a hæmatoma may be withdrawn by an exploring needle, and thepuncture sealed with collodion. Infective complications must be lookedfor and dealt with on general principles. WOUNDS A wound is a solution in the continuity of the skin or mucous membraneand of the underlying tissues, caused by violence. Three varieties of wounds are described: incised, punctured, andcontused and lacerated. #Incised Wounds. #--Typical examples of incised wounds are those made bythe surgeon in the course of an operation, wounds accidentally inflictedby cutting instruments, and suicidal cut-throat wounds. It should beborne in mind in connection with medico-legal inquiries, that wounds ofsoft parts that closely overlie a bone, such as the skull, the tibia, orthe patella, although, inflicted by a blunt instrument, may have all theappearances of incised wounds. _Clinical Features. _--One of the characteristic features of an incisedwound is its tendency to gape. This is evident in long skin wounds, andespecially when the cut runs across the part, or when it extends deeplyenough to divide muscular fibres at right angles to their long axis. Thegaping of a wound, further, is more marked when the underlying tissuesare in a state of tension--as, for example, in inflamed parts. Incisedwounds in the palm of the hand, the sole of the foot, or the scalp, however, have little tendency to gape, because of the close attachmentof 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 tocontract, it continues to bleed longer than when completely cut across. The _special risks_ of incised wounds are: (1) division of large bloodvessels, leading to profuse hæmorrhage; (2) division of nerve-trunks, resulting in motor and sensory disturbances; and (3) division of tendonsor muscles, interfering with movement. _Treatment. _--If hæmorrhage is still going on, it must be arrested bypressure, torsion, or ligature, as the accumulation of blood in a woundinterferes with union. If necessary, the wound should be purified bywashing with saline solution or eusol, and the surrounding skin paintedwith iodine, after which the edges are approximated by sutures. The rawsurfaces must be brought into accurate apposition, care being taken thatno inversion of the cutaneous surface takes place. In extensive and deepwounds, to ensure more complete closure and to prevent subsequentstretching of the scar, it is advisable to unite the differentstructures--muscles, fasciæ, and subcutaneous tissue--by separate seriesof _buried sutures_ of catgut or other absorbable material. For theapproximation of the skin edges, stitches of horse-hair, fishing-gut, orfine silk are the most appropriate. These _stitches of coaptation_ maybe interrupted or continuous. In small superficial wounds on exposedparts, stitch marks may be avoided by approximating the edges withstrips of gauze fixed in position by collodion, or by subcutaneoussutures of fine catgut. Where the skin is loose, as, for example, in theneck, on the limbs, or in the scrotum, the use of Michel's clips isadvantageous in so far as these bring the deep surfaces of the skin intoaccurate apposition, are introduced with comparatively little pain, andleave only a slight mark if removed within forty-eight hours. When there is any difficulty in bringing the edges of the wound intoapposition, a few interrupted _relaxation stitches_ may be introducedwide of the margins, to take the strain off the coaptation stitches. Stout silk, fishing-gut, or silver wire may be employed for thispurpose. When the tension is extreme, Lister's button suture may beemployed. The tension is relieved and death of skin prevented by scoringit freely with a sharp knife. Relaxation stitches should be removed infour 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 removedin two or three days, thus diminishing the marks they leave. _Drainage. _--In wounds in which no cavity has been left, and in whichthere is no reason to suspect infection, drainage is unnecessary. When, however, the deeper parts of an extensive wound cannot be brought intoaccurate apposition, and especially when there is any prospect of oozingof blood or serum--as in amputation stumps or after excision of thebreast--drainage is indicated. It is a wise precaution also to insertdrainage tubes into wounds in fat patients when there is the slightestreason to suspect the presence of infection. Glass or rubber tubes arethe best drains; but where it is desirable to leave little mark, a fewstrands of horse-hair, or a small roll of rubber, form a satisfactorysubstitute. Except when infection occurs, the drain is removed in fromone to four days and the opening closed with a Michel's clip or asuture. #Punctured Wounds. #--Punctured wounds are produced by narrow, pointedinstruments, and the sharper and smoother the instrument the more doesthe resulting injury resemble an incised wound; while from more roundedand rougher instruments the edges of the wound are more or less contusedor lacerated. The depth of punctured wounds greatly exceeds their width, and the damage to subcutaneous parts is usually greater than that to theskin. When the instrument transfixes a part, the edges of the wound ofentrance may be inverted, and those of the exit wound everted. If theinstrument is a rough one, these conditions may be reversed by itssudden withdrawal. Punctured wounds neither gape nor bleed much. Even when a large vesselis implicated, the bleeding usually takes place into the tissues ratherthan externally. The _risks_ incident to this class of wounds are: (1) the extremedifficulty, especially when a dense fascia has been perforated, ofrendering them aseptic, on account of the uncertainty as to their depth, and of the way in which the surface wound closes on the withdrawal ofthe instrument; (2) different forms of aneurysm may result from thepuncture of a large vessel; (3) perforation of a joint, or of a serouscavity, such as the abdomen, thorax, or skull, materially adds to thedanger. _Treatment. _--The first indication is to purify the whole extent of thewound, and to remove any foreign body or blood-clot that may be in it. It is usually necessary to enlarge the wound, freely dividing injuredfasciæ, paring away bruised tissues, and purifying the wholewound-surface. Any blood vessel that is punctured should be cut acrossand tied; and divided muscles, tendons, or nerves must be sutured. Afterhæmorrhage has been arrested, iodoform and bismuth paste is rubbed intothe raw surface, and the wound closed. If there is any reason to doubtthe 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, asthey so occur in practice. They are produced by crushing, biting, ortearing forms of violence--such as result from machinery accidents, firearms, or the bites of animals. In addition to the irregular wound ofthe integument, there is always more or less bruising of the partsbeneath and around, and the subcutaneous lesions are much wider thanappears on the surface. Wounds of this variety usually gape considerably, especially when thereis much laceration of the skin. It is not uncommon to have considerableportions of skin, muscle, or tendon completely torn away. Hæmorrhage is seldom a prominent feature, as the crushing or tearing ofthe vessel wall leads to the obliteration of the lumen. The _special risks_ of these wounds are: (1) Sloughing of the bruisedtissues, especially when attempts to sterilise the wound have not beensuccessful. (2) Reactionary hæmorrhage after the initial shock haspassed off. (3) Secondary hæmorrhage as a result of infective processesensuing in the wound. (4) Loss of muscle or tendon, interfering withmotion. (5) Cicatricial contraction. (6) Gangrene, which may followocclusion of main vessels, or virulent infective processes. (7) It isnot uncommon to have particles of carbon embedded in the tissues afterlacerated wounds, leaving unsightly, pigmented scars. This is often seenin coal-miners, and in those injured by firearms, and is to be preventedby removing all gross dirt from the edges of the wound. _Treatment. _--In severe wounds of this class implicating theextremities, the most important question that arises is whether or notthe limb can be saved. In examining the limb, attention should first bedirected to the state of the main blood vessels, in order to determineif the vascular supply of the part beyond the lesion is sufficient tomaintain its vitality. Amputation is usually called for if there iscomplete absence of pulsation in the distal arteries and if the partbeyond is cold. If at the same time important nerve-trunks arelacerated, so that the function of the limb would be seriously impaired, it is not worth running the risk of attempting to save it. If, inaddition, there is extensive destruction of large muscular masses or ofimportant tendons, or comminution of the bones, amputation is usuallyimperative. Stripping of large areas of skin is not in itself a reasonfor removing a limb, as much can be done by skin grafting, but when itis associated with other lesions it favours amputation. In consideringthese points, it must be borne in mind that the damage to the deepertissues is always more extensive than appears on the surface, and thatin many cases it is only possible to estimate the real extent of theinjury by administering an anæsthetic and exploring the wound. Indoubtful cases the possibility of rendering the parts aseptic will oftendecide the question for or against amputation. If thorough purificationis accomplished, the success which attends conservative measures isoften remarkable. It is permissible to run an amount of risk to save anupper extremity which would be unjustifiable in the case of a lowerlimb. The age and occupation of the patient must also be taken intoaccount. It having been decided to try and save the limb, the question is onlysettled 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 mustbe thoroughly purified. All bruised tissue in which gross dirt hasbecome engrained should be cut away with knife or scissors. The rawsurface is then cleansed with eusol, washed with sterilised saltsolution followed by methylated spirit, and rubbed all over with "bipp"paste. If the purification is considered satisfactory the wound may beclosed, 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 charactersof wounds produced by modern weapons. For further details the reader isreferred to works on military surgery. Experience has shown that thenature and severity of the injuries sustained in warfare vary widely indifferent campaigns, and even in different fields of the same campaign. Slight variations in the size, shape, and weight of rifle bullets, forexample, may profoundly modify the lesions they produce: witness thedestructive effect of the pointed bullet compared with that of theconical form previously used. The conditions under which the fighting iscarried on also influence the wounds. Those sustained in the open, long-range fighting of the South African campaign of 1899–1902 were verydifferent from those met with in the entrenched warfare in France in1914–1918. It has been found also that the infective complications aregreatly influenced by the terrain in which the fighting takes place. Inthe dry, sandy, uncultivated veldt of South Africa, bullet wounds seldombecame infected, while those sustained in the highly manured fields ofBelgium were almost invariably contaminated with putrefactive organisms, and gaseous gangrene and tetanus were common complications. It has beenfound also that wounds inflicted in naval engagements present differentcharacters from those sustained on land. Many other factors, such as thephysical and mental condition of the men, the facilities for affordingfirst aid, and the transport arrangements, also play a part indetermining the nature and condition of the wounds that have to be dealtwith by military surgeons. Whatever the nature of the weapon concerned, the wound is of the_punctured, contused, and lacerated_ variety. Its severity depends onthe size, shape, and velocity of the missile, the range at which theweapon is discharged, and the part of the body struck. Shock is a prominent feature, but its degree, as well as the time of itsonset, varies with the extent and seat of the injury, and with themental state of the patient when wounded. We have observed pronouncedshock in children after being shot even when no serious injury wassustained. At the moment of injury the patient experiences a sensationwhich is variously described as being like the lash of a whip, a blowwith a stick, or an electric shock. There is not much pain at first, butlater it may become severe, and is usually associated with intensethirst, especially when much blood has been lost. In all forms of wounds sustained in warfare, septic infectionconstitutes the main risk, particularly that resulting fromstreptococci. The presence of anaërobic organisms introduces theadditional danger of gaseous forms of gangrene. The earlier the wound is disinfected the greater is the possibility ofdiminishing this risk. If cleansing is carried out within the first sixhours the chance of eliminating sepsis is good; with every succeedingsix hours it diminishes, until after twenty-four hours it is seldompossible to do more than mitigate sepsis. (J.  T.  Morrison. ) The presence of a metallic foreign body having been determined and itsposition localised by means of the X-rays, all devitalised andcontaminated tissue is excised, the foreign material, _e. G. _, a missile, fragments of clothing, gravel and blood-clot, removed, the woundpurified with antiseptics and closed or drained according tocircumstances. #Pistol-shot Wounds. #--Wounds inflicted by pistols, revolvers, and smallair-guns are of frequent occurrence in civil practice, the weapon beingdischarged usually by accident, but frequently with suicidal, andsometimes with homicidal intent. With all calibres and at all ranges, except actual contact, the wound ofentrance is smaller than the bullet. If the weapon is discharged withina foot of the body, the skin surrounding the wound is usually stainedwith powder and burned, and the hair singed. At ranges varying from sixinches to thirty feet, grains of powder may be found embedded in theskin or lying loose on the surface, the greater the range the widerbeing the area of spread. When black powder is used, the embedded grainsusually leave a permanent bluish-black tattooing of the skin. When theweapon is placed in contact with the skin, the subcutaneous tissues arelacerated over an area of two or three inches around the opening made bythe bullet and smoke and powder-staining and scorching are more markedthan at longer ranges. When the bullet perforates, the exit wound is usually larger and moreextensively lacerated than the wound of entrance. Its margins are as arule everted, and it shows no marks of flame, smoke, or powder. Thesefeatures 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 areimplicated. In the abdomen a lethal injury may readily be caused even bypistols of the "toy" order. These injuries will be described withregional surgery. Pistol-shot wounds of _joints_ and _soft parts_ are seldom of seriousimport apart from the risk of hæmorrhage and of infection. _Treatment. _--The treatment of wounds of the soft parts consists inpurifying the wounds of entrance and exit and the surrounding skin, andin providing for drainage if this is indicated. There being no urgency for the removal of the bullet, time should betaken to have it localised by the X-rays, preferably by stereoscopicplates. In some cases it is not necessary to remove the bullet. #Wounds by Sporting Guns. #--In the common sporting or scatter gun, withwhich accidents so commonly occur during the shooting season, the chargeof small shot or pellets leave the muzzle of the gun as a solid masswhich makes a single ragged wound having much the appearance of thatcaused by a single bullet. At a distance of from four to five feet fromthe muzzle the pellets begin to disperse so that there are separatepunctures around the main central wound. As the range increases, theseoutlying punctures make a wider and wider pattern, until at a distanceof from eighteen to twenty feet from the muzzle, the scattering iscomplete, there is no longer any central wound, and each individualpellet makes its own puncture. From these elementary data, it is usuallypossible, from the features of the wound, to arrive at an approximatelyaccurate 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 afew feet, there is widespread laceration and disruption; if a bone isstruck it is shattered, and portions of bone may be displaced or evendriven out through the exit wound. When the charge impinges over one of the large cavities of the body, theshot may scatter widely through the contained viscera, and there isoften no exit wound. In the thorax, for example, if a rib is struck, thecharge and possibly fragments of bone, will penetrate the pleura, and bedispersed throughout the lung; in the head, the skull may be shatteredand the brain torn up; and in the abdomen, the hollow viscera may beperforated in many places and the solid organs lacerated. On covered parts the clothing, by deflecting the shot, influences thesize and shape of the wound; the entrance wound is increased in size andmore 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 pushessuch structures aside without dividing them. In the abdomen and chest, also, the damage done by a full charge of shot is much more extensivethan that inflicted by a single bullet, the deflection of the pelletsleading to a greater number of perforations of the intestine and morewidespread laceration of solid viscera. When the charge impinges on one of the extremities at close range, weoften have the opportunity of observing that the exit wound is larger, more ragged than that of entrance, and that its edges are everted; theextensive 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 iscomplete, the pellets are still close together, so that if theyencounter the shaft of a long bone, even the femur, they fracture thebone across, often along with some longitudinal splintering. Individual pellets striking the shafts of long bones become flattened ordistorted, and when cancellated bone is struck they become embedded init (Fig. 62). The skin, when it is closely peppered with shot, is liable to lose itsvitality, and with the addition of a little sepsis, readily necroses andcomes away as a slough. When the shot have diverged so as to strike singly, they seldom do muchharm, but fatal damage may be done to the brain or to the aorta, or theeye may be seriously injured by a single pellet. Small shot fired at longer ranges--over about a hundred and fiftyfeet--usually go through the skin, but seldom pierce the fascia, and lieembedded in the subcutaneous tissue, from which they can readily beextracted. The wad of the cartridge behaves erratically: so long as it remains flatit goes off with the rest of the charge, and is often buried in thewound; but if it curls up or turns on its side, it is usually deflectedand flies clear of the shot. It may make a separate wound. Wounds from sporting guns are to be _treated_ on the usual lines, theearly efforts being directed to the alleviation of shock and theprevention of septic infection. There is rarely any urgency in theremoval of pellets from the tissues. #Wounds by Rifle Bullets. #--The vast majority of wounds inflicted byrifle bullets are met with in the field during active warfare, and fallto be treated by military surgeons. They occasionally occuraccidentally, however, during range practice for example, and may thencome under the notice of the civil surgeon. It is only necessary here to consider the effects of modern small-borerifle or machine-gun bullets. The trajectory is practically flat up to 675 yards. In destructiveeffect there is not much difference between the various high velocitybullets used in different armies; they will kill up to a distance of twomiles. The hard covering is employed to enable the bullet to take thegrooves in the rifle, and to prevent it stripping as it passes throughthe barrel. It also increases the penetrating power of the missile, butdiminishes its "stopping" power, unless a vital part or a long bone isstruck. By removing the covering from the point of the bullet, as isdone in the Dum-Dum bullet, or by splitting the end, the bullet is madeto expand or "mushroom" when it strikes the body, and its stopping poweris thereby greatly increased, the resulting wound being much moresevere. These "soft-nosed" expanding bullets are to be distinguishedfrom "explosive" bullets which contain substances which detonate onimpact. High velocity bullets are unlikely to lodge in the body unlessspent, or pulled up by a sandbag, or metal buckle on a belt, or a bookin the pocket, or the core and the case separating--"stripping" of thebullet. Spent shot may merely cause bruising of the surface, or they maypass through the skin and lodge in the subcutaneous tissue, or may evendamage some deeper structure such as a nerve trunk. A blank cartridge fired at close range may cause a severe wound, and, ifcharged with black powder, may leave a permanent bluish-blackpigmentation of the skin. The lesions of individual tissues--bones, nerves, blood vessels--areconsidered with these. #Treatment of Gunshot Wounds under War Conditions. #--It is onlynecessary to indicate briefly the method of dealing with gunshot woundsin warfare as practised in the European War. 1. _On the Field. _--Hæmorrhage is arrested in the limbs by an improvisedtourniquet; in the head by a pad and bandage; in the thorax or abdomenby packing if necessary, but this should be avoided if possible, as itfavours septic infection. If a limb is all but detached it should becompletely severed. A full dose of morphin is given hypodermically. Theampoule of iodine carried by the wounded man is broken, and its contentsare poured over and around the wound, after which the field dressing isapplied. In extensive wounds, the "shell-dressing" carried by thestretcher bearers is preferred. All bandages are applied loosely toallow for subsequent swelling. The fragments of fractured bones areimmobilised by some form of emergency splint. 2. _At the Advanced Dressing Station_, after the patient has had aliberal allowance of warm fluid nourishment, such as soup or tea, a fulldose of anti-tetanic serum is injected. The tourniquet is removed andthe wound inspected. Urgent amputations are performed. Moribund patientsare detained lest they die _en route_. 3. _In the Field Ambulance or Casualty Clearing Station_ furthermeasures are employed for the relief of shock, and urgent operations areperformed, such as amputation for gangrene, tracheotomy for dyspnœa, orlaparotomy for perforated or lacerated intestine. In the majority ofcases the main object is to guard against infection; the skin isdisinfected over a wide area and surrounded with towels; damaged tissue, especially muscle, is removed with the knife or scissors, and foreignbodies are extracted. Torn blood vessels, and, if possible, nerves andtendons are repaired. The wound is then partly closed, provision beingmade for free drainage, or some special method of irrigation, such asthat 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 becalled for according to the progress of the wound and the condition ofthe patient. #Shell Wounds and Wounds produced by Explosions. #--It is convenient toconsider together the effects of the bursting of shells fired from heavyordnance and those resulting in the course of blasting operations fromthe discharge of dynamite or other explosives, or from the bursting ofsteam boilers or pipes, the breaking of machinery, and similar accidentsmet with in civil practice. Wounds inflicted by shell fragments and shrapnel bullets tend to beextensive in area, and show great contusion, laceration, and destructionof the tissues. The missiles frequently lodge and carry portions of theclothing and, it may be, articles from the man's pocket, with them. Shell wounds are attended with a considerable degree of shock. Onaccount of the wide area of contusion which surrounds the actual woundproduced by shell fragments, amputation, when called for, should beperformed some distance above the torn tissues, as there is considerablerisk of sloughing of the flaps. Wounds produced by dynamite explosions and the bursting of boilers havethe same general characters as shell wounds. Fragments of stone, coal, or metal may lodge in the tissues, and favour the occurrence ofinfective complications. All such injuries are to be treated on the general principles governingcontused and lacerated wounds. EMBEDDED FOREIGN BODIES In the course of many operations foreign substances are introduced intothe tissues and intentionally left there, for example, suture andligature materials, steel or aluminium plates, silver wire or ivory pegsused to secure the fixation of bones, or solid paraffin employed tocorrect 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, forexample, bullets, needles, splinters of wood, or fragments of clothing. The needles of hypodermic syringes sometimes break and a portion remainsembedded in the tissues. As a result of explosions, particles of carbon, in the form of coal-dust or gunpowder, or portions of shale, may lodgein a wound. The embedded foreign body at first acts as an irritant, and induces areaction in the tissues in which it lodges, in the form of hyperæmia, local leucocytosis, proliferation of fibroblasts, and the formation ofgranulation tissue. The subsequent changes depend upon whether or notthe wound is infected with pyogenic bacteria. If it is so infected, suppuration ensues, a sinus forms, and persists until the foreign bodyis either cast out or removed. If the wound is aseptic, the fate of the foreign body varies with itscharacter. A substance that is absorbable, such as catgut or fine silk, is surrounded and permeated by the phagocytes, which soften anddisintegrate it, the debris being gradually absorbed in much the samemanner as a fibrinous exudate. Minute bodies that are not capable ofbeing absorbed, such as particles of carbon, or of pigment used intattooing, are taken up by the phagocytes, and in course of timeremoved. Larger bodies, such as needles or bullets, which are notcapable of being destroyed by the phagocytes, become encapsulated. Inthe granulation tissue by which they are surrounded large multinucleargiant-cells appear ("_foreign-body giant-cells_") and attach themselvesto the foreign body, the fibroblasts proliferate and a capsule of scartissue is eventually formed around the body. The tissues of the capsulemay show evidence of iron pigmentation. Sometimes fluid accumulatesaround a foreign body within its capsule, constituting a cyst. Substances like paraffin, strands of silk used to bridge a gap in atendon, or portions of calcined bone, instead of being encapsulated, aregradually permeated and eventually replaced by new connective tissue. Embedded bodies may remain in the tissues for an indefinite periodwithout giving rise to inconvenience. At any time, however, they maycause trouble, either as a result of infective complications, or byinducing the formation of a mass of inflammatory tissue around them, which may simulate a gumma, a tuberculous focus, or a sarcoma. Thislatter condition may give rise to difficulties in diagnosis, particularly if there is no history forthcoming of the entrance of theforeign body. The ignorance of patients regarding the possible lodgmentin the tissues of a foreign body--even of considerable size--isremarkable. In such cases the X-rays will reveal the presence of theforeign body if it is sufficiently opaque to cast a shadow. The heavy, lead-containing varieties of glass throw very definite shadows littleinferior in sharpness and definition to those of metal; almost all theordinary forms of commercial glass also may be shown up by the X-rays. Foreign bodies encapsulated in the peritoneal cavity are speciallydangerous, as the proximity of the intestine furnishes a constantpossibility of infection. The question of removal of the foreign body must be decided according tothe conditions present in individual cases; in searching for a foreignbody in the tissues, unless it has been accurately located, a generalanæsthetic is to be preferred. BURNS AND SCALDS The distinction between a burn which results from the action of dry heaton the tissues of the body and a scald which results from the action ofmoist heat, has no clinical significance. In young and debilitated subjects hot poultices may produce injuries ofthe nature of burns. In old people with enfeebled circulation mereexposure to a strong fire may cause severe degrees of burning, theclothes covering the part being uninjured. This may also occur about thefeet, legs, or knees of persons while intoxicated who have fallen asleepbefore the fire. The damage done to the tissues by strong caustics, such as fuming nitricacid, sulphuric acid, caustic potash, nitrate of silver, or arsenicalpaste, presents pathological and clinical features almost identical withthose resulting from heat. Electricity and the Röntgen rays also producelesions of the nature of burns. _Pathology of Burns. _--Much discussion has taken place regarding theexplanation of the rapidly fatal issue in extensive superficial burns. On post-mortem examination the lesions found in these cases are: (1)general hyperæmia of all the organs of the abdominal, thoracic, andcerebro-spinal cavities; (2) marked leucocytosis, with destruction ofred corpuscles, setting free hæmoglobin which lodges in the epithelialcells of the tubules of the kidneys; (3) minute thrombi andextravasations throughout the tissues of the body; (4) degeneration ofthe ganglion cells of the solar plexus; (5) œdema and degeneration ofthe lymphoid tissue throughout the body; (6) cloudy swelling of theliver and kidneys, and softening and enlargement of the spleen. Bardeensuggests that these morbid phenomena correspond so closely to those metwith where the presence of a toxin is known to produce them, that in allprobability death is similarly due to the action of some poison producedby the action of heat on the skin and on the proteins of the blood. #Clinical Features--Local Phenomena. #--The most generally acceptedclassification of burns is that of Dupuytren, which is based upon thedepth of the lesion. Six degrees are thus, recognised: (1) hyperæmia orerythema; (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 alwaysillustrate more than one of these degrees, the deeper forms always beingassociated with those less deep, and the clinical picture is made up ofthe combined characters of all. A burn is classified in terms of itsmost severe portion. It is also to be remarked that the extent andseverity of a burn usually prove to be greater than at first sightappears. _Burns of the first degree_ are associated with erythema of the skin, due to hyperæmia of its blood vessels, and result from scorching byflame, from contact with solids or fluids below 212° F. , or fromexposure to the sun's rays. They are characterised clinically by acutepain, redness, transitory swelling from œdema, and subsequentdesquamation of the surface layers of the epidermis. A special form ofpigmentation of the skin is seen on the front of the legs of women fromexposure to the heat of the fire. _Burns of Second Degree--Vesication of the Skin. _--These arecharacterised by the occurrence of vesicles or blisters which arescattered over the hyperæmic area, and contain a clear yellowish orbrownish fluid. On removing the raised epidermis, the congested andhighly sensitive papillæ of the skin are exposed. Unna has found thatpyogenic bacteria are invariably present in these blisters. Burns of thesecond degree leave no scar but frequently a persistent discoloration. In rare instances the burned area becomes the seat of a peculiarovergrowth of fibrous tissue of the nature of keloid (p 401). _Burns of Third Degree--Partial Destruction of the Skin. _--The epidermisand papillæ are destroyed in patches, leaving hard, dry, and insensitivesloughs of a yellow or black colour. The pain in these burns isintense, but passes off during the first or second day, to return again, however, when, about the end of a week, the sloughs separate and exposethe nerve filaments of the underlying skin. Granulations spring up tofill the gap, and are rapidly covered by epithelium, derived partly fromthe margins and partly from the remains of skin glands which have notbeen completely destroyed. These latter appear on the surface of thegranulations as small bluish islets which gradually increase in size, become of a greyish-white colour, and ultimately blend with one anotherand 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 followthe more prolonged action of any form of intense heat. Large, black, dryeschars are formed, surrounded by a zone of intense congestion. Pain isless severe, and is referred to the parts that have been burned to aless degree. Infection is liable to occur and to lead to widedestruction of the surrounding skin. The amount of granulation tissuenecessary to fill the gap is therefore great; and as the epithelialcovering can only be derived from the margins--the skin glands beingcompletely destroyed--the healing process is slow. The resulting scarsare irregular, deep and puckered, and show a great tendency to contract. Keloid frequently develops in such cicatrices. When situated in theregion of the face, neck, or flexures of joints, much deformity andimpairment of function may result (Fig. 63). [Illustration: FIG.  63. --Cicatricial Contraction following Severe Burn. ] In _burns of the fifth degree_ the lesion extends through thesubcutaneous 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 usuallyproduced by prolonged contact with hot metal or caustics. Burns of thefifth and sixth degrees are met with in epileptics or intoxicatedpersons 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 ofa severe burn into three periods; but it is to be observed that thefeatures characteristic of the periods have been greatly modified sinceburns 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 stateof _shock_, and there is a remarkable absence of pain. When shock isabsent 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 producedin the burned tissues. In fatal cases there is often evidence ofcerebral congestion and œdema. The _second period_ begins when the shock passes off, and lasts till thesloughs separate. The outstanding feature of this period is _toxæmia_, manifested by fever, the temperature rising to 102°, 103°, or 104° F. , and congestive or inflammatory conditions of internal organs, givingrise to such clinical complications as bronchitis, broncho-pneumonia, orpleurisy--especially in burns of the thorax; or meningitis andcerebritis, when the neck or head is the seat of the burn. Intestinalcatarrh associated with diarrhœa is not uncommon; and ulceration of theduodenum leading to perforation has been met with in a few cases. Thesephenomena are much more prominent when bacterial infection has takenplace, and it seems probable that they are to be attributed chiefly tothe infection, as they have become less frequent and less severe sinceburns have been treated like other breaches of the surface. Albuminuriais a fairly constant symptom in severe burns, and is associated withcongestion of the kidneys. In burns implicating the face, neck, mouth, or pharynx, œdema of the glottis is a dangerous complication, entailingas it does the risk of suffocation. The _third period_ begins when the sloughs separate, usually betweenthe seventh and fourteenth days, and lasts till the wound heals, itsduration depending upon the size, depth, and asepticity of the raw area. The chief causes of death during this period are toxin absorption in anyof its forms; waxy disease of the liver, kidneys, or intestine; lesscommonly erysipelas, tetanus, or other diseases due to infection byspecific organisms. We have seen nothing to substantiate the belief thatduodenal ulcers are liable to perforate during the third period. The _prognosis_ in burns depends on (1) the superficial extent, and, toa much less degree, the depth of the injury. When more than one-third ofthe entire surface of the body is involved, even in a mild degree, theprognosis is grave. (2) The situation of the burn is important. Burnsover the serous cavities--abdomen, thorax, or skull--are, other thingsbeing equal, much more dangerous than burns of the limbs. The risk ofœdema of the glottis in burns about the neck and mouth has already beenreferred to. (3) Children are more liable to succumb to shock during theearly period, but withstand prolonged suppuration better than adults. (4) When the patient survives the shock, the presence or absence ofinfection 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 onantiseptic lines, a general anæsthetic being administered, if necessary, to enable the purification to be carried out thoroughly. After carefullyremoving the clothing, the whole of the burned area is gently, butthoroughly, cleansed with peroxide of hydrogen or warm boracic lotion, followed by sterilised saline solution. As pyogenic bacteria areinvariably found in the blisters of burns, these must be opened and theraised epithelium removed. The dressings subsequently applied should meet the followingindications: the relief of pain; the prevention of sepsis; and thepromotion of cicatrisation. An application which satisfactorily fulfils these requirements is_picric acid_. Pads of lint or gauze are lightly wrung out of a solutionmade up of picric acid, 1½ drams; absolute alcohol, 3 ounces;distilled water, 40 ounces, and applied over the whole of the reddenedarea. These are covered with antiseptic wool, _without_ any waterproofcovering, and retained in position by a many-tailed bandage. Thedressing should be changed once or twice a week, under the guidance ofthe temperature chart, any portion of the original dressing whichremains perfectly dry being left undisturbed. The value of a generalanæsthetic in dressing extensive burns, especially in children, canscarcely be overestimated. Picric acid yields its best results in superficial burns, and it isuseful as _a primary dressing_ in all. As soon as the sloughs separateand a granulating surface forms, the ordinary treatment for a healingsore is instituted. Any slough under which pus has collected should becut away with scissors to permit of free drainage. An occlusive dressing of melted _paraffin_ has also been employed. Auseful preparation consists of: Paraffin molle 25 per cent. , paraffindurum 67 per cent. , olive oil 5 per cent. , oil of eucalyptus 2 percent. , and beta-naphthol ¼ per cent. It has a melting point of 48° C. It is also known as _Ambrine_ and _Burnol_. After the burned area hasbeen cleansed and thoroughly dried, it is sponged or painted with themelted paraffin, and before solidification takes place a layer ofsterilised gauze is applied and covered with a second coating ofparaffin. Further coats of paraffin are applied every other day toprevent the gauze sticking to the skin. An alternative method of treating extensive burns is by immersing thepart, or even the whole body when the trunk is affected, in a bath ofboracic lotion kept at the body temperature, the lotion being frequentlyrenewed. If a burn is already infected when first seen, it is to be treated onthe same principles as govern the treatment of other infected wounds. All moist or greasy applications, such as Carron oil, carbolic oil andointments, and all substances like collodion and dry powders, whichretain discharges, entirely fail to meet the indications for therational treatment of burns, and should be abandoned. Skin-grafting is of great value in hastening healing after extensiveburns, and in preventing cicatricial contraction. The _deformities_which are so liable to develop from contraction of the cicatrices aretreated on general principles. In the region of the face, neck, andflexures of joints (Fig. 63), where they are most marked, the contractedbands may be divided and the parts stretched, the raw surface left beingcovered by Thiersch grafts or by flaps of skin raised from adjacentsurfaces or from other parts of the body (Fig. 1). INJURIES PRODUCED BY ELECTRICITY #Injuries produced by Exposure to X-Rays and Radium. #--In the routinetreatment of disease by radiations, injury is sometimes done to thetissues, even when the greatest care is exercised as to dosage andfrequency of application. Robert Knox describes the followingill-effects. _Acute dermatitis_ varying in degree from a slight erythema to deepulceration or even necrosis of skin. When ulcers form they are extremelypainful and slow to heal. When hair-bearing areas are affected, epilation may occur without destroying the hair follicles and the hairsare reproduced, but if the reaction is excessive permanent alopecia mayresult. _Chronic dermatitis_, which results from persistence of the acute form, is most intractable and may assume malignant characters. X-ray warts area late manifestation of chronic dermatitis and may become malignant. Among the _late manifestations_ are neuritis, telangiectasis, and apainful and intractable form of ulceration, any of which may come onmonths or even years after the cessation of exposure. _Sterility_ may beinduced in X-ray workers who are imperfectly protected from the effectsof the rays. #Electrical burns# usually occur in those who are engaged in industrialundertakings where powerful electrical currents are employed. The lesions--which vary from a slight superficial scorching to completecharring of parts--are most evident at the points of entrance and exitof the current, the intervening tissues apparently escaping injury. The more superficial degrees of electrical burns differ from thoseproduced 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 theshock in an ordinary burn of corresponding severity. The parts at thepoint of entrance of the current are charred to a greater or lesserdepth. The eschar is at first dry and crisp, and is surrounded by a zoneof pallor. For the first thirty-six to forty-eight hours there iscomparatively little suffering, but at the end of that time the partsbecome exceedingly painful. In a majority of cases, in spite of carefulpurification, a slow form of moist gangrene sets in, and the sloughspreads both in area and in depth, until the muscles and often thelarge blood vessels and nerves are exposed. A line of demarcationeventually forms, but the sloughs are exceedingly slow to separate, taking from three to five times as long as in an ordinary burn, andduring the process of separation there is considerable risk of secondaryhæmorrhage from erosion of large vessels. _Treatment. _--Electrical burns are treated on the same lines as ordinaryburns, by thorough purification and the application of dry dressings, with a view to avoiding the onset of moist gangrene. After granulationshave formed, skin-grafting is of value in hastening healing. #Lightning-stroke. #--In a large proportion of cases lightning-strokeproves instantly fatal. In non-fatal cases the patient suffers from aprofound degree of shock, and there may or may not be any externalevidence of injury. In the mildest cases red spots or wheals--closelyresembling those of urticaria--may appear on the body, but they usuallyfade again in the course of twenty-four hours. Sometimes large patchesof skin are scorched or stained, the discoloured area showing anarborescent appearance. In other cases the injured skin becomes dry andglazed, resembling parchment. Appearances are occasionally met withcorresponding to those of a superficial burn produced by heat. The chiefdifference from ordinary burns is the extreme slowness with whichhealing takes place. Localised paralysis of groups of muscles, or evenof a whole limb, may follow any degree of lightning-stroke. Treatment ismainly directed towards combating the shock, the surface-lesions beingtreated 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 alreadybroken_, or in which a communication with a mucous surface exists; and(2) those that he himself makes _through intact skin_, no infectedmucous surface being involved. Infection by bacteria must be assumed to have taken place in all woundsmade in any other way than by the knife of the surgeon operating throughunbroken skin. On this assumption the modern system of wound treatmentis based. Pathogenic bacteria are so widely distributed, that in theordinary circumstances of everyday life, no matter how trivial a woundmay be, or how short a time it may remain exposed, the access oforganisms to it is almost certain unless preventive measures areemployed. It cannot be emphasised too strongly that rigid precautions are to betaken to exclude fresh infection, not only in dealing with wounds thatare free of organisms, but equally in the management of wounds and otherlesions that are already infected. Any laxity in our methods whichadmits of fresh organisms reaching an infected wound adds materially tothe severity of the infective process and consequently to the patient'srisk. There are many ways in which accidental infection may occur. Take, forexample, the case of a person who receives a cut on the face by beingknocked down in a carriage accident on the street. Organisms may beintroduced to such a wound from the shaft or wheel by which he wasstruck, from the ground on which he lay, from any portion of hisclothing that may have come in contact with the wound, or from his ownskin. Or, again, the hands of those who render first aid, the water usedto bathe the wound, the handkerchief or other extemporised dressingapplied to it, may be the means of conveying bacterial infection. Shouldthe wound open on a mucous surface, such as the mouth or nasal cavity, the organisms constantly present in such situations are liable to proveagents of infection. Even after the patient has come under professional care the risks of hiswound becoming infected are not past, because the hands of the doctor, his instruments, dressings, or other appliances may all, unlesspurified, become the sources of infection. In the case of an operation carried out through unbroken skin, organismsmay be introduced into the wound from the patient's own skin, from thehands of the surgeon or his assistants, through the medium ofcontaminated instruments, swabs, ligature or suture materials, or otherthings used in the course of the operation, or from the dressingsapplied to the wound. Further, bacteria may gain access to devitalised tissues by way of theblood-stream, being carried hither from some infected area elsewhere inthe body. _The Antiseptic System of Surgery. _--Those who only know the surgicalconditions of to-day can scarcely realise the state of matters whichexisted before the introduction of the antiseptic system by JosephLister in 1867. In those days few wounds escaped the ravages of pyogenicand other bacteria, with the result that suppuration ensued after mostoperations, and such diseases as erysipelas, pyæmia, and "hospitalgangrene" were of everyday occurrence. The mortality after compoundfractures, amputations, and many other operations was appalling, anddeath from blood-poisoning frequently followed even the most trivialoperations. An operation was looked upon as a last resource, and theinherent risk from blood-poisoning seemed to have set an impassablebarrier to the further progress of surgery. To the genius of Lister weowe it that this barrier was removed. Having satisfied himself that theseptic process was due to bacterial infection, he devised a means ofpreventing the access of organisms to wounds or of counteracting theireffects. Carbolic acid was the first antiseptic agent he employed, andby its use in compound fractures he soon obtained results such as hadnever before been attained. The principle was applied to otherconditions with like success, and so profoundly has it affected thewhole aspect of surgical pathology, that many of the infective diseaseswith which surgeons formerly had to deal are now all but unknown. Thebroad principles upon which Lister founded his system remain unchanged, although the methods employed to put them into practice have beenmodified. #Means taken to Prevent Infection of Wounds. #--The avenues by whichinfective agents may gain access to surgical wounds are so numerous andso wide, that it requires the greatest care and the most watchfulattention on the part of the surgeon to guard them all. It is only byconstant practice and patient attention to technical details in theoperating room and at the bedside, that the carrying out of surgicalmanipulations in such a way as to avoid bacterial infection will becomean instinctive act and a second nature. It is only possible here toindicate the chief directions in which danger lies, and to describe themeans most generally adopted to avoid it. To prevent infection, it is essential that everything which comes intocontact with a wound should be sterilised or disinfected, and to ensurethe best results it is necessary that the efficiency of our methods ofsterilisation should be periodically tested. The two chief agencies atour disposal are heat and chemical antiseptics. #Sterilisation by Heat. #--The most reliable, and at the same time themost convenient and generally applicable, means of sterilisation is byheat. All bacteria and spores are completely destroyed by beingsubjected for fifteen minutes to _saturated circulating steam_ at atemperature of 130° to 145° C. (= 266° to 293° F. ). The articles to besterilised are enclosed in a perforated tin casket, which is placed in aspecially constructed steriliser, such as that of Schimmelbusch. Thisapparatus is so arranged that the steam circulates under a pressure offrom two to three atmospheres, and permeates everything contained in it. Objects so sterilised are dry when removed from the steriliser. Thismethod is specially suitable for appliances which are not damaged bysteam, such, for example, as gauze swabs, towels, aprons, gloves, andmetal instruments; it is essential that the efficiency of the steriliserbe tested from time to time by a self-registering thermometer or othermeans. The best substitute for circulating steam is _boiling_. The articles areplaced in a "fish-kettle steriliser" and boiled for fifteen minutes in a1 per cent. Solution of washing soda. To prevent contamination of objects that have been sterilised they muston no account be touched by any one whose hands have not beendisinfected and protected by sterilised gloves. #Sterilisation by Chemical Agents. #--For the purification of the skin ofthe patient, the hands of the surgeon, and knives and other instrumentsthat are damaged by heat, recourse must be had to chemical agents. These, however, are less reliable than heat, and are open to certainother objections. #Disinfection of the Hands. #--It is now generally recognised that one ofthe most likely sources of wound infection is the hands of the surgeonand his assistants. It is only by carefully studying to avoid allcontact with infective matter that the hands can be kept surgicallypure, and that this source of wound infection can be reduced to aminimum. The risk of infection from this source has further been greatlyreduced by the systematic use of rubber gloves by house-surgeons, dressers, and nurses. The habitual use of gloves has also been adoptedby the great majority of surgeons; the minority, who find they arehandicapped by wearing gloves as a routine measure, are obliged to do sowhen operating in infective cases or dressing infected wounds, and inmaking rectal and vaginal examinations. The gloves may be sterilised by steam, and are then put on dry, or byboiling, in which case they are put on wet. The gauntlet of the gloveshould overlap and confine the end of the sleeve of the sterilisedoverall, and the gloved hands are rinsed in lotion before and atfrequent intervals during the operation. The hands are sterilised beforeputting on the gloves, preferably by a method which dehydrates the skin. Cotton gloves may be worn by the surgeon when tying ligatures, orbetween operations, and by the anæsthetist during operations on thehead, neck, and chest. The first step in the disinfection of the hands is the mechanicalremoval of gross surface dirt and loose epithelium by soap, a stream ofrunning water as hot as can be borne, and a loofah or nail-brush, thathas been previously sterilised by heat. The nails should be cut downtill there is no sulcus between the nail edge and the pulp of the fingerin which organisms may lodge. They are next washed for three minutes inmethylated spirit to dehydrate the skin, and then for two or threeminutes 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 theskin of the patient before operation, reliance is to be placed chieflyin the mechanical removal of dirt and grease by the same means as aretaken for the cleansing of the surgeon's hands. Hair-covered partsshould be shaved. The skin is then dehydrated by washing with methylatedspirit, followed by 70 per cent. Sublimate or biniodide alcohol (1 in1000). This is done some hours before the operation, and the part isthen covered with pads of dry sterilised gauze or a sterilised towel. Immediately before the operation the skin is again purified in the sameway. The _iodine method_ of disinfecting the skin introduced by Grossich issimple, and equally efficient. The day before operation the skin, afterbeing washed with soap and water, is shaved, dehydrated by means ofmethylated spirit, and then painted with a 5 per cent. Solution ofiodine in rectified spirit. The painting with iodine is repeated justbefore the operation commences, and again after it is completed. Thefinal application is omitted in the case of children. In emergencyoperations the skin is shaved dry and dehydrated with spirit, afterwhich the iodine is applied as described above. The staining of the skinis an advantage, as it enables the operator to recognise the area thathas been prepared. If any acne pustules or infected sinuses are present, they should bedestroyed or purified by means of the thermo-cautery or pure carbolicacid, after the patient is anæsthetised. #Appliances used at Operation. #--_Instruments_ that are not damaged byheat must be boiled in a fish-kettle or other suitable steriliser forfifteen minutes in a 1 per cent. Solution of cresol or washing soda. Just before the operation begins they are removed in the tray of thesteriliser and placed on a sterilised towel within reach of the surgeonor his assistant. Knives and instruments that are liable to be damagedby heat should be purified by being soaked in pure cresol for a fewminutes, or in 1 in 20 carbolic for at least an hour. _Pads of Gauze_ sterilised by compressed circulating steam have almostentirely superseded marine sponges for operative purposes. To avoid therisk of leaving swabs in the peritoneal cavity, large square pads ofgauze, to one corner of which a piece of strong tape about a foot longis securely stitched, should be employed. They should be removed fromthe caskets in which they are sterilised by means of sterilised forceps, and handed direct to the surgeon. The assistant who attends to the swabsshould wear sterilised gloves. _Ligatures and Sutures. _--To avoid the risk of implanting infectivematter in a wound by means of the materials used for ligatures andsutures, great care must be taken in their preparation. _Catgut. _--The following methods of preparing catgut have provedsatisfactory: (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 gutpreserved in 1 in 1000 solution of corrosive sublimate in alcohol(Kocher). (2) The gut is placed in a brass receiver and boiled forthree-quarters of an hour in a solution consisting of 85 per cent. Absolute alcohol, 10 per cent. Water, and 5 per cent. Carbolic acid, andis then stored in 90 per cent. Alcohol. (3) Cladius recommends that thecatgut, just as it is bought from the dealers, be loosely rolled on aspool, and then immersed in a solution of--iodine, 1 part; iodide ofpotassium, 1 part; distilled water, 100 parts. At the end of eight daysit is ready for use. Moschcowitz has found that the tensile strength ofcatgut so prepared is increased if it is kept dry in a sterile vessel, instead of being left indefinitely in the iodine solution. IfSalkindsohn's formula is used--tincture of iodine, 1 part; proof spirit, 15 parts--the gut can be kept permanently in the solution withoutbecoming brittle. To avoid contamination from the hands, catgut shouldbe removed from the bottle with aseptic forceps and passed direct to thesurgeon. Any portion unused should be thrown away. _Silk_ is prepared by being soaked for twelve hours in ether, for othertwelve in alcohol, and then boiled for ten minutes in 1 in 1000sublimate solution. It is then wound on spools with purified handsprotected by sterilised gloves, and kept in absolute alcohol. Before anoperation the silk is again boiled for ten minutes in the same solution, and is used directly from this (Kocher). Linen thread is sterilised inthe same way as silk. Fishing-gut and silver wire, as well as the needles, should be boiledalong with the instruments. Horse-hair and fishing-gut may be sterilisedby prolonged immersion in 1 in 20 carbolic, or in the iodine solutionsemployed to sterilise catgut. The field of operation is surrounded by sterilised towels, clipped tothe edges of the wound, and securely fixed in position so that nocontamination may take place from the surroundings. The surgeon and his assistants, including the anæsthetist, wearoveralls sterilised by steam. To avoid the risk of infection from dust, scurf, or drops of perspiration falling from the head, the surgeon andhis assistants may wear sterilised cotton caps. To obviate the risk ofinfection taking place by drops of saliva projected from the mouth intalking or coughing in the vicinity of a wound, a simple mask may beworn. The risk of infection from the _air_ is now known to be very small, solong as there is no excess of floating dust. All sweeping, dusting, anddisturbing of curtains, blinds, or furniture must therefore be avoidedbefore or during an operation. It has been shown that the presence of spectators increases the numberof organisms in the atmosphere. In teaching clinics, therefore, the riskfrom air infection is greater than in private practice. To facilitate primary union, all hæmorrhage should be arrested, and theaccumulation of fluid in the wound prevented. When much oozing isanticipated, a glass or rubber drainage-tube is inserted through a smallopening specially made for the purpose. In aseptic wounds the tube maybe removed in from twenty-four to forty-eight hours, and where it isimportant to avoid a scar, the opening should be closed with a Michel'sclip; in infected wounds the tube must remain as long as the dischargecontinues. The fascia and skin should be brought into accurate apposition bysutures. If any cavity exists in the deeper part of the wound it shouldbe obliterated by buried sutures, or by so adjusting the dressing as tobring its walls into apposition. If these precautions have been successful, the wound will heal under theoriginal dressing, which need not be interfered with for from seven toten days, according to the nature of the case. #Dressings. #--_Gauze_, sterilised by heat, is almost universallyemployed for the dressing of wounds. _Double cyanide gauze_ may be usedin such regions as the neck, axilla, or groin, where completesterilisation of the skin is difficult to attain, and where it isdesirable to leave the dressing undisturbed for ten days or more. _Iodoform_ or _bismuth gauze_ is of special value for the packing ofwounds treated by the open method. One variety or another of _wool_, rendered absorbent by the extractionof its fat, and sterilised by heat, forms a part of almost everysurgical dressing, and various antiseptic agents may be added to it. Ofthese, corrosive sublimate is the most generally used. Wood-wooldressings are more highly and more uniformly absorbent than cottonwools. As evaporation takes place through wool dressings, the dischargebecomes dried, and so forms an unfavourable medium for bacterial growth. Pads of _sphagnum moss_, sterilised by heat, are highly absorbent, andbeing economical are used when there is much discharge, and in caseswhere a leakage of urine has to be soaked up. #Means adopted to combat Infection. #--As has already been indicated, thesame antiseptic precautions are to be taken in dealing with infected aswith aseptic wounds. In _recent injuries_ such as result from railway or machinery accidents, with bruising and crushing of the tissues and grinding of gross dirtinto the wounds, the scissors must be freely used to remove the tissuesthat have been devitalised or impregnated with foreign material. Hair-covered parts should be shaved and the surrounding skin paintedwith iodine. Crushed and contaminated portions of bone should bechiselled away. Opinions differ as to the benefit derived from washingsuch wounds with chemical antiseptics, which are liable to devitalisethe tissues with which they come in contact, and so render them lessable to resist the action of any organisms that may remain in them. Allare agreed, however, that free washing with normal salt solution isuseful in mechanically cleansing the injured parts. Peroxide of hydrogensprayed over such wounds is also beneficial in virtue of its oxidisingproperties. Efficient drainage must be provided, and stitches should beused sparingly, if at all. The best way in which to treat such wounds is by the _open method_. Thisconsists in packing the wound with iodoform or bismuth gauze, which isleft in position as long as it adheres to the raw surface. The packingmay be renewed at intervals until the wound is filled by granulations;or, in the course of a few days when it becomes evident that theinfection has been overcome, _secondary_ sutures may be introduced andthe edges drawn together, provision being made at the ends for furtherpacking or for drainage-tubes. If earth or street dirt has entered the wound, the surface may withadvantage be painted over with pure carbolic acid, as virulentorganisms, such as those of tetanus or spreading gangrene, are liable tobe present. Prophylactic injection of tetanus antitoxin may beindicated. 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, althoughdepending on different causes, bear a superficial resemblance to oneanother. #Syncope or Fainting. #--Syncope is the result of a suddenly producedanæmia of the brain from temporary weakening or arrest of the heart'saction. In surgical practice, this condition is usually observed innervous persons who have been subjected to pain, as in the reduction ofa dislocation or the incision of a whitlow; or in those who have rapidlylost a considerable quantity of blood. It may also follow the suddenwithdrawal of fluid from a large cavity, as in tapping an abdomen forascites, or withdrawing fluid from the pleural cavity. Syncope sometimesoccurs also during the administration of a general anæsthetic, especially if there is a tendency to sickness and the patient is notcompletely under. During an operation the onset of syncope is oftenrecognised by the cessation of oozing from the divided vessels beforethe 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 themouth. The pupils dilate; the pulse becomes small and almostimperceptible; the respirations shallow and hurried; consciousnessgradually fades away, and he falls in a heap on the floor. Sometimes vomiting ensues before the patient completely losesconsciousness, and the muscular exertion entailed may ward off theactual faint. This is frequently seen in threatened syncopal attacksduring chloroform administration. Recovery begins in a few seconds, the patient sighing or gasping, or, itmay be, vomiting; the strength of the pulse gradually increases, andconsciousness slowly returns. In some cases, however, syncope is fatal. _Treatment. _--The head should at once be lowered--in imitation ofnature's method--to encourage the flow of blood to the brain, thepatient, if necessary, being held up by the heels. All tight clothing, especially round the neck or chest, must be loosened. The heart may bestimulated reflexly by dashing cold water over the face or chest, or byrubbing the face vigorously with a rough towel. The application ofvolatile substances, such as ammonia or smelling-salts, to the nose; theadministration by the mouth of sal-volatile, whisky or brandy, and theintra-muscular injection of ether, are the most speedily efficaciousremedies. In severe cases the application of hot cloths over the heart, or of the faradic current over the line of the phrenic nerve, just abovethe clavicle, may be called for. #Surgical Shock. #--The condition known as surgical shock may be lookedupon as a state of profound exhaustion of the mechanism that exists inthe body for the transformation of energy. This mechanism consists of(1) the _brain_, which, through certain special centres, regulates allvital activity; (2) the _adrenal glands_, the secretion ofwhich--adrenalin--acting as a stimulant of the sympathetic system, socontrols the tone of the blood vessels as to maintain efficientoxidation of the tissues; and (3) _the liver_, which stores and deliversglycogen as it is required by the muscles, and in addition, deals withthe by-products of metabolism. Crile and his co-workers have shown that in surgical shock histologicalchanges occur in the cells of the brain, the adrenals, and the liver, and that these are identical, whatever be the cause that leads to theexhaustion of the energy-transforming mechanism. These changes vary indegree, and range from slight alterations in the structure of theprotoplasm to complete disorganisation of the cell elements. The influences which contribute to bring about this form of exhaustionthat we call shock are varied, and include such emotional states asfear, anxiety, or worry, physical injury and toxic infection, and theeffects of these factors are augmented by anything that tends to lowerthe vitality, such as loss of blood, exposure, insufficient food, lossof sleep or antecedent illness. Any one or any combination of these influences may cause shock, but themost potent, and the one which most concerns the surgeon, is physicalinjury, _e. G. _, a severe accident or an operation (_traumatic shock_). This is usually associated with some emotional disturbance, such as fearor anxiety (_emotional shock_), or with hæmorrhage; and may be followedby septic infection (_toxic shock_). The exaggerated afferent impulses reaching the brain as a result oftrauma, inhibit the action of the nuclei in the region of the fourthventricle and cerebellum which maintain the muscular tone, with theresult that the muscular tone is diminished and there is a marked fallin the arterial blood pressure. The capillaries dilate--the bloodstagnating in them and giving off its oxygen and transuding its fluidelements into the tissues--with the result that an insufficient quantityof oxygenated blood reaches the heart to enable it to maintain anefficient circulation. As the sarco-lactic acid liberated in the musclesis not oxygenated a condition of acidosis ensues. The more highly the injured part is endowed with sensory nerves the moremarked is the shock; a crush of the hand, for example, is attended witha more intense degree of shock than a correspondingly severe crush ofthe foot; and injuries of such specially innervated parts as the testis, the urethra, the face, or the spinal cord, are associated with severedegrees, as are also those of parts innervated from the sympatheticsystem, such as the abdominal or thoracic viscera. It is to be borne inmind that a state of general anæsthesia does not prevent injuriousimpulses reaching the brain and causing shock during an operation. Ifthe main nerves of the part are "blocked" by injection of a localanæsthetic, however, the central nervous system is protected from theseimpulses. While the aged frequently manifest but few signs of shock, they have acorrespondingly feeble power of recovery; and while many young childrensuffer little, even after severe operations, others with much less causesuccumb to shock. When the injured person's mind is absorbed with other matters than hisown condition, --as, for example, during the heat of a battle or in theexcitement of a railway accident or a conflagration, --even severeinjuries may be unattended by pain or shock at the time, although whenthe period of excitement is over, the severity of the shock is all thegreater. The same thing is observed in persons injured while under theinfluence of alcohol. _Clinical Features. _--The patient is in a state of prostration. He isroused from his condition of indifference with difficulty, but answersquestions intelligently, if only in a whisper. The face is pale, beadsof sweat stand out on the brow, the features are drawn, the eyessunken, and the cheeks hollow. The lips and ears are pallid; the skin ofthe body of a greyish colour, cold, and clammy. The pulse is rapid, fluttering, and often all but imperceptible at the wrist; therespiration is irregular, shallow, and sighing; and the temperature mayfall to 96° F. Or even lower. The mouth is parched, and the patientcomplains of thirst. There is little sensibility to pain. Except in very severe cases, shock tends towards recovery within a fewhours, the _reaction_, as it is called, being often ushered in byvomiting. The colour improves; the pulse becomes full and bounding; therespiration deeper and more regular; the temperature rises to 100° F. Orhigher; and the patient begins to take notice of his surroundings. Thecondition of neurasthenia which sometimes follows an operation may beassociated with the degenerative changes in nerve cells described byCrile. In certain cases the symptoms of traumatic shock blend with thoseresulting from toxin absorption, and it is difficult to estimate therelative importance of the two factors in the causation of thecondition. The conditions formerly known as "delayed shock" and"prostration with excitement" are now generally recognised to be due totoxæmia. _Question of Operating during Shock. _--Most authorities agree thatoperations should only be undertaken during profound shock when they areimperatively demanded for the arrest of hæmorrhage, the prevention ofinfection of serous cavities, or for the relief of pain which isproducing or intensifying the condition. _Prevention of Operation Shock. _--In the preparation of a patient foroperation, drastic purgation and prolonged fasting must be avoided, andabout half an hour before a severe operation a pint of saline solutionshould be slowly introduced into the rectum; this is repeated, ifnecessary, during the operation, and at its conclusion. Theoperating-room must be warm--not less than 70° F. --and the patientshould be wrapped in cotton wool and blankets, and surrounded byhot-bottles. All lotions used must be warm (100° F. ); and the operationshould be completed as speedily and as bloodlessly as possible. Theelement of fear may to some extent be eliminated by the preliminaryadministration of such drugs as scopolamin or morphin, and with a viewto preventing the passage of exciting afferent impulses, Crile advocates"blocking" of the nerves by the injection of a 1 per cent. Solution ofnovocaine into their substance on the proximal side of the field ofoperation. To prevent after-pain in abdominal wounds he recommendsinjecting the edges with quinine and urea hydrochlorate before suturing, the resulting anæsthesia lasting for twenty-four to forty-eight hours. To these preventive measures the term _anoci-association_ has beenapplied. In selecting an anæsthetic, it may be borne in mind thatchloroform lowers the blood pressure more than ether does, and that withspinal anæsthesia there is no lowering of the blood pressure. _Treatment. _--A patient suffering from shock should be placed in therecumbent position, with the foot of the bed raised to facilitate thereturn circulation in the large veins, and so to increase the flow ofblood to the brain. His bed should be placed near a large fire, and thepatient himself surrounded by cotton wool and blankets and hot-bottles. If he has lost much blood, the limbs should be wrapped in cotton wooland firmly bandaged from below upwards, to conserve as much of thecirculating blood as possible in the trunk and head. If the shock ismoderate in degree, as soon as the patient has been put to bed, about apint of saline solution should be introduced into the rectum, and 10 to15 minims of adrenalin chloride (1 in 1000) may with advantage be addedto the fluid. The injection should be repeated every two hours until thecirculation is sufficiently restored. In severe cases, especially whenassociated with hæmorrhage, transfusion of whole blood from a compatibledonor, is the most efficient means (_Op. Surg. _, p. 37). Cardiacstimulants such as strychnin, digitalin, or strophanthin arecontra-indicated in shock, as they merely exhaust the already impairedvaso-motor centre. Artificial respiration may be useful in tiding a patient over thecritical period of shock, especially at the end of a severe operation. Failing this, the introduction of saline solution at a temperature ofabout 105° F. Into a vein or into the subcutaneous tissue is usefulwhere much blood has been lost (p. 276). Two or three pints may beinjected into a vein, or smaller quantities under the skin. Thirst is best met by giving small quantities of warm water by themouth, or by the introduction of saline solution into the rectum. Iceonly relieves thirst for a short time, and as it is liable to induceflatulence should be avoided, especially in abdominal cases. Dryness ofthe tongue may be relieved by swabbing the mouth with a mixture ofglycerine and lemon juice. If severe pain calls for the use of morphin, 1/120th grain of atropinshould be added, or heroin alone may be given in doses of 1/24th to1/12th grain. #Collapse# is a clinical condition which comes on more insidiously thanshock, and which does not attain its maximum degree of severity forseveral hours. It is met with in the course of severe illnesses, especially such as are associated with the loss of large quantities offluid from the body--for example, by severe diarrhœa, notably in Asiaticcholera; by persistent vomiting; or by profuse sweating, as in somecases of heat-stroke. Severe degrees of collapse follow sudden andprofuse loss of blood. Collapse often follows upon shock--for example, in intestinalperforations, or after abdominal operations complicated by peritonitis, especially if there is vomiting, as in cases of obstruction high up inthe intestine. The symptoms of collapse are aggravated if toxinabsorption is superadded to the loss of fluid. The _clinical features_ of this condition are practically the same asthose of shock; and it is treated on the same lines. FAT EMBOLISM. --After various injuries and operations, butespecially such as implicate the marrow of long bones--for example, comminuted fractures, osteotomies, resections of joints, or the forciblecorrection of deformities--fluid fat may enter the circulation invariable quantity. In the vast majority of cases no ill effects follow, but when the quantity is large or when the absorption is long continuedcertain symptoms ensue, either immediately, or more frequently not fortwo or three days. These are mostly referable to the lungs and brain. In the lung the fat collects in the minute blood vessels and producesvenous congestion and œdema, and sometimes pneumonia. Dyspnœa, withcyanosis, a persistent cough and frothy or blood-stained sputum, afeeble pulse and low temperature, are the chief symptoms. When the fat lodges in the capillaries of the brain, the pulse becomessmall, rapid, and irregular, delirium followed by coma ensues, and thecondition 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 ofhis illness, until the fat is eliminated from the blood vessels. TRAUMATIC ASPHYXIA OR TRAUMATIC CYANOSIS. --This term has beenapplied to a condition which results when the thorax is so forciblycompressed that respiration is mechanically arrested for severalminutes. It has occurred from being crushed in a struggling crowd, orunder a fall of masonry, and in machinery accidents. When the patient isreleased, the face and the neck as low down as the level of theclavicles present an intense coloration, varying from deep purple toblue-black. The affected area is sharply defined, and on closeinspection the appearance is found to be due to the presence ofcountless minute reddish-blue or black spots, with small areas orstreaks of normal skin between them. The punctate nature of thecoloration is best recognised towards the periphery of the affectedarea--at the junction of the brow with the hairy scalp, and where thedark patch meets the normal skin of the chest (Beach and Cobb). Pressureover the skin does not cause the colour to disappear as in ordinarycyanosis. It has been shown by Wright of Boston, that the coloration isdue to stasis from mechanical over-distension of the veins andcapillaries; actual extravasation into the tissues is exceptional. Thesharply defined distribution of the coloration is attributed to theabsence of functionating valves in the veins of the head and neck, sothat when the increased intra-thoracic pressure is transmitted to theseveins they become engorged. Under the conjunctivæ there areextravasations of bright red blood; and sublingual hæmatoma has beenobserved (Beatson). The discoloration begins to fade within a few hours, and after thesecond or third day it disappears, without showing any of the chromaticchanges which characterise a bruise. The sub-conjunctival ecchymosis, however, persists for several weeks and disappears like otherextravasations. Apart from combating the shock, or dealing withconcomitant injuries, no treatment is called for. DELIRIUM IN SURGICAL PATIENTS Delirium is a temporary disturbance of mind which occurs in the courseof certain diseases, and sometimes after injuries or operations. It maybe associated with any of the acute pyogenic infections; witherysipelas, especially when it affects the head or face; or with chronicinfective diseases of the urinary organs. In the various forms ofmeningitis also, and in some cases of injury to the head, it is common;and it is sometimes met with after severe hæmorrhage, and in cases ofpoisoning by such drugs as iodoform, cocain, or alcohol. Delirium mayalso, of course, be a symptom of insanity. Often there is merely incoherent muttering regarding past incidents oroccupations, or about absent friends; or the condition may assume theform of excitement, of dementia, or of melancholia; and the symptoms areusually worst at night. #Delirium Tremens# is seen in persons addicted to alcohol, who, as theresult of accident or operation, are suddenly compelled to lie in bed. Although oftenest met with in habitual drunkards or chronic tipplers, itis by no means uncommon in moderate drinkers, and has even been seen inchildren. _Clinical Features. _--The delirium, which has been aptly described asbeing of a "busy" character, usually manifests itself within a few daysof the patient being laid up. For two or three days he refuses food, isdepressed, suspicious, sleepless and restless, demanding to be allowedup. Then he begins to mutter incoherently, to pull off the bedclothes, and to attempt to get out of bed. There is general muscular tremor, mostmarked in the tongue, the lips, and the hands. The patient imagines thathe sees all sorts of horrible beings around him, and is sometimesgreatly distressed because of rats, mice, beetles, or snakes, which hefancies are crawling over him. The pulse is soft, rapid, andcompressible; the temperature is only moderately raised (100°–101° F. ), and as a rule there is profuse sweating. The digestion is markedlyimpaired, and there is often vomiting. Patients in this condition arepeculiarly insensitive to pain, and may even walk about with a fracturedleg without apparent discomfort. In most cases the symptoms begin to pass off in three or four days; thepatient sleeps, the hallucinations and tremors cease, and he graduallyrecovers. 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 doneby the administration of bromides, chloral, or paraldehyde, or of one orother of the drugs of which sulphonal, trional, and veronal areexamples. Heroin in doses of from 1/24th to 1/12th grain is often ofservice. Morphin must be used with great caution. In some cases hyoscin(1/200 grain) injected hypodermically is found efficacious when allother means have failed, but this drug must be used with greatdiscrimination. The patient must be encouraged to take plenty of easilydigested fluid food, supplemented, if necessary, by nutrient enemata andsaline infusions. In the early stage a brisk mercurial purge is often of value. Alcoholshould be withheld, unless failing of the pulse strongly indicates itsuse, and then it should be given along with the food. A delirious patient must be constantly watched by a trained attendant orother competent person, lest he get out of bed and do harm to himself orothers. Mechanical restraint is often necessary, but must be avoided ifpossible, as it is apt to increase the excitement and exhaust thepatient. On account of the extreme restlessness, there is often greatdifficulty in carrying out the proper treatment of the primary surgicalcondition, and considerable modifications in splints and otherappliances are often rendered necessary. A form of delirium, sometimes spoken of as #Traumatic Delirium#, mayfollow on severe injuries or operations in persons of neurotictemperament, or in those whose nervous system is exhausted by overwork. It is met with apart from alcoholic intemperance. This form of deliriumseems to be specially prone to ensue on operations on the face, thethyreoid gland, or the genito-urinary organs. The symptoms appear infrom two to five days after the operation, and take the form ofrestlessness, sleeplessness, low incoherent muttering, and picking atthe bedclothes. It is not necessarily attended by fever or by musculartremors. The patient may show hysterical symptoms. This condition isprobably to be regarded as a form of insanity, as it is liable to mergeinto mania or melancholia. The _treatment_ is carried out on the same lines as that of deliriumtremens. CHAPTER XIV THE BLOOD VESSELS Anatomy--INJURIES OF ARTERIES: _Varieties_--INJURIES OF VEINS: _Air Embolism_--Repair of blood vessels and natural arrest of hæmorrhage--HÆMORRHAGE: _Varieties_; _Prevention_; _Arrest_--Constitutional effects of hæmorrhage--Hæmophilia--DISEASES OF BLOOD VESSELS: Thrombosis; Embolism--Arteritis: _Varieties_; Arterio-sclerosis--Thrombo-phlebitis--Phlebitis: _Varieties_--VARIX--ANGIOMATA--Nævus: _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 liningthe lumen; outside of this a layer of delicate connective tissue; andstill farther out a dense tissue composed of longitudinally arrangedelastic fibres--the internal elastic lamina. The tunica intima is easilyruptured. The middle coat, or _tunica media_, consists of non-stripedmuscular fibres, arranged for the most part concentrically round thevessel. In this coat also there is a considerable proportion of elastictissue, especially in the larger vessels. The thickness of the vesselwall depends chiefly on the development of the muscular coat. Theexternal coat, or _tunica externa_, is composed of fibrous tissue, containing, especially in vessels of medium calibre, some yellow elasticfibres in its deeper layers. In most parts of the body the arteries lie in a sheath of connectivetissue, from which fine fibrous processes pass to the tunica externa. The connection, however, is not a close one, and the artery when dividedtransversely is capable of retracting for a considerable distance withinits sheath. In some of the larger arteries the sheath assumes the formof a definite membrane. The arteries are nourished by small vessels--the _vasa vasorum_--whichramify chiefly in the outer coat. They are also well supplied withnerves, which regulate the size of the lumen by inducing contraction orrelaxation 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 lesseasily ruptured, and the middle coat contains a smaller proportion ofmuscular tissue. In one important point veins differ structurally fromarteries--namely, in being provided with valves which prevent reflux ofthe blood. These valves are composed of semilunar folds of the tunicaintima strengthened by an addition of connective tissue. Each valveusually consists of two semilunar flaps attached to opposite sides ofthe vessel wall, each flap having a small sinus on its cardiac side. The distension of these sinuses with blood closes the valve andprevents regurgitation. Valves are absent from the superior and inferiorvenæ cavæ, the portal vein and its tributaries, the hepatic, renal, uterine, and spermatic veins, and from the veins in the lower part ofthe rectum. They are ill-developed or absent also in the iliac andcommon femoral veins--a fact which has an important bearing on theproduction of varix in the veins of the lower extremity. The wall of _capillaries_ consists of a single layer of endothelialcells. HÆMORRHAGE Various terms are employed in relation to hæmorrhage, according to itsseat, its origin, the time at which it occurs, and other circumstances. The term _external hæmorrhage_ is employed when the blood escapes on thesurface; when the bleeding takes place into the tissues or into a cavityit is spoken of as _internal_. The blood may infiltrate the connectivetissue, constituting an _extravasation_ of blood; or it may collect in aspace or cavity and form a _hæmatoma_. The coughing up of blood from the lungs is known as _hæmoptysis_;vomiting of blood from the stomach, as _hæmatemesis_; the passage ofblack-coloured stools due to the presence of blood altered by digestion, as _melæna_; and the passage of bloody urine, as _hæmaturia_. Hæmorrhage is known as arterial, venous, or capillary, according to thenature of the vessel from which it takes place. In _arterial_ hæmorrhage the blood is bright red in colour, and escapesfrom the cardiac end of the divided vessel in pulsating jetssynchronously with the systole of the heart. In vascular parts--forexample the face--both ends of a divided artery bleed freely. The bloodflowing from an artery may be dark in colour if the respiration isimpeded. When the heart's action is weak and the blood tension low theflow may appear to be continuous and not in jets. The blood from adivided artery at the bottom of a deep wound, escapes on the surface ina 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 fromthe distal end. The blood is dark red under ordinary conditions, but maybe purplish, or even black, if the respiration is interfered with. Whenone of the large veins in the neck is wounded, the effects ofrespiration produce a rise and fall in the stream which may resemblearterial pulsation. In _capillary_ hæmorrhage, red blood escapes from numerous points on thesurface of the wound in a steady ooze. This form of bleeding is seriousin those who are the subjects of hæmophilia. INJURIES OF ARTERIES The following description of the injuries of arteries refers to thelarger, named trunks. The injuries of smaller, unnamed vessels areincluded in the consideration of wounds and contusions. #Contusion. #--An artery may be contused by a blow or crush, or by theoblique impact of a bullet. The bruising of the vessel wall, especiallyif it is diseased, may result in the formation of a thrombus whichoccludes the lumen temporarily or even permanently, and in rare casesmay lead to gangrene of the limb beyond. #Subcutaneous Rupture. #--An artery may be ruptured subcutaneously by ablow or crush, or by a displaced fragment of bone. This injury has beenproduced also during attempts to reduce dislocations, especially thoseof old standing at the shoulder. It is most liable to occur when thevessels are diseased. The rupture may be incomplete or complete. _Incomplete Subcutaneous Rupture. _--In the majority of cases the ruptureis incomplete--the inner and middle coats being torn, while the outerremains intact. The middle coat contracts and retracts, and theinternal, because of its elasticity, curls up in the interior of thevessel, forming a valvular obstruction to the blood-flow. In most casesthis results in the formation of a thrombus which occludes the vessel. In some cases the blood-pressure gradually distends the injured segmentof the vessel wall and leads to the formation of an aneurysm. The pulsation in the vessels beyond the seat of rupture is arrested--fora time at least--owing to the occlusion of the vessel, and the limbbecomes cold and powerless. The pulsation seldom returns within five orsix weeks of the injury, if indeed it is not permanently arrested, but, as a rule, a collateral circulation is rapidly established, sufficientto nourish the parts beyond. If the pulsation returns within a week ofthe injury, the presumption is that the occlusion was due to pressurefrom without--for example, by hæmorrhage into the sheath or the pressureof a fragment of bone. _Complete Subcutaneous Rupture. _--When the rupture is complete, all thecoats of the vessel are torn and the blood escapes into the surroundingtissues. If the original injury is attended with much shock, thebleeding may not take place until the period of reaction. Rupture of thepopliteal artery in association with fracture of the femur, or of theaxillary or brachial artery with fracture of the humerus or dislocationof the shoulder, are familiar examples of this injury. Like incomplete rupture, this lesion is accompanied by loss of pulsationand power, and by coldness of the limb beyond; a tense and excessivelypainful swelling rapidly appears in the region of the injury, and, wherethe cellular tissue is loose, may attain a considerable size. Thepressure of the effused blood occludes the veins and leads to congestionand œdema of the limb beyond. The interference with the circulation, andthe damage to the tissues, may be so great that gangrene ensues. _Treatment. _--When an artery has been contused or ruptured, the limbmust be placed in the most favourable condition for restoration of thecirculation. The skin is disinfected and the limb wrapped in cotton woolto conserve its heat, and elevated to such an extent as to promote thevenous return without at the same time interfering with the inflow ofblood. A careful watch must be kept on the state of nutrition of thelimb, lest gangrene occurs. If no complications supervene, the swelling subsides, and recovery maybe complete in six or eight weeks. If the extravasation is great and theskin threatens to give way, or if the vitality of the limb is seriouslyendangered, it is advisable to expose the injured vessel, and, afterclearing 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. Ifthis is impracticable, a ligature is applied above and below therupture. If gangrene ensues, amputation must be performed. These descriptions apply to the larger arteries of the extremities. Agood illustration of subcutaneous rupture of the arteries of the head isafforded by the tearing of the middle meningeal artery caused by theapplication of blunt violence to the skull; and of the arteries of thetrunk--caused by the tearing of the renal artery in rupture of thekidney. #Open Wounds of Arteries--Laceration. #--Laceration of large arteries isa common complication of machinery and railway accidents. The violencebeing usually of a tearing, twisting, or crushing nature, such injuriesare seldom associated with much hæmorrhage, as torn or crushed vesselsquickly become occluded by contraction and retraction of their coats andby the formation of a clot. A whole limb even may be avulsed from thebody with comparatively little loss of blood. The risk in such cases issecondary hæmorrhage resulting from pyogenic infection. The _treatment_ is that applicable to all wounds, with, in addition, theligation of the lacerated vessels. #Punctured wounds# of blood vessels may result from stabs, or they maybe accidentally inflicted in the course of an operation. The division of the coats of the vessel being incomplete, the naturalhæmostasis that results from curling up of the intima and contraction ofthe media, fails to take place, and bleeding goes on into thesurrounding tissues, and externally. If the sheath of the vessel is notwidely damaged, the gradually increasing tension of the extravasatedblood retained within it may ultimately arrest the hæmorrhage. A clotthen forms between the lips of the wound in the vessel wall and projectsfor a short distance into the lumen, without, however, materiallyinterfering with the flow through the vessel. The organisation of thisclot results in the healing of the wound in the vessel wall. In other cases the blood escapes beyond the sheath and collects in thesurrounding tissues, and a traumatic aneurysm results. Secondaryhæmorrhage may occur if the wound becomes infected. The _treatment_ consists in enlarging the external wound to permit ofthe damaged vessel being ligated above and below the puncture. In somecases it may be possible to suture the opening in the vessel wall. Whencircumstances prevent these measures being taken, the bleeding may bearrested by making firm pressure over the wound with a pad; but thisprocedure is liable to be followed by the formation of an aneurysm. _Minute puncture of arteries_ such as frequently occur in the hypodermicadministration of drugs and in the use of exploring needles, are notattended with any escape of blood, chiefly because of the elastic recoilof the arterial wall; a tiny thrombus of platelets and thrombus forms atthe point where the intima is punctured. #Incised Wounds. #--We here refer only to such incised wounds as partlydivide the vessel wall. Longitudinal wounds show little tendency to gape, and are therefore notattended with much bleeding. They usually heal rapidly, but, likepunctured wounds, are liable to be followed by the formation of ananeurysm. When, however, the incision in the vessel wall is oblique or transverse, the retraction of the muscular coat causes the opening to gape, with theresult that there is hæmorrhage, which, even in comparatively smallarteries, may be so profuse as to prove dangerous. When the associatedwound in the soft parts is valvular the hæmorrhage is arrested and ananeurysm may develop. When a large arterial trunk, such as the external iliac, the femoral, the common carotid, the brachial, or the popliteal, has been partlydivided, for example, in the course of an operation, the opening shouldbe closed with sutures--_arteriorrhaphy_. The circulation beingcontrolled by a tourniquet, or the artery itself occluded by a clamp, fine silk or catgut stitches are passed through the outer and middlecoats after the method of Lembert, a fine, round needle being employed. The sheath of the vessel or an adjacent fascia should be stitchedover the line of suture in the vessel wall. If infection be excluded, there is little risk of thrombosis or secondary hæmorrhage; and even ifthrombosis should develop at the point of suture, the artery isobstructed gradually, and the establishment of a collateral circulationtakes place better than after ligation. In the case of smaller trunks, or when suture is impracticable, the artery should be tied above andbelow the opening, and divided between the ligatures. #Gunshot Wounds of Blood Vessels. #--In the majority of cases injuries oflarge vessels are associated with an external wound; the profusion ofthe bleeding indicates the size of the damaged vessel, and the colour ofthe blood and the nature of the flow denote whether an artery or a veinis implicated. When an artery is wounded a firm _hæmatoma_ may form, with an expansilepulsation and a palpable thrill--whether such a hæmatoma remainscircumscribed or becomes diffuse depends upon the density or laxity ofthe tissues around it. In course of time a _traumatic arterial aneurysm_may develop from such a hæmatoma. When an artery and its companion vein are injured simultaneously an_arterio-venous aneurysm_ (p. 310) may develop. This frequently takesplace without the formation of a hæmatoma as the arterial blood findsits way into the vein and so does not escape into the tissues. Even if ahæmatoma forms it seldom assumes a great size. In time a swelling isrecognised, with a palpable thrill and a systolic bruit, loudest at thelevel of the communication and accompanied by a continuous venous hum. If leakage occurs into the tissues, the extravasated blood may occludethe vein by pressure, and the symptoms of arterial aneurysm replacethose of the arterio-venous form, the systolic bruit persisting, whilethe venous hum disappears. _Gangrene_ may ensue if the blood supply is seriously interfered with, or the signs of _ischæmia_ may develop; the muscles lose theirelasticity, become hard and paralysed, and anæsthesia of the "glove" or"stocking" type, with other alterations of sensation ensue. Apart fromischæmia, _reflex paralysis_ of motion and sensation of a transient kindmay follow injury of a large vessel. _Treatment_ is carried out on the same lines as for similar injuries dueto other causes. INJURIES OF VEINS Veins are subject to the same forms of injury as arteries, and theresults are alike in both, such variations as occur being dependentpartly on the difference in their anatomical structure, and partly onthe conditions of the circulation through them. #Subcutaneous rupture# of veins occur most frequently in associationwith fractures and in the reduction of dislocations. The veins mostcommonly ruptured are the popliteal, the axillary, the femoral, and thesubclavian. On account of the smaller amount of elastic and musculartissue in the wall of a vein, the contraction and retraction of itswalls are less than in an artery, and so bleeding may continue for alonger period. On the other hand, owing to the lower blood-pressure theoutflow goes on more slowly, and the gradually increasing pressureproduced by the extravasated blood is usually sufficient to arrest thehæmorrhage before it becomes serious. As an aid in diagnosing the sourceof the bleeding, it should be remembered that the rupture of a vein doesnot affect the pulsation in the limb beyond. The risks are practicallythe same as when an artery is ruptured, excepting that of aneurysm, andthe treatment is carried out on the same lines, but it is seldomnecessary to operate for the purpose of applying a ligature to theinjured vein. #Wounds# of veins--punctured and incised--frequently occur in the courseof operations; for example, in the removal of tumours or diseased glandsfrom the neck, the axilla, or the groin. They are also met with as aresult of accidental stabs and of suicidal or homicidal injuries. Thehæmorrhage from a large vein so damaged is usually profuse, but it ismore readily controlled by external pressure than that from an artery. When a vein is merely punctured, the bleeding may be arrested bypressure with a pad of gauze, or by a lateral ligature--that is, pickingup the margins of the rent in the wall and securing them with aligature without occluding the lumen. In the large veins, such as theinternal jugular, the femoral, or the axillary, it is usually possibleto suture the opening in the wall. This does not necessarily result inthrombosis in the vessel, or in obliteration of its lumen. When an _artery and vein are simultaneously wounded_, the featurespeculiar to each are present in greater or less degree. In the limbsgangrene may ensue, especially if the wound is infected. Punctured andgun-shot wounds implicating both artery and vein are liable to befollowed by the development of arterio-venous aneurysm. #Entrance of Air into Veins--Air Embolism. #--This serious, thoughfortunately rare, accident is apt to occur in the course of operationsin the region of the thorax, neck, or axilla, if a large vein is openedand fails to collapse on account of the rigidity of its walls, itsincorporation in a dense fascia, or from traction being made upon it. Ifthe wound in a vein is thus held open, the negative pressure duringinspiration sucks air into the right side of the heart. This isaccompanied by a hissing or gurgling sound, and with the next expirationsome frothy blood escapes from the wound. The patient instantly becomespale, the pupils dilate, respiration becomes laboured, and although theheart may continue to beat forcibly, the peripheral pulse is weak, andmay even be imperceptible. On auscultating the heart, a churning soundmay be heard. Death may result in a few minutes; or the heart may slowlyregain its power and recovery take place. _Prevention. _--In operations in the "dangerous area"--as the region ofthe root of the neck is called in this connection--care must be takennot to cut or divide any vein before it has been secured by forceps, andto apply ligatures securely and at once. Deep wounds in this regionshould be kept filled with normal salt solution. Immediately a cut isrecognised in a vein, a finger should be placed over the vessel on thecardiac side of the wound, and kept there until the opening is secured. _Treatment. _--Little can be done after the air has actually entered thevein beyond endeavouring to maintain the heart's action by hypodermicinjections of ether or strychnin and the application of mustard or hotcloths over the chest. The head at the same time should be lowered toprevent syncope. Attempts to withdraw the air by suction, and theemployment of artificial respiration, have proved futile, and are, bysome, considered dangerous. In a desperate case massage of the heartmight be tried. THE NATURAL ARREST OF HÆMORRHAGE AND THE REPAIR OF BLOODVESSELS #Primary Hæmorrhage. #--The term primary hæmorrhage is applied to thebleeding which follows immediately on the wounding of a blood vessel. The natural process by which such hæmorrhage is arrested varies with thecharacter of the wound in the vessel and may be modified by accidentalcircumstances. (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 timeeach segment retracts within its sheath in virtue of the recoil of theelastic elements in its walls, the tunica intima curls up in theinterior of the vessel, and the tunica externa collapses over the cutends. The blood that escapes from the injured vessel fills theinterstices of the tissues, and, coagulating, forms a clot whichtemporarily arrests the bleeding. That part of the clot which liesbetween the divided ends of the vessel and in the cellular tissueoutside, is known as the _external clot_, while the portion whichprojects into the lumen of the vessel is known as the _internal clot_, and it usually extends as far as the nearest collateral branch. Theseprocesses constitute what is known as the _temporary arrest ofhæmorrhage_, which, it will be observed, is effected by the contractionand retraction of the divided artery and by clotting. The _permanent arrest_ takes place by the transformation of the clotinto scar tissue. The internal clot plays the most important part in theprocess; it becomes invaded by leucocytes and proliferating endothelialand connective-tissue cells, and new blood vessels permeate the mass, which is thus converted into granulation tissue. This is ultimatelyreplaced by fibrous tissue, which permanently occludes the end of thevessel. Concurrently and by the same process the external clot isconverted into scar tissue. If a divided artery is _ligated at its cut end_, the tension of theligature is usually sufficient to rupture the inner and middle coats, which curl up within the lumen, the outer coat alone being held in thegrasp of the ligature. An internal clot forms and, becoming organised, permanently occludes the vessel as above described. The ligature and thesmall portion of vessel beyond it are subsequently absorbed. In course of time the collateral branches of the vessel above and belowthe level of section enlarge and their inter-communication becomes morefree, so that even when large trunks have been divided the vascularsupply of the parts beyond may be completely restored. This is known asthe development of the _collateral circulation_. _Imperfect Collateral Circulation. _--While the development of thecollateral circulation after the ligation or obstruction from othercause of a main arterial trunk may be sufficient to prevent gangrene ofthe limb, it may be insufficient for its adequate nourishment; it may becold, bluish in colour, and there may be necrosis of the skin over bonypoints; this is notably the case in the lower extremity after ligationof the femoral or popliteal artery, when patches of skin may die overthe prominence of the heel, the balls of the toes, the projecting baseof the fifth metatarsal and the external malleolus. If, during the period of reaction, the blood-pressure risesconsiderably, the occluding clot at the divided end of the vessel may bewashed away or the ligature displaced, permitting of fresh bleedingtaking place--_reactionary_ or _intermediary hæmorrhage_ (p. 272). In the event of the wound becoming infected with pyogenic organisms, theoccluding blood-clot or the young fibrous tissue may becomedisintegrated in the suppurative process, and the bleeding startafresh--_secondary hæmorrhage_ (p. 273). (b) If an artery is only _partly cut across_, the divided fibres ofthe tunica muscularis contract and those of the tunica externa retract, with the result that a more or less circular hole is formed in the wallof the vessel, from which free bleeding takes place, as the conditionsare unfavourable for the formation of an occluding clot. Even if a clotdoes form, when the blood-pressure rises it is readily displaced, leading to reactionary hæmorrhage. Should the wound become infected, secondary hæmorrhage is specially liable to occur. A further riskattends this form of injury, in that the intra-vascular tension may intime lead to gradual stretching of the scar tissue which closes the gapin the vessel wall, with the result that a localised dilatation ordiverticulum forms, constituting a _traumatic aneurysm_. (c) When the injury merely takes the form of a _puncture_ or _smallincision_ a blood-clot forms between the edges, becomes organised, andis converted into cicatricial tissue which seals the aperture. Suchwounds may also be followed by reactionary or secondary hæmorrhage, orlater by the formation of a traumatic aneurysm. _Conditions which influence the Natural Arrest of Hæmorrhage. _--Thenatural arrest of bleeding is favoured by tearing or crushing of thevessel walls, owing to the contraction and retraction of the coats andthe tendency of blood to coagulate when in contact with damaged tissue. Hence the primary hæmorrhage following lacerated wounds is seldomcopious. The occurrence of syncope or of profound shock also helps tostop 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 andretraction of the muscular coat, instead of diminishing the calibre ofthe artery, causes the wound in the vessel to gape; by completing thedivision of the vessel under these circumstances the bleeding can oftenbe arrested. In certain situations, also, the arteries are so intimatelyconnected with their sheaths, that when cut across they were unable toretract and contract--for example, in the scalp, in the penis, and inbones--and copious bleeding may take place from comparatively smallvessels. This inability of the vessels to contract and retract is metwith also in inflamed and œdematous parts and in scar tissue. Arteriesdivided in the substance of a muscle also sometimes bleed unduly. Anyincrease in the force of the heart's action, such as may result fromexertion, excitement, or over-stimulation, also interferes with thenatural arrest. Lastly, in bleeders, there are conditions whichinterfere with the natural arrest of hæmorrhage. #Repair of a Vessel ligated in its Continuity. #--When a ligature isapplied to an artery it should be pulled sufficiently tight to occludethe lumen without causing rupture of its coats. It often happens, however, that the compression causes rupture of the inner and middlecoats, 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 ofhastening coagulation, by bringing the blood into contact with damagedtissue. Whether the inner and middle coats are ruptured or not, bloodcoagulates both above and below the ligature, the proximal clot beinglonger and broader than that on the distal side. In small arteries theseclots extend as far as the nearest collateral branch, but in the largertrunks their length varies. The permanent occlusion of those portions ofthe vessel occupied by clot is brought about by the formation ofgranulation tissue, and its replacement by cicatricial tissue, so thatthe occluded segment of the vessel is represented by a fibrous cord. Inthis process the coagulum only plays a passive rôle by forming ascaffolding on which the granulation tissue is built up. The ligaturesurrounding the vessel, and the elements of the clot, are ultimatelyabsorbed. #Repair of Veins. #--The process of repair in veins is the same as thatin arteries, but the thrombosed area may become canalised and thecirculation through the vessel be re-established. HÆMORRHAGE IN SURGICAL OPERATIONS The management of the hæmorrhage which accompanies an operation includes(a) preventive measures, and (b) the arrest of the bleeding. #Prevention of Hæmorrhage. #--Whenever possible, hæmorrhage should becontrolled by _digital compression_ of the main artery supplying thelimb rather than by a tourniquet. If efficiently applied compressionreduces the immediate loss of blood to a minimum, and the bleeding fromsmall vessels that follows the removal of the tourniquet is avoided. Further, the pressure of a tourniquet has been shown to be a materialfactor in producing shock. In selecting a point at which to apply digital compression, it isessential that the vessel should be lying over a bone which will furnishthe necessary resistance. The common carotid, for example, is pressedbackward and medially against the transverse process (carotid tubercle)of the sixth cervical vertebra; the temporal against the temporalprocess (zygoma) in front of the ear; and the facial against themandible at the anterior edge of the masseter. In the upper extremity, the subclavian is pressed against the first ribby making pressure downwards and backwards in the hollow above theclavicle; the axillary and brachial by pressing against the shaft of thehumerus. In the lower extremity, the femoral is controlled by pressing in adirection backward and slightly upward against the brim of the pelvis, midway between the symphysis pubis and the anterior superior iliacspine. The abdominal aorta may be compressed against the bodies of the lumbarvertebræ opposite the umbilicus, if the spine is arched well forwardsover a pillow or sand-bag, or by the method suggested by Macewen, inwhich the patient's spine is arched forwards by allowing the lowerextremities and pelvis to hang over the end of the table, while theassistant, standing on a stool, applies his closed fist over theabdominal aorta and compresses it against the vertebral column. Momburg recommends an elastic cord wound round the body between theiliac crest and the lower border of the ribs, but this procedure hascaused serious damage to the intestine. When digital compression is not available, the most convenient andcertain means of preventing hæmorrhage--say in an amputation--is by theuse of some form of _tourniquet_, such as the elastic tube of Esmarch orof 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 heldvertical for three or four minutes; the veins are thus emptied bygravitation, and they collapse, and as a physiological result of thisthe arteries reflexly contract, so that the quantity of blood enteringthe limb is reduced to a minimum. With the limb still elevated thetourniquet is firmly applied, a part being selected where the vessel canbe pressed directly against a bone, and where there is no risk ofexerting injurious pressure on the nerve-trunks. The tourniquet shouldbe applied over several layers of gauze or lint to protect the skin, andthe first turn of the tourniquet must be rapidly and tightly applied toarrest completely the arterial flow, otherwise the veins only areobstructed and the limb becomes congested. In the lower extremity thebest place to apply a tourniquet is the middle third of the thigh; inthe upper extremity, in the middle of the arm. A tourniquet should neverbe applied tighter or left on longer than is absolutely necessary. The screw tourniquet of Petit is to be preferred when it is desired tointermit the flow through the main artery as in operations for aneurysm. When a tourniquet cannot conveniently be applied, or when its presenceinterferes with the carrying out of the operation--as, for example, inamputations at the hip or shoulder--the hæmorrhage may be controlled bypreliminary ligation of the main artery above the seat of operation--forinstance, the external iliac or the subclavian. For such contingenciesalso the steel skewers used by Spence and Wyeth, or a special clamp orforceps, such as that suggested by Lynn Thomas, may be employed. In thecase of vessels which it is undesirable to occlude permanently, such asthe common carotid, the temporary application of a ligature or clamp isuseful. #Arrest of Hæmorrhage. #--_Ligature. _--This is the best means of securingthe larger vessels. The divided vessel having been caught with forcepsas near to its cut end as possible, a ligature of catgut or silk is tiedround it. When there is difficulty in applying a ligature securely, forexample in a dense tissue like the scalp or periosteum, or in a friabletissue like the thyreoid gland or the mesentery, a stitch should bepassed so as to surround the bleeding vessel a short distance from itsend, in this way ensuring a better hold and preventing the ligature fromslipping. If the hæmorrhage is from a partly divided vessel, this should becompletely cut across to enable its walls to contract and retract, andto facilitate the application of forceps and ligatures. _Torsion. _--This method is seldom employed except for comparativelysmall vessels, but it is applicable to even the largest arteries. Inemploying torsion, the end of the vessel is caught with forceps, and theterminal portion twisted round several times. The object is to tear theinner and middle coats so that they curl up inside the lumen, while theouter fibrous coat is twisted into a cord which occludes the end of thevessel. _Forci-pressure. _--Bleeding from the smallest arteries and fromarterioles can usually be arrested by firmly squeezing them for a fewminutes with artery forceps. It is usually found that on the removal ofthe forceps at the end of an operation no further hæmorrhage takesplace. By the use of specially strong clamps, such as the angiotribes ofDoyen, large trunks may be occluded by pressure. _Cautery. _--The actual cautery or Paquelin's thermo-cautery is seldomemployed to arrest hæmorrhage, but is frequently useful in preventingit, as, for example, in the removal of piles, or in opening the bowel incolostomy. It is used at a dull-red heat, which sears the divided endsof the vessel and so occludes the lumen. A bright-red or a white heatcuts the vessel across without occluding it. The separation of theslough produced by the charring of the tissues is sometimes attendedwith secondary bleeding. _Hæmostatics_ or _Styptics_. --The local application of hæmostatics isseldom to be recommended. In the treatment of epistaxis or bleeding fromthe nose, of hæmorrhage from the socket of a tooth, and sometimes fromulcerating or granulating surfaces, however, they may be useful. Allclots must be removed and the drug applied directly to the bleedingsurface. Adrenalin and turpentine are the most useful drugs for thispurpose. Hæmorrhage from bone, for example the skull, may be arrested by means ofHorsley's aseptic plastic wax. To stop persistent oozing from softtissues, Horsley successfully applied a portion of living vasculartissue, such as a fragment of muscle, which readily adheres to theoozing surface and yields elements that cause coagulation of the bloodby thrombo-kinetic processes. When examined after two or three days themuscle has been found to be closely adherent and undergoingorganisation. #Arrest of Accidental Hæmorrhage. #--The most efficient means oftemporarily controlling hæmorrhage is by pressure applied with thefinger, or with a pad of gauze, directly over the bleeding point. Whilethis is maintained an assistant makes digital pressure, or applies atourniquet, over the main vessel of the limb on the proximal side of thebleeding point. A useful _emergency tourniquet_ may be improvised byfolding a large handkerchief _en cravatte_, with a cork or piece of woodin the fold to act as a pad. The handkerchief is applied round thelimb, with the pad over the main artery, and the ends knotted on thelateral aspect of the limb. With a strong piece of wood the handkerchiefis wound up like a Spanish windlass, until sufficient pressure isexerted to arrest the bleeding. When hæmorrhage is taking place from a number of small vessels, itsarrest may be effected by elevation of the bleeding part, particularlyif it is a limb. By this means the force of the circulation isdiminished and the formation of coagula favoured. Similarly, in woundsof the hand or forearm, or of the foot or leg, bleeding may be arrestedby placing a pad in the flexure and acutely flexing the limb at theelbow or knee respectively. #Reactionary Hæmorrhage. #--Reactionary or intermediary hæmorrhageis really a recurrence of primary bleeding. As the name indicates, itoccurs during the period of reaction--that is, within the first twelvehours after an operation or injury. It may be due to the increase in theblood-pressure that accompanies reaction displacing clots which haveformed in the vessels, or causing vessels to bleed which did not bleedduring the operation; to the slipping of a ligature; or to the givingway of a grossly damaged portion of the vessel wall. In the scrotum, therelaxation of the dartos during the first few hours after operationoccasionally leads to reactionary hæmorrhage. As a rule, reactionary hæmorrhage takes place from small vessels as aresult of the displacement of occluding clots, and in many cases thehæmorrhage stops when the bandages and soaked dressings are removed. Ifnot, it is usually sufficient to remove the clots and apply firmpressure, and in the case of a limb to elevate it. Should the hæmorrhagerecur, the wound must be reopened, and ligatures applied to the bleedingvessels. Douching the wound with hot sterilised water (about 110° F. ), and plugging it tightly with gauze, are often successful in arrestingcapillary oozing. When the bleeding is more copious, it is usually dueto a ligature having slipped from a large vessel such as the externaljugular vein after operations in the neck, and the wound must be openedup and the vessel again secured. The internal administration of heroinor morphin, by keeping the patient quiet, may prove useful in preventingthe recurrence of hæmorrhage. #Secondary Hæmorrhage. #--The term secondary hæmorrhage refers tobleeding that is delayed in its onset and is due to pyogenic infectionof the tissues around an artery. The septic process causes softening anderosion of the wall of the artery so that it gives way under thepressure of the contained blood. The leakage may occur in drops, or as arush of blood, according to the extent of the erosion, the size of theartery concerned, and the relations of the erosion to the surroundingtissues. When met with as a complication of a wound there is aninterval--usually a week to ten days--between the receipt of the woundand the first hæmorrhage, this time being required for the extension ofthe septic process to the wall of the artery and the consequent erosionof its coats. When secondary hæmorrhage occurs apart from a wound, thereis a similar septic process attacking the wall of the artery from theoutside; for example in sloughing sore-throat, the separation of aslough may implicate the wall of an artery and be followed by seriousand it may be fatal hæmorrhage. The mechanical pressure of a fragment ofbone or of a rubber drainage tube upon the vessel may aid the septicprocess in causing erosion of the artery. In pre-Listerian days, thesilk ligature around the artery likewise favoured the changes that leadto secondary hæmorrhage, and the interesting observation was often made, that when the collateral circulation was well established, the leakageoccurred on the _distal_ side of the ligature. While it may happen thatthe initial hæmorrhage is rapidly fatal, as for example when theexternal carotid or one of its branches suddenly gives way, it is quitecommon to have one, two or more _warning hæmorrhages_ before the leakageon a large scale, which is rapidly fatal. The _appearances of the wound_ in cases complicated by secondaryhæmorrhage are only characteristic in so far that while obviouslyinfected, there is an absence of all reaction; instead of franklysuppurating, there is little or no discharge and the surroundingcellular tissue and the limb beyond are œdematous and pit on pressure. The _general symptoms_ of septic poisoning in cases of secondaryhæmorrhage vary widely in severity: they may be so slight that thegeneral health is scarcely affected and the convalescence from anoperation, for example, may be apparently normal except that the wounddoes not heal satisfactorily. For example, a patient may be recoveringfrom an operation such as the removal of an epithelioma of the mouth, pharynx or larynx and the associated lymph glands in the neck, and beable to be up and going about his room, when, suddenly, without warningand without obvious cause, a rush of blood occurs from the mouth or theincompletely healed wound in the neck, causing death within a fewminutes. On the other hand, the toxæmia may be of a profound type associated withmarked pallor and progressive failure of strength, which, of itself, even when the danger from hæmorrhage has been overcome, may have a fataltermination. The _prognosis_ therefore in cases of secondary hæmorrhagecan never be other than uncertain and unfavourable; the danger from lossof blood _per se_ is less when the artery concerned is amenable tocontrol by surgical measures. _Treatment. _--The treatment of secondary hæmorrhage includes the use oflocal measures to arrest the bleeding, the employment of generalmeasures to counteract the accompanying toxæmia, and when the loss ofblood has been considerable, the treatment of the bloodless state. _Local Measures to arrest the Hæmorrhage. _--The occurrence of evenslight hæmorrhages from a septic wound in the vicinity of a large bloodvessel is to be taken seriously; it is usually necessary to _open up thewound_, 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 someantiseptic, such as "bipp, " so that, if the bleeding does not recur, itmay be left undisturbed for several days. The packing should if possiblebe brought into actual contact with the leaking point in the vessel, andso arranged as to make pressure on the artery above the erosion. Thedressings and bandage are then applied, with the limb in the attitudethat will diminish the force of the stream through the main artery, forexample, flexion at the elbow in hæmorrhage from the deep palmar arch. Other measures for combating the local sepsis, such as the irrigationmethod of Carrel, may be considered. If the wound involves one of the extremities, it may be useful; and itimparts confidence to the nurse, and, it may be, to the patient, if aPetit's tourniquet is loosely applied above the wound, which the nurseis instructed to tighten up in the event of bleeding taking place. _Ligation of the Artery. _--If the hæmorrhage recurs in spite of packingthe wound, or if it is serious from the outset and likely to be criticalif repeated, ligation of the artery itself or of the trunk from which itsprings, at a selected spot higher up, should be considered. This ismost often indicated in wounds of the extremities. As examples of proximal ligation for secondary hæmorrhage may be citedligation of the hypogastric artery for hæmorrhage in the buttock, of thecommon iliac for hæmorrhage in the thigh, of the brachial in the upperarm for hæmorrhage from the deep palmar arch, and of the posteriortibial behind the medial malleolus for hæmorrhage from the sole of thefoot. _Amputation_ is the last resource, and should be decided upon if thehæmorrhage recurs after proximal ligation, or if this has been followedby gangrene of the limb; it should also be considered if the nature ofthe wound and the virulence of the sepsis would of themselves justifyremoval of the limb. Every surgeon can recall cases in which a timelyamputation has been the means of saving life. The _counteraction of the toxæmia_ and the _treatment of the bloodlessstate_, are carried out on the usual lines. #Hæmorrhage of Toxic Origin. #--Mention must also be made of hæmorrhageswhich depend upon infective or toxic conditions and in which no grosslesion of the vessels can be discovered. The bleeding occurs as anoozing, which may be comparatively slight and unimportant, or by itspersistence may become serious. It takes place into the superficiallayers of the skin, from mucous membranes, and into the substance ofsuch organs as the pancreas. Hæmorrhage from the stomach and intestine, attended with a brown or black discoloration of the vomit and of thestools, is one of the best known examples: it is not uncommonly met within infective conditions originating in the appendix, intestine, gall-bladder, and other abdominal organs. Hæmorrhage from the mucousmembrane of the stomach after abdominal operations--apparently also dueto toxic causes and not to the operation--gives rise to the so-called_post-operative hæmatemesis_. #Constitutional Effects of Hæmorrhage. #--The severity of the symptomsresulting from hæmorrhage depends as much on the rapidity with which thebleeding takes place as on the amount of blood lost. The sudden loss ofa large quantity, whether from an open wound or into a serouscavity--for example, after rupture of the liver or spleen--is attendedwith 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. Thepulse becomes feeble, soft, and rapid, and the patient is dull andlistless, and complains of extreme thirst. The temperature is usuallysub-normal; and the respiration rapid, shallow, and sighing incharacter. Abnormal visual sensations, in the form of flashes of lightor spots before the eyes; and rushing, buzzing, or ringing sounds in theears, 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 bloodcirculating through the body, and the diminished hæmoglobin content ofthe blood, the tissues are imperfectly oxygenated, and the patientbecomes extremely restless, gasping for breath, constantly throwingabout his arms and baring his chest in the vain attempt to breath morefreely. Faintness and giddiness are marked features. The diminishedsupply of oxygen to the brain and to the muscles produces musculartwitchings, and sometimes convulsions. Finally the pupils dilate, thesphincters 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, andthe ill effects last longer. Women, on the whole, stand loss of bloodbetter than men, and in them the blood is more rapidly re-formed. A fewhours after a severe hæmorrhage there is usually a leucocytosis of from15, 000 to 30, 000. #Treatment of the Bloodless State. #--The patient should be placed in awarm, well-ventilated room, and the foot of the bed elevated. Cardiacstimulants, such as strychnin or alcohol, must be judiciouslyadministered, over-stimulation being avoided. The inhalation of oxygenhas been found useful in relieving the urgent symptoms of dyspnœa. 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 fewminutes, and then applying a firm elastic bandage over a layer of cottonwool, from the periphery towards the trunk. _Introduction of Fluids into the Circulation. _--The most valuablemeasure for maintaining the circulation, however, is by transfusion ofblood (_Op. Surg. _, p. 37). If this is not immediately available theintroduction of from one to three pints of physiological saltsolution (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. Thesolution is sterilised by boiling, and cooled to a temperature of about105° 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 ofsaline solution with adrenalin should be slowly introduced into therectum, by means of a long rubber tube and a filler. Satisfactory, although less rapidly obtained results follow the introduction of salinesolution into the cellular tissue--for example, under the mamma, intothe 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 theinjury necessitates operative treatment under a general anæsthetic. Transfusion of blood is most valuable as _a preliminary to operation_ inpatients who are bloodless as a result of hæmorrhage from gastric andduodenal ulcers, and in bleeders. HÆMOPHILIA The term hæmophilia is applied to an inherited disease which renders thepatient liable to serious hæmorrhage from even the most trivialinjuries; and the subjects of it are popularly known as "bleeders. " The cause of the disease and its true nature are as yet unknown. Thereis no proof of any structural defect in the blood vessels, and beyondthe fact that there is a diminution in the number of blood-plates, ithas not been demonstrated that there is any alteration in thecomposition of the blood. The affection is in a marked degree hereditary, all the branches of anaffected family being liable to suffer. Its mode of transmission toindividuals, moreover, is characteristic: the male members of the stockalone suffer from the affection in its typical form, while the tendencyis transmitted through the female line. Thus the daughters of a fatherwho is a bleeder, whilst they do not themselves suffer from the disease, transmit the tendency to their male offspring. The sons, on the otherhand, neither suffer themselves nor transmit the disease to theirchildren (Fig. 64). The female members of a hæmophilic stock are oftenvery prolific, and there is usually a predominance of daughters in theirfamilies. FIG 64. --Genealogical Tree of a Hæmophilic Family. Great-Great-Grandmother                Great-Great-GrandfatherMrs 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      NoDied       Grandmother      |          |               | Childbed    Family æt.          . |            |     +-----------+   +----+--- 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 usuallymanifests itself during the first few years of life. In rare instancesprofuse hæmorrhage takes place when the umbilical cord separates. As arule the first evidence is the occurrence of long-continued anduncontrollable bleeding from a comparatively slight injury, such as thescratch of a pin, the extraction of a tooth, or after the operation ofcircumcision. The blood oozes slowly from the capillaries; at first itappears normal, but after flowing for some days, or it may be weeks, itbecomes pale, thin, and watery, and shows less and less tendency tocoagulate. Female members of hæmophilia families sometimes show a tendency toexcessive hæmorrhage, but they seldom manifest the characteristicfeatures met with in the male members. Sometimes the hæmorrhage takes place apparently spontaneously from thegums, the nasal or the intestinal mucous membrane. In other cases thebleeding occurs into the cellular tissue under the skin or mucousmembrane, producing large areas of ecchymosis and discoloration. One ofthe commonest manifestations of the disease is the occurrence ofhæmorrhage into the cavities of the large joints, especially the knee, elbow, or hip. The patient suffers repeatedly from such hæmorrhages, thedetermining injury being often so slight as to have passed unobserved. There is evidence that the tendency to bleed is greater at certain timesthan at others--in some cases showing almost a cyclicalcharacter--although nothing is known as to the cause of the variation. After a severe hæmorrhage into the cellular tissue or into a joint, thepatient becomes pale and anæmic, the temperature may rise to 102° or103° F. , the pulse become small and rapid, and hæmic murmurs aresometimes developed over the heart and large arteries. The swelling istense, fluctuating, and hot, and there is considerable pain andtenderness. In exceptional cases, blisters form over the seat of the effusion, orthe skin may even slough, and the clinical features may therefore cometo simulate closely those of an acute suppurative condition. When theskin sloughs, an ulcer is formed with altered blood-clot in its floorlike that seen in scurvy, and there is a remarkable absence of anyattempt at healing. The acute symptoms gradually subside, and the blood is slowly absorbed, the discoloration of the skin passing through the same series of changesas occur after an ordinary bruise. The patients seldom manifest thesymptoms of the bloodless state, and the blood is rapidly regenerated. The _diagnosis_ is easy if the patient or his friends are aware of thefamily tendency to hæmorrhage and inform the doctor of it, but they areoften sensitive and reticent regarding the fact, and it may only beelicited after close investigation. From the history it is usually easyto exclude scurvy and purpura. Repeated hæmorrhages into a joint mayresult in appearances which closely simulate those of tuberculousdisease. Recent hæmorrhages into the cellular tissue often presentclinical features closely resembling those of acute cellulitis orosteomyelitis. A careful examination, however, may reveal ecchymoses onother parts of the body which give a clue to the nature of thecondition, and may prevent the disastrous consequences that may followincision. These patients usually succumb sooner or later to hæmorrhage, althoughthey often survive several severe attacks. After middle life thetendency to bleed appears to diminish. _Treatment. _--As a rule the ordinary means of arresting hæmorrhage areof little avail. From among the numerous means suggested, the followingmay be mentioned: The application to the bleeding point of gauze soakedin a 1 in 1000 solution of adrenalin; prolonged inhalation of oxygen;freezing the part with a spray of ethyl-chloride; one or moresubcutaneous injections of gelatin--5 ounces of a 2½ per cent. Solution of white gelatin in normal salt solution being injected at atemperature of about 100° F. ; the injection of pituitary extract. Theapplication of a pad of gauze soaked in the blood of a normal personsometimes arrests the bleeding. To prevent bleeding in hæmophilics, intra-venous or subcutaneousinjections of fresh blood serum, taken from the human subject, thesheep, the dog, or the horse, have proved useful. If fresh serum is notavailable, anti-diphtheritic or anti-tetanic serum or tradepreparations, such as hemoplastin, may be employed. We have removed theappendix and amputated through the thigh in hæmophilic subjects withoutexcessive loss of blood after a course of fresh sheep's serum given bythe mouth over a period of several weeks. The chloride and lactate of calcium, and extract of thymus gland havebeen employed to increase the coagulability of the blood. The patientshould drink large quantities of milk, which also increases thecoagulability of the blood. Monro has observed remarkable results fromthe hypodermic injection of emetin hydrochloride in ½-grain doses. THROMBOSIS AND EMBOLISM The processes known as thrombosis and embolism are so intimatelyassociated with the diseases of blood vessels that it is convenient todefine these terms in the first instance. #Thrombosis. #--The term _thrombus_ is applied to a clot of blood formedin the interior of the heart or of a blood vessel, and the process bywhich such a clot forms is known as _thrombosis_. It would appear thatslowing or stagnation of the blood-stream, and interference with theintegrity of the lining membrane of the vessel wall, are the mostimportant factors determining the formation of the clot. Alterations inthe blood itself, such as occur, for example, in certain toxæmias, alsofavour coagulation. When the thrombus is formed slowly, it consists ofwhite blood cells with a small proportion of fibrin, and, beingdeposited in successive layers, has a distinctly laminated appearance onsection. It is known as a _white thrombus_ or laminated clot, and isoften met with in the sac of an aneurysm (Fig. 72). When rapidly formedin a vessel in which the blood is almost stagnant--as, for example, in apouched varicose vein--the blood coagulates _en masse_, and the clotconsists of all the elements of the blood, constituting a _red thrombus_(Fig. 66). Sometimes the thrombus is _mixed_--a red thrombus beingdeposited on a white one, it may be in alternate layers. When aseptic, a thrombus may become detached and be carried off in theblood-stream as an embolus; it may become organised; or it maydegenerate and undergo calcification. Occasionally a small thrombussituated behind a valve in a varicose vein or in the terminal end of adilated vein--for example in a pile--undergoes calcification, and isthen spoken of as a _phlebolith_; it gives a shadow with the X-rays. When infected with pyogenic bacteria, the thrombus becomes convertedinto pus and a localised abscess forms; or portions of the thrombus maybe carried as emboli in the circulation to distant parts, where theygive rise to secondary foci of suppuration--pyæmic abscesses. #Embolism. #--The term _embolus_ is applied to any body carried along inthe circulation and ultimately becoming impacted in a blood vessel. Thisoccurrence is known as _embolism_. The commonest forms of embolus areportions of thrombi or of fibrinous formations on the valves of theheart, the latter being usually infected with micro-organisms. Embolism plays an important part in determining one form of gangrene, ashas already been described. Infective emboli are the direct cause of thesecondary abscesses that occur in pyæmia; and they are sometimesresponsible for the formation of aneurysm. Portions of malignant tumours also may form emboli, and their impactionin the vessels may lead to the development of secondary growths indistant parts of the body. Fat and air embolism have already been referred to. ARTERITIS _Pyogenic. _--Non-suppurative inflammation of the coats of an artery mayso soften the wall of the vessel as to lead to aneurysmal dilatation. Itis not uncommon in children, and explains the occurrence of aneurysm inyoung subjects. When suppuration occurs, the vessel wall becomes disintegrated and givesway, leading to secondary hæmorrhage. If the vessel ruptures into anabscess cavity, dangerous bleeding may occur when the abscess bursts oris opened. _Syphilitic. _--The inflammation associated with syphilis results inthickening of the tunica intima, whereby the lumen of the vessel becomesnarrowed, or even obliterated--_endarteritis obliterans_. The middlecoat usually escapes, but the tunica externa is generally thickened. These changes cause serious interference with the nutrition of the partssupplied by the affected arteries. In large trunks, by diminishing theelasticity of the vessel wall, they are liable to lead to the formationof aneurysm. Changes in the arterial walls closely resembling those of syphiliticarteritis are sometimes met with in _tuberculous_ lesions. #Arterio-sclerosis# or #Chronic Arteritis#. --These terms are applied tocertain changes which result in narrowing of the lumen and loss ofelasticity in the arteries. The condition may affect the whole vascularsystem or may be confined to particular areas. In the smaller arteriesthere is more or less uniform thickening of the tunica intima fromproliferation of the endothelium and increase in the connective tissuein the elastic lamina--a form of obliterative endarteritis. Thenarrowing of the vessels may be sufficient to determine gangrene in theextremities. In course of time, particularly in the larger arteries, this new tissue undergoes degeneration, at first of a fatty nature, butprogressing in the direction of calcification, and this is followed bythe deposit of lime salts in the young connective tissue and theformation of calcareous plates or rings over a considerable area of thevessel wall. To this stage in the process the term _atheroma_ isapplied. The endothelium over these plates often disappears, leavingthem exposed to the blood-stream. Changes of a similar kind sometimes occur in the middle coat, the limesalts being deposited among the muscle fibres in concentric rings. The primary cause of arterio-sclerosis is not definitely known, but itsalmost constant occurrence, to a greater or less degree, in the agedsuggests that it is of the nature of a senile degeneration. It isfavoured by anything which throws excessive strain on the vessel walls, such as heavy muscular work; by chronic alcoholism and syphilis; or bysuch general diseases as tend to raise the blood-pressure--for example, chronic Bright's disease or gout. It occurs with greater frequency andwith 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 theflexures of joints, at the mouths of large branches, and at parts wherethe vessel lies in contact with bone. The presence of diseased patchesin the wall of an artery diminishes its elasticity and favoursaneurysmal dilatation. Such a vessel also is liable to be ruptured byexternal violence and so give rise to traumatic aneurysm. Thrombosis isliable to occur when calcareous plates are exposed in the lumen of thevessel by destruction of the endothelium, and this predisposes toembolism. Arterio-sclerosis also interferes with the natural arrest ofhæmorrhage, and by rendering the vessels brittle, makes it difficult tosecure them by ligature. In advanced cases the accessible arteries--suchas the radial, the temporal or the femoral--may be felt as firm, tortuous cords, which are sometimes so hard that they have been aptlycompared to "pipe-stems. " The pulse is smaller and less compressiblethan normal, and the vessel moves bodily with each pulsation. It must beborne in mind, however, that the condition of the radial artery may failto afford a clue to that of the larger arteries. Calcified arteries arereadily 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 elderlywomen, affecting especially the great vessels at the root of the neck, in which the artery is remarkably attenuated and dilated, and so friablethat the wall readily tears when seized with an artery-forceps, rendering ligation of the vessel in the ordinary way well-nighimpossible. Matas suggests infolding the wall of the vessel withinterrupted sutures that do not pierce the intima, and wrapping itround with a strip of peritoneum or omentum. The most serious form of arterial _thrombosis_ is that met with _in theabdominal aorta_, which is attended with violent pains in the lowerlimbs, 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 slowingof the blood-stream and irritation of the endothelium of the vessel wallare, owing to the conditions of the venous circulation, more readilyinduced in veins. Venous thrombosis may occur from purely mechanical causes--as, forexample, when the wall of a vein is incised, or the vessel included in aligature, or when it is bruised or crushed by a fragment of a brokenbone or by a bandage too tightly applied. Under these conditionsthrombosis is essentially a reparative process, and has already beenconsidered in relation to the repair of blood vessels. In other cases thrombosis is associated with certain constitutionaldiseases--gout, for example; the endothelium of the veins undergoingchanges--possibly the result of irritation by abnormal constituents inthe blood--which favour the formation of thrombi. Under these various conditions the formation of a thrombus is notnecessarily associated with the action of bacteria, although in anyof them this additional factor may be present. The most common cause of venous thrombosis, however, is inflammation ofthe wall of the vein--phlebitis. #Phlebitis. #--Various forms of phlebitis are met with, but for practicalpurposes they may be divided into two groups--one in which there is atendency to the formation of a thrombus; the other in which theinfective element predominates. In surgical patients, the _thrombotic form_ is almost invariably metwith in the lower extremity, and usually occurs in those who aredebilitated and anæmic, and who are confined to bed for prolongedperiods--for example, during the treatment of fractures of the leg orpelvis, or after such operations as herniotomy, prostatectomy, orappendectomy. _Clinical Features. _--The most typical example of this form of phlebitisis that so frequently met with in the great saphena vein, especiallywhen it is varicose. The onset of the attack is indicated by a suddenpain in the lower limb--sometimes below, sometimes above the knee. Thisinitial pain may be associated with shivering or even with a rigor, andthe temperature usually rises one or two degrees. There is swelling andtenderness along the line of the affected vein, and the skin over it isa dull-red or purple colour. The swollen vein may be felt as a firmcord, with bead-like enlargements in the position of the valves. Thepatient experiences a feeling of stiffness and tightness throughout thelimb. There is often œdema of the leg and foot, especially when the limbis in the dependent position. The acute symptoms pass off in a few days, but the swelling and tenderness of the vein and the œdema of the limbmay last for many weeks. When the deep veins--iliac, femoral, popliteal--are involved, there isgreat swelling of the whole limb, which is of a firm almost "wooden"consistence, and of a pale-white colour; the œdema may be so great thatit is impossible to feel the affected vein until the swelling hassubsided. 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 footof the bed raised on blocks 10 or 12 inches high, and the limbimmobilised by sand-bags or splints. It is necessary to avoid handlingthe parts, lest the clot be displaced and embolism occur. To avoidfrequent movement of the limb, the necessary dressings should be kept inposition by means of a many-tailed rather than a roller bandage. To relieve the pain, warm fomentations or lead and opium lotion shouldbe applied. Later, ichthyol-glycerin, or glycerin and belladonna, may besubstituted. When, at the end of three weeks, the danger of embolism is past, douching and gentle massage may be employed to disperse the œdema; andwhen the patient gets up he should wear a supporting elastic bandage. The _infective_ form usually begins as a peri-phlebitis arising inconnection with some focus of infection in the adjacent tissues. Theelements of the vessel wall are destroyed by suppuration, and thethrombus in its lumen becomes infected with pyogenic bacteria andundergoes softening. _Occlusion of the inferior vena cava_ as a result of infectivethrombosis is a well-known condition, the thrombosis extending into themain trunk from some of its tributaries, either from the femoral oriliac veins below or from the hepatic veins above. Portions of the softened thrombus are liable to become detached and toenter the circulating blood, in which they are carried as emboli. Thesemay lodge in distant parts, and give rise to secondary foci ofsuppuration--pyæmic abscesses. _Clinical Features. _--Infective phlebitis is most frequently met with inthe transverse sinus as a sequel to chronic suppuration in the mastoidantrum and middle ear. It also occurs in relation to the peripheralveins, but in these it can seldom be recognised as a separate entity, being merged in the general infective process from which it takesorigin. Its occurrence may be inferred, if in the course of asuppurative lesion there is a sudden rise of temperature, with pain, redness, and swelling along the line of a venous trunk, and a rapidlydeveloped œdema of the limb, with pitting of the skin on pressure. Inrare cases a localised abscess forms in the vein and points towards thesurface. _Treatment. _--Attention must be directed towards the condition withwhich the phlebitis is associated. Ligation of the vein on the cardiacside of the thrombus with a view to preventing embolism is seldomfeasible in the peripheral veins, although, as will be pointed outlater, the jugular vein is ligated with this object in cases ofphlebitis of the transverse sinus. VARIX--VARICOSE VEINS The term varix is applied to a condition in which veins are so alteredin structure that they remain permanently dilated, and are at the sametime lengthened and tortuous. Two types are met with: one in whichdilatation of a large superficial vein and its tributaries is the mostobvious feature; the other, in which bunches of distended and tortuousvessels develop at one or more points in the course of a vein, acondition 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 rareexcept in the veins of the lower extremity, in the veins of thespermatic cord (varicocele), and in the veins of the anal canal(hæmorrhoids). We are here concerned with varix as it occurs in the veins of the lowerextremity. _Etiology. _--Considerable difference of opinion exists as to theessential cause of varix. The weight of evidence is in favour of theview that, when dilatation is the predominant element, it results from acongenital deficiency in the number, size, and strength of the valves ofthe affected veins, and in an inherent weakness in the vessel walls. The _angioma racemosum venosum_ is probably also due to a congenitalalteration in the structure of the vessels, and is allied to tumours ofblood vessels. The view that varix is congenital in origin, as was firstsuggested by Virchow, is supported by the fact that in a largeproportion of cases the condition is hereditary; not only may severalmembers of the same family in succeeding generations suffer from varix, but it is often found that the same vein, or segment of a vein, isinvolved in all of them. The frequent occurrence of varix in youth isalso an indication of its congenital origin. In the majority of cases it is only when some exciting factor comes intooperation that the clinical phenomena associated with varix appear. Themost common exciting cause is increased pressure within the veins, andthis may be produced in a variety of ways. In certain diseases of theheart, lungs, and liver, for example, the venous pressure may be soraised as to cause a localised dilatation of such veins as arecongenitally weak. The direct pressure of a tumour, or of the graviduterus on the large venous trunks in the pelvis, may so obstruct theflow as to distend the veins of the lower extremity. It is a commonexperience in women that the signs of varix date from an antecedentpregnancy. The importance of the wearing of tight garters as a factor inthe production of varicose veins has been exaggerated, although it mustbe admitted that this practice is calculated to aggravate the conditionwhen it is once established. It has been proved experimentally that thebackward pressure in the veins may be greatly increased by straining, afact which helps to explain the frequency with which varicosity occursin the lower limbs of athletes and of those whose occupation involvesrepeated and violent muscular efforts. There is reason to believe, moreover, that a sudden strain may, by rupturing the valves and sorendering them incompetent, induce varicosity independently of anycongenital defect. Prolonged standing or walking, by allowing gravity toact on the column of blood in the veins of the lower limbs, is also animportant determining factor in the production of varix. Thrombosis of the deep veins--in the leg, for example--may induce markeddilatation of the superficial veins, by throwing an increased amount ofwork upon them. This is to be looked upon rather as a compensatoryhypertrophy of the superficial vessels than as a true varix. _Morbid Anatomy. _--In the lower extremity the varicosity most commonlyaffects the vessels of the great saphena system; less frequently thoseof the small saphena system. Sometimes both systems are involved, andlarge communicating branches may develop between the two. The essential lesion is the absence or deficiency of valves, so thatthey are incompetent and fail to support the column of blood which bearsback upon them. Normally the valves in the femoral and iliac veins andin the inferior vena cava are imperfectly developed, so that in theerect posture the great saphena receives a large share of the backwardpressure of the column of venous blood. The whole length of the vein may be affected, but as a rule the diseaseis confined to one or more segments, which are not only dilated, but arealso increased in length, so that they become convoluted. The adjacentloops of the convoluted vein are often bound together by fibrous tissue. All the coats are thickened, chiefly by an increased development ofconnective tissue, and in some cases changes similar to those ofarterio-sclerosis occur. The walls of varicose veins are oftenexceedingly brittle. In some cases the thickening is uniform, and inothers it is irregular, so that here and there thin-walled sacs orpouches project from the side of the vein. These pouches vary in sizefrom a bean to a hen's egg, the larger forms being called _venouscysts_, and being most commonly met with in the region of the saphenousopening and of the opening in the popliteal fascia. Such pouches, beingexposed to injury, are frequently the seat of thrombosis (Fig. 66). [Illustration: FIG.  66. --Thrombosis in Tortuous and Pouched GreatSaphena Vein, in longitudinal section. ] _Clinical Features. _--Varix is most frequently met with between pubertyand the age of thirty, and the sexes appear to suffer about equally. The amount of discomfort bears no direct proportion to the extent ofthe varicosity. It depends rather upon the degree of pressure in theveins, as is shown by the fact that it is relieved by elevation of thelimb. When the whole length of the main trunk of the great saphena isimplicated, the pressure in the vein is high and the patient suffers agood deal of pain and discomfort. When, on the contrary, the upper partof the saphena and its valves are intact, and only the more distal veinsare involved, the pressure is not so high and there is comparativelylittle suffering. The usual complaint is of a sense of weight andfulness in the limb after standing or walking, sometimes accompanied byactual pain, from which relief is at once obtained by raising the limb. Cramp-like pains in the muscles are often associated with varix of thedeep veins. The dilated and tortuous vein can be readily seen and felt when thepatient is examined in the upright posture. In advanced cases, bead-likeswellings are sometimes to be detected over the position of the valves, and, on running the fingers along the course of the vessel, a firmridge, due to periphlebitis, may be detected on each side of the vein. When the limb is œdematous, the outline of the veins is obscured, butthey can be identified on palpation as gutter-like tracks. When largeveins are implicated, a distinct impulse on coughing may be seen to passdown as far as the knee; and if the vessel is sharply percussed a fluidwave may be detected passing both up and down the vein. If the patient is placed on a couch and the limb elevated, the veins areemptied, and if pressure is then made over the region of the saphenousopening and the patient allowed to stand up, so long as the greatsaphena system alone is involved, the veins fill again very slowly frombelow. If the small saphena system also is involved, and ifcommunicating branches are dilated, the veins fill up from below morerapidly. When the pressure over the saphenous opening is removed, theblood rapidly rushes into the varicose vessels from above; this is knownas Trendelenburg's test. The most marked dilatation usually occurs on the medial side of thelimb, between the middle of the thigh and the middle of the calf, thearrangement of the veins showing great variety (Fig. 67). There are usually one or more bunches of enlarged and tortuous veins inthe region of the knee. Frequently a large branch establishes acommunication between the systems of the great and small saphenous veinsin the region of the popliteal space, or across the front of the upperpart of the tibia. The superficial position of this last branch and itsproximity to the bone render it liable to injury. [Illustration: FIG.  67. --Extensive Varix of Internal Saphena System onLeft Leg, of many years' standing. ] The small veins of the skin of the ankle and foot often show as fineblue streaks arranged in a stellate or arborescent manner, especially inwomen who have borne children. _Complications. _--When the varix is of long standing, the skin in thelower 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 thisis frequently a precursor of ulceration. _Chronic dermatitis_ (_varicose eczema_) is often met with in the lowerpart of the leg, and is due to interference with the nutrition of theskin. The incompetence of the valves allows the pressure in the varicoseveins to equal that in the arterioles, so that the capillary circulationis impeded. From the same cause the blood in the deep veins is enabledto enter the superficial veins, where the backward pressure is so greatthat 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 tonourish the tissues. The _ulcer_ of the leg associated with varicose veins has already beendescribed. _Hæmorrhage_ may take place from a varicose vein as a result of a woundor of ulceration of its wall. Increased intra-venous pressure producedby severe muscular strain may determine rupture of a vein exposed in thefloor of an ulcer. If the limb is dependent, the incompetency of thevalves permits of rapid and copious bleeding, which may prove fatal, particularly if the patient is intoxicated when the rupture takes placeand no means are taken to arrest the hæmorrhage. The bleeding may bearrested at once by elevating the limb, or by applying pressure directlyover the bleeding point. _Phlebitis and thrombosis_ are common sequelæ of varix, and may provedangerous, either by spreading into the large venous trunks or by givingrise to emboli. The larger the varix the greater is the tendency for athrombus to spread upwards and to involve the deep veins. Thrombiusually originate in venous cysts or pouches, and at acute bends on thevessel, 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 aradiogram. In a certain proportion of cases, especially in elderlypeople, the occurrence of thrombosis leads to cure of the condition bythe thrombus becoming organised and obliterating the vein. _Treatment. _--At best the treatment of varicose veins is onlypalliative, as it is obviously impossible to restore to the vesselstheir normal structure. The patient must avoid wearing anything, such asa garter, which constricts the limb, and any obvious cause of directpressure on the pelvic veins, such as a tumour, persistentconstipation, 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 muscularexertion and prolonged standing or walking are to be avoided, and thepatient may with benefit rest the limb in an elevated position for a fewhours each day. To support the distended vessels, a closely woven silkor worsted stocking, or a light and porous form of elastic bandage, applied as a puttee, should be worn. These appliances should be put onbefore the patient leaves his bed in the morning, and should only beremoved after he lies down at night. In this way the vessels are neverallowed to become dilated. Elastic stockings, and bandages made entirelyof india-rubber, are to be avoided. In early and mild cases thesemeasures are usually sufficient to relieve the patient's discomfort. _Operative Treatment. _--In aggravated cases, when the patient issuffering pain, when his occupation is interfered with by repeatedattacks of phlebitis, or when there are large pouches on the veins, operative treatment is called for. The younger the patient the cleareris the indication to operate. It may be necessary to operate to enable apatient to enter one of the public services, even although no symptomsare present. The presence of an ulcer does not contra-indicateoperation; the ulcer should be excised, and the raw surface covered withskin grafts, before dealing with the veins. The _operation of Trendelenburg_ is especially appropriate to cases inwhich the trunk of the great saphena vein in the thigh is aloneinvolved. It consists in exposing three or four inches of the vein inits upper part, applying a ligature at the upper and lower ends of theexposed portion, and, after tying all tributary branches, resecting thisportion of the vein. The procedure of C.  H.  Mayo is adapted to cases in which it is desirableto remove longer segments of the veins. It consists in the employment ofspecial instruments known as "ring-enucleators" or "vein-strippers, " bymeans of which long portions of the vein are removed throughcomparatively small incisions. An alternative procedure consists in avulsing segments of the vein bymeans of Babcock's stylet, which consists of a flexible steel rod, 30inches in length, with acorn-shaped terminals. The instrument is passedalong the lumen of the segment to be dealt with, and a ligature appliedaround the vein above the bulbous end of the stylet enables nearly thewhole length of the great saphena vein to be dragged out in one piece. These methods are not suitable when the veins are brittle, when thereare pouches or calcareous deposits in their walls, or where there hasbeen periphlebitis binding the coils together. Mitchell of Belfast advises exposing the varices at numerous points byhalf-inch incisions, and, after clamping the vein between two pairs offorceps, cutting it across and twisting out the segments of the veinbetween adjacent incisions. The edges of the incisions are sutured; andthe limb is firmly bandaged from below upwards, and kept in an elevatedposition. 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 thelate John Duncan. Tumours of blood vessels may be divided, according to the nature of thevessels of which they are composed, into the capillary, the venous, andthe arterial angiomas. CAPILLARY ANGIOMA The most common form of capillary angioma is the nævus or congenitaltelangiectasis. #Nævus. #--A nævus is a collection of dilated capillaries, the afferentarterioles and the efferent venules of which often share in thedilatation. Little is known regarding the _etiology_ of nævi beyond thefact that they are of congenital origin. They often escape notice untilthe child is some days old, but attention is usually drawn to themwithin a fortnight of birth. For practical purposes the most usefulclassification of nævi is into the cutaneous, the subcutaneous, and themixed forms. _The cutaneous nævus_, "mother's mark, " or "port-wine stain, " consistsof 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 avein winding about among the capillaries may sometimes be detected. These nævi occur on any part of the body, but they are most frequentlymet 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 ofthe body. In colour they present every tint from purple to brilliantred; in the majority there is a considerable dash of blue, especially incold weather. Unlike the other forms of nævi, the cutaneous variety shows littletendency to disappear, and it is especially persistent when associatedwith overgrowth of the epidermis and of the hairs--_nævoid mole_. The _treatment_ of the cutaneous nævus is unsatisfactory, owing to thedifficulty of removing the nævus without leaving a scar which is evenmore disfiguring. Very small nævi may be destroyed by a fine pointedPaquelin thermo-cautery, or by escharotics, such as nitric acid. Forlarger nævi, radium and solidified carbon dioxide ("CO₂ snow") may beused. The extensive port-wine stains so often met with on the face arebest left alone. The _subcutaneous nævus_ is comparatively rare. It constitutes awell-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, asubcutaneous nævus is often overlooked, especially when on a coveredpart of the body, and may not be discovered till the patient is someyears old. It forms a rounded, lobulated swelling, seldom of large sizeand yielding a sensation like that of a sponge; the skin over it isnormal, or may exhibit a bluish tinge, especially in cold weather. Insome cases the tumour is diminished by pressing the blood out of it, butslowly fills again when the pressure is relaxed, and it swells up whenthe child struggles or cries. From a cold abscess it is diagnosed by thehistory and progress of the swelling and by the absence of fluctuation. When situated over one of the hernial openings, it closely simulates ahernia; and when it occurs in the middle line of the face, head, orback, it may be mistaken for such other congenital conditions asmeningocele or spina bifida. When other means fail, the use of anexploring needle clears up the diagnosis. _Mixed Nævus. _--As its name indicates, the mixed nævus partakes of thecharacters of the other two varieties; that is, it is a subcutaneousnævus with involvement of the skin. It is frequently met with on the face and head, but may occur on anypart of the body. It also affects parts covered by mucous membrane, suchas the cheek, tongue, and soft palate. The swelling is rounded orlobulated, and projects beyond the level of its surroundings. Sometimesthe skin is invaded by the nævoid tissue over the whole extent of thetumour, sometimes only over a limited area. Frequently the margin onlyis of a bright-red colour, while the skin in the centre resembles acicatrix. The swelling is reduced by steady pressure, and increases insize and becomes tense when the child cries. [Illustration: FIG.  68. --Mixed Nævus of Nose which was subsequentlycured by Electrolysis. ] _Prognosis. _--The rate of growth of the subcutaneous and mixed forms ofnævi varies greatly. They sometimes increase rapidly, especially duringthe first few months of life; after this they usually grow at the samerate as the child, or more slowly. There is a decided tendency todisappearance of these varieties, fully 50 per cent. Undergoing naturalcure by a process of obliteration, similar to the obliteration ofvessels in cicatricial tissue. This usually begins about the period ofthe first dentition, sometimes at the second dentition, and sometimes atpuberty. On the other hand, an increased activity of growth may be shownat these periods. The onset of natural cure is recognised by the tumourbecoming firmer and less compressible, and, in the mixed variety, by thecolour becoming less bright. Injury, infection, or ulceration of theoverlying skin may initiate the curative process. Towards adult life the spaces in a subcutaneous nævus may become greatlyenlarged, leading to the formation of a cavernous angioma. _Treatment. _--In view of the frequency with which subcutaneous and mixednævi disappear spontaneously, interference is only called for when thegrowth 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 markedincrease in its size would render it less amenable to treatment. The methods of treatment most generally applicable are the use of radiumand carbon dioxide snow, igni-puncture, electrolysis, and excision. For nævi situated on exposed parts, where it is desirable to avoid ascar, the use of _radium_ is to be preferred. The tube of radium isapplied at intervals to different parts of the nævus, the duration andfrequency of the applications varying with the strength of theemanations and the reaction produced. The object aimed at is to induceobliteration of the nævoid tissue by cicatricial contraction withoutdestroying the overlying skin. _Carbon-dioxide snow_ may be employed inthe same manner, but the results are inferior to those obtained byradium. _Igni-puncture_ consists in making a number of punctures at differentparts of the nævus with a fine-pointed thermo-cautery, with the objectof starting at each point a process of cicatrisation which extendsthroughout the nævoid tissue and so obliterates the vessels. _Electrolysis_ acts by decomposing the blood and tissues into theirconstituent elements--oxygen and acids appearing at the positive, hydrogen and bases at the negative electrode. These substances and gasesbeing given off in a nascent condition, at once enter into newcombinations with anything in the vicinity with which they have achemical affinity. In the nævus the practical result of this reaction isthat at the positive pole nitric acid, and at the negative pole causticpotash, both in a state of minute subdivision, make their appearance. The effect on the tissues around the positive pole, therefore, isequivalent to that of an acid cauterisation, and on those round thenegative pole, to an alkaline cauterisation. As the process is painful, a general anæsthetic is necessary. Thecurrent used should be from 20 to 80 milliampères, gradually increasingfrom zero, without shock; three to six large Bunsen cells give asufficient 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 nævus, the positivebeing kept fixed at one spot, while the negative is moved about so as toproduce a number of different tracks of cauterisation. On no accountmust either pole be allowed to come in contact with the skin, lest aslough be formed. The duration of the sitting is determined by theeffect produced, as indicated by the hardening of the tumour, theaverage duration being from fifteen to twenty minutes. If pallor of theskin appears, it indicates that the needles are too near the surface, orthat the blood supply to the integument is being cut off, and is anindication to stop. To cauterise the track and so prevent bleeding, theneedles should be slowly withdrawn while the current is flowing. Whenthe skin is reached the current is turned off. The punctures are coveredwith collodion. Six or eight weeks should be allowed to elapse beforerepeating the procedure. From two to eight or ten sittings may benecessary, according to the size and character of the nævus. _Excision_ is to be preferred for nævi of moderate size situated oncovered parts of the body, where a scar is of no importance. Its chiefadvantages over electrolysis are that a single operation is sufficient, and that the cure is speedy and certain. The operation is attended withmuch less hæmorrhage than might be expected. #Cavernous Angioma. #--This form of angioma consists of a series of largeblood spaces which are usually derived from the dilatation of thecapillaries of a subcutaneous nævus. The spaces come to communicatefreely with one another by the disappearance of adjacent capillarywalls. While the most common situation is in the subcutaneous tissue, acavernous angioma is sometimes met with in internal organs. It mayappear at any age from early youth to middle life, and is of slow growthand may become stationary. The swelling is rounded or oval, there is nopulsation or bruit, and the tumour is but slightly compressible. Thetreatment consists in dissecting it out. #Aneurysm by Anastomosis# is the name applied to a vascular tumour inwhich the arteries, veins, and capillaries are all involved. It is metwith chiefly on the upper part of the trunk, the neck, and the scalp. Ittends gradually to increase in size, and may, after many years, attainan enormous size. The tumour is ill-defined, and varies in consistence. It is pulsatile, and a systolic bruit or a "thrilling" murmur may beheard over it. The chief risk is hæmorrhage from injury or ulceration. [Illustration: FIG.  69. --Cirsoid Aneurysm of Forehead in a boy æt.  10. (Mr. J.  W.  Dowden's case. )] The _treatment_ is conducted on the same lines as for nævus. Whenelectrolysis is employed, it should be directed towards the afferentvessels; and if it fails to arrest the flow through these, it is uselessto persist with it. In some cases ligation of the afferent vessels hasbeen successful. #Arterial Angioma# or #Cirsoid Aneurysm#. --This is composed of theenlarged branches of an arterial trunk. It originates in the smallerbranches of an artery--usually the temporal--and may spread to the maintrunk, and may even involve branches of other trunks with which theaffected artery anastomoses. The condition is probably congenital in origin, though its appearance isfrequently preceded by an injury. It almost invariably occurs in thescalp, and is usually met with in adolescent young adults. The affected vessels slowly increase in size, and become tortuous, withnarrowings and dilatations here and there. Grooves and gutters arefrequently found in the bone underlying the dilated vessels. There is a constant loud bruit in the tumour, which greatly troubles thepatient and may interfere with sleep. There is no tendency either tonatural cure or to rupture, but severe and even fatal hæmorrhage mayfollow a wound of the dilated vessels. [Illustration: FIG.  70. --Cirsoid Aneurysm of Orbit and Face, whichdeveloped 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 excisionthe hæmorrhage is controlled by an elastic tourniquet appliedhorizontally round the head, or by ligation of the feeding trunks. Inlarge tumours the bleeding is formidable. In many cases electrolysis isto be preferred, and is performed in the same way as for nævus. Thepositive pole is placed in the centre of the tumour, while the negativeis introduced into the main affluents one after another. ANEURYSM An aneurysm is a sac communicating with an artery, and containing fluidor coagulated blood. Two types are met with--the pathological and the traumatic. It isconvenient to describe in this section also certain conditions in whichthere is an abnormal communication between an artery and avein--arterio-venous aneurysm. PATHOLOGICAL ANEURYSM In this class are included such dilatations as result from weakening ofthe arterial coats, combined, in most cases, with a loss of elasticityin the walls and increase in the arterial tension due toarterio-sclerosis. In some cases the vessel wall is softened byarteritis--especially the embolic form--so that it yields before thepressure of the blood. Repeated and sudden raising of the arterial tension, as a result, forexample, of violent muscular efforts or of excessive indulgence inalcohol, plays an important part in the causation of aneurysm. Thesefactors probably explain the comparative frequency of aneurysm in thosewho follow such arduous occupations as soldiers, sailors, dock-labourers, and navvies. In these classes the condition usuallymanifests itself between the ages of thirty and fifty--that is, when thevessels are beginning to degenerate, although the heart is stillvigorous and the men are hard at work. The comparative immunity of womenmay also be explained by the less severe muscular strain involved bytheir occupations and recreations. Syphilis plays an important part in the production of aneurysm, probablyby predisposing the patient to arterio-sclerosis and atheroma, andinducing an increase in the vascular tension in the peripheral vessels, from loss of elasticity of the vessel wall and narrowing of the lumen asa result of syphilitic arteritis. It is a striking fact that aneurysm isseldom met with in women who have not suffered from syphilis. #Varieties--Fusiform Aneurysm. #--When the _whole circumference_ of anartery has been weakened, the tension of the blood causes the walls todilate uniformly, so that a fusiform or tubular aneurysm results. Allthe 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 inlength. This form is chiefly met with in the arch of the aorta, but mayoccur in any of the main arterial trunks. As the sac of the aneurysmincludes all three coats, and as the inner and outer coats are usuallythickened by the deposit in them of connective tissue, this varietyincreases in size slowly and seldom gives rise to urgent symptoms. As a rule a fusiform aneurysm contains fluid blood, but when the intimais 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 occasionallyeffected by the emerging artery becoming occluded by a clot; it has alsolittle tendency to rupture. #Sacculated Aneurysm. #--When a _limited area_ of the vessel wall isweakened--for example by atheroma or by other form of arteritis--thisportion yields before the pressure of the blood, and a sacculatedaneurysm results. The internal and middle coats being already damaged, or, it may be, destroyed, by the primary disease, the stress falls onthe external coat, which in the majority of cases constitutes the sac. To withstand the pressure the external coat becomes thickened, and asthe aneurysm increases in size it forms adhesions to surroundingtissues, so that fasciæ, tendons, nerves, and other structures may befound matted together in its wall. The wall is further strengthened bythe deposit on its inner aspect of blood-clot, which may eventuallybecome organised. The contents of the sac consist of fluid blood and a varying amount ofclot which is deposited in concentric layers on the inner aspect of thesac, where it forms a pale, striated, firm mass, which constitutes alaminated clot. Near the blood-current the clot is soft, red, andfriable (Fig. 72). The laminated clot not only strengthens the sac, enabling it to resist the blood-pressure and so prevent rupture, but, ifit increases sufficiently to fill the cavity, may bring about cure. Theprinciple upon which all methods of treatment are based is to imitatenature in producing such a clot. Sacculated aneurysm, as compared with the fusiform variety, tends torupture and also to cure by the formation of laminated clot; naturalcure is sometimes all but complete when extension and rupture occur andcause death. An aneurysm is said to be _diffused_ when the sac ruptures and the bloodescapes into the cellular tissue. #Clinical Features of Aneurysm. #--Surgically, the sacculated is by farthe most important variety. The outstanding feature is the existence inthe line of an artery of a globular swelling, which pulsates. Thepulsation is of an expansile character, which is detected by observingthat when both hands are placed over the swelling they are separatedwith each beat of the heart. If the main artery be compressed on thecardiac side of the swelling, the pulsation is arrested and the tumourbecomes smaller and less tense, and it may be still further reduced insize by gentle pressure being made over it so as to empty it of fluidblood. On allowing the blood again to flow through the artery, thepulsation returns at once, but several beats are required before the sacregains its former size. In most cases a distinct thrill is felt onplacing the hand over the swelling, and a blowing, systolic murmur maybe heard with the stethoscope. It is to be borne in mind thatoccasionally, when the interchange of blood between an aneurysm and theartery from which it arises is small, pulsation and bruit may be slightor even absent. This is also the case when the sac contains aconsiderable quantity of clot. When it becomes filled withclot--_consolidated aneurysm_--these signs disappear, and the clinicalfeatures 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 aneurysmwith that in the corresponding artery on the healthy side, shows that onthe affected side the wave is smaller in volume, and delayed in time. Apulse 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, showinglaminated clot and erosion of bodies of vertebræ. The intervertebraldiscs are intact. ] An aneurysm exerts pressure on the surrounding structures, which areusually thickened and adherent to it and to one another. Adjacent veinsmay be so compressed that congestion and œdema of the parts beyond areproduced. Pain, disturbances of sensation, and muscular paralyses mayresult from pressure on nerves. Such bones as the sternum and vertebræundergo erosion and are absorbed by the gradually increasing pressure ofthe aneurysm. Cartilage, on the other hand, being elastic, yields beforethe pressure, so that the intervertebral discs or the costal cartilagesmay escape while the adjacent bones are destroyed (Fig. 71). The skinover the tumour becomes thinned and stretched, until finally a sloughforms, and when it separates hæmorrhage takes place. [Illustration: FIG.  72. --Sacculated Aneurysm of Abdominal Aorta nearlyfilled with laminated clot. Note greater density of clot towardsperiphery. ] In the progress of an aneurysm towards rupture, timely clotting mayavert death for the moment, but while extension in one direction hasbeen arrested there is apt to be extension in another, with imminence ofrupture, or it may be again postponed. #Differential Diagnosis. #--The diagnosis is to be made from otherpulsatile swellings. Pulsation is sometimes transmitted from a largeartery to a tumour, a mass of enlarged lymph glands, or an inflammatoryswelling which lies in its vicinity, but the pulsation is notexpansile--a most important point in differential diagnosis. Suchswellings may, by appropriate manipulation, be moved from the artery andthe pulsation ceases, and compression of the artery on the cardiac sideof the swelling, although it arrests the pulsation, does not produce anydiminution in the size or tension of the swelling, and when the pressureis removed the pulsation is restored immediately. Fluid swellings overlying an artery, such as cysts, abscesses, orenlarged bursæ, may closely simulate aneurysm. An apparent expansion mayaccompany the pulsation, but careful examination usually enables this tobe distinguished from the true expansion of an aneurysm. Compression ofthe artery makes no difference in the size or tension of the swelling. Vascular tumours, such as sarcoma and goitre, may yield an expansilepulsation and a soft, whifling bruit, but they differ from an aneurysmin that they are not diminished in size by compression of the mainartery, 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 bythe formation of laminated clot, which gradually increases in amounttill it fills the sac. Sometimes a portion of the clot in the sac isseparated and becomes impacted as an embolus in the artery beyond, leading to thrombosis which first occludes the artery and then extendsinto the sac. The progress of natural cure is indicated by the aneurysm becomingsmaller, firmer, less expansile, and less compressible; the murmur andthrill diminish and the pressure effects become less marked. When thecure is complete the expansile pulsation is lost, and there remains afirm swelling attached to the vessel (_consolidated aneurysm_). Whilethese changes are taking place the collateral arteries become enlarged, and an anastomotic circulation is established. An aneurysm may prove _fatal_ by exerting pressure on importantstructures, by causing syncope, by rupture, or from the occurrence ofsuppuration. _Pressure_ symptoms are usually most serious from aneurysmssituated in the neck, thorax, or skull. Sudden fatal _syncope_ is notinfrequent in cases of aneurysm of the thoracic aorta. _Rupture_ may take place through the skin, on a mucous or seroussurface, or into the cellular tissue. The first hæmorrhage is oftenslight and stops naturally, but it soon recurs, and is so profuse, especially when the blood escapes externally, that it rapidly provesfatal. When the bleeding takes place into the cellular tissue, theaneurysm is said to become _diffused_, and the extravasated bloodspreads widely through the tissues, exerting great pressure on thesurrounding structures. The _clinical features_ associated with rupture are sudden and severepain in the part, and the patient becomes pale, cold, and faint. If acomparatively small escape of blood takes place into the tissues, thesudden alteration in the size, shape, and tension of the aneurysm, together with loss of pulsation, may be the only local signs. When thebleeding is profuse, however, the parts beyond the aneurysm becomegreatly swollen, livid, and cold, and the pulse beyond is completelylost. The arrest of the blood supply may result in gangrene. Sometimesthe pressure of the extravasated blood causes the skin to slough and, later, give way, and fatal hæmorrhage results. The _treatment_ is carried out on the same lines as for a rupturedartery (p. 261), it being remembered, however, that the artery isdiseased and does not lend itself to reconstructive procedures. _Suppuration_ may occur in the vicinity of an aneurysm, and the aneurysmmay burst into the abscess which forms, so that when the latter pointsthe pus is mixed with broken-down blood-clot, and finally freehæmorrhage takes place. It has more than once happened that a surgeonhas incised such an abscess without having recognised its associationwith aneurysm, with tragic results. #Treatment. #--In treating an aneurysm, the indications are to imitateNature's method of cure by means of laminated clot. _Constitutional treatment_ consists in taking measures to reduce thearterial tension and to diminish the force of the heart's action. Thepatient must be kept in bed. A dry and non-stimulating diet isindicated, the quantity being gradually reduced till it is justsufficient to maintain nutrition. Saline purges are employed to reducethe vascular tension. The benefit derived from potassium iodideadministered in full doses, as first recommended by George W.  Balfour, probably depends on its depressing action on the heart and itstherapeutic benefit in syphilis. Pain or restlessness may call for theuse of opiates, of which heroin is the most efficient. _Local Treatment. _--When constitutional treatment fails, local measuresmust be adopted, and many methods are available. #Endo-aneurysmorrhaphy. #--The operation devised by Rudolf Matas in 1888aims at closing the opening between the sac and its feeding artery, andin addition, folding the wall of the sac in such a way as to leave novacant space. If there is marked disease of the vessel, Matas' operationis not possible and recourse is then had to ligation of the artery justabove the sac. _Extirpation of the Sac--The Old Operation. _--The procedure which goesby 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 asthey are circumscribed and free from complications. It has beensuccessfully practised also in aneurysm of the subclavian, carotid, andexternal iliac arteries. It is not applicable to cases in which there issuch a degree of atheroma as would interfere with the successfulligation of the artery. The continuity of the artery may be restored bygrafting into the gap left after excision of the sac a segment of thegreat saphena vein. _Ligation of the Artery. _--The object of tying the artery is to diminishor to arrest the flow of blood through the aneurysm so that the bloodcoagulates both in the sac and in the feeding artery. The ligature maybe applied on the cardiac side of the aneurysm--proximal ligation, or tothe artery beyond--distal ligation. _Proximal Ligation. _--The ligature may be applied immediately above thesac (Anel, 1710) or at a distance above (John Hunter, 1785). The_Hunterian operation_ ensures that the ligature is applied to a part ofthe artery that is presumably healthy and where relations areundisturbed by the proximity of the sac; the best example is theligation of the superficial femoral artery in Scarpa's triangle or inHunter's canal for popliteal aneurysm; it is on record that Symeperformed this operation with cure of the aneurysm on thirty-nineoccasions. 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 todiminish its volume and force as to favour the deposition within the sacof laminated clot. The development of the collateral circulation whichfollows upon ligation of the artery at a distance above the sac may beattended with just that amount of return stream which favours thedeposit of laminated clot, and consequently the cure of the aneurysm;the return stream may, however, be so forcible as to prevent coagulationof the blood in the sac, or only to allow of the formation of a redthrombus which may in its turn be dispersed so that pulsation in the sacrecurs. This does not necessarily imply failure to cure, as therecurrent pulsation may only be temporary; the formation of laminatedclot may ultimately take place and lead to consolidation of theaneurysm. The least desirable result of the Hunterian ligature is met with incases where, owing to widespread arterial disease, the collateralcirculation does not develop and gangrene of the limb supervenes. _Anel's ligature_ is only practised as part of the operation which dealswith the sac directly. _Distal Ligation. _--The tying of the artery beyond the sac, or of itstwo branches where it bifurcates (Brasdor, 1760, and Wardrop, 1825), mayarrest or only diminish the flow of blood through the sac. It is lesssuccessful than the proximal ligature, and is therefore restricted toaneurysms so situated as not to be amenable to other methods; forexample, in aneurysm of the common carotid near its origin, the arterymay be ligated near its bifurcation, or in aneurysm of the innominateartery, the carotid and subclavian arteries are tied at the seat ofelection. _Compression. _--Digital compression of the feeding artery has been givenup except as a preparation for operations on the sac with a view tofavouring the development of a collateral circulation. _Macewen's acupuncture or "needling"_ consists in passing one or morefine, highly tempered steel needles through the tissues overlying theaneurysm, and through its outer wall. The needles are made to touch theopposite wall of the sac, and the pulsation of the aneurysm imparts amovement to them which causes them to scarify the inner surface of thesac. White thrombus forms on the rough surface produced, and leads tofurther coagulation. The needles may be left in position for some hours, being shifted from time to time, the projecting ends being surroundedwith sterile gauze. The _Moore-Corradi method_ consists in introducing through the wall ofthe aneurysm a hollow insulated needle, through the lumen of which from10 to 20 feet of highly drawn silver or other wire is passed into thesac, where it coils up into an open meshwork (Fig. 73). The positivepole of a galvanic battery is attached to the wire, and the negativepole placed over the patient's back. A current, varying in strength from20 to 70 milliampères, is allowed to flow for about an hour. The hollowneedle is then withdrawn, but the wire is left _in situ_. The resultsare somewhat similar to those obtained by needling, but the clot formedon the large coil of wire is more extensive. [Illustration: FIG.  73. --Radiogram of Innominate Aneurysm aftertreatment by the Moore-Corradi method. Two feet of finely drawn silverwire were introduced. The patient, a woman, æt.  47, lived for ten monthsafter operation, free from pain (cf. Fig. 75). ] Colt's method of wiring has been mainly used in the treatment ofabdominal aneurysm; gilt wire in the form of a wisp is introducedthrough the cannula and expands into an umbrella shape. _Subcutaneous Injections of Gelatin. _--Three or four ounces of a 2 percent. Solution of white gelatin in sterilised water, at a temperature ofabout 100° F. , are injected into the subcutaneous tissue of the abdomenevery two, three, or four days. In the course of a fortnight or threeweeks improvement may begin. The clot which forms is liable to softenand be absorbed, but a repetition of the injection has in several casesestablished a permanent cure. _Amputation of the limb_ is indicated in cases complicated bysuppuration, by secondary hæmorrhage after excision or ligation, or bygangrene. Amputation at the shoulder was performed by Fergusson in acase of subclavian aneurysm, as a means of arresting the blood-flowthrough the sac. TRAUMATIC ANEURYSM The essential feature of a traumatic aneurysm is that it is produced bysome form of injury which divides all the coats of the artery. The wallsof the injured vessel are presumably healthy, but they form no part ofthe sac of the aneurysm. The sac consists of the condensed and thickenedtissues around the artery. The injury to the artery may be a subcutaneous one such as a tear by afragment of bone: much more commonly it is a punctured wound from a stabor from a bullet. The aneurysm usually forms soon after the injury is inflicted; the bloodslowly escapes into the surrounding tissues, gradually displacing andcondensing them, until they form a sac enclosing the effused blood. Less frequently a traumatic aneurysm forms some considerable time afterthe injury, from gradual stretching of the fibrous cicatrix by which thewound in the wall of the artery has been closed. The gradual stretchingof this cicatrix results in condensation of the surrounding structureswhich form the sac, on the inner aspect of which laminated clot isdeposited. A traumatic aneurysm is almost always sacculated, and, so long as itremains circumscribed, has the same characters as a pathologicalsacculated aneurysm, with the addition that there is a scar in theoverlying skin. A traumatic aneurysm is liable to become diffuse--achange which, although attended with considerable risk of gangrene, hassometimes been the means of bringing about a cure. The treatment is governed by the same principles as apply to thepathological varieties, but as the walls of the artery are not diseased, operative measures dealing with the sac and the adjacent segment of theaffected artery are to be preferred. ARTERIO-VENOUS ANEURYSM An abnormal communication between an artery and a vein constitutes anarterio-venous aneurysm. Two varieties are recognised--one in which thecommunication is direct--_aneurysmal varix_; the other in which thevein communicates with the artery through the medium of a sac--_varicoseaneurysm_. Either variety may result from pathological causes, but in the majorityof cases they are traumatic in origin, being due to such injuries asstabs, punctured wounds, and gun-shot injuries which involve both arteryand vein. In former times the most common situation was at the bend ofthe elbow, the brachial artery being accidentally punctured inblood-letting from the median basilic vein. Arterio-venous aneurysm is afrequent result of injuries by modern high-velocity bullets--forexample, in the neck or groin. In _aneurysmal varix_ the higher blood pressure in the artery forcesarterial blood into the vein, which near the point of communication withthe 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, butthe entrance of arterial blood into the dilated veins causes them topulsate, and produces in them a vibratory thrill and a loud murmur. Inthose at the groin, the distension of the veins may be so great thatthey look like sinuses running through the muscles, a feature that mustbe taken into account in any operation. As the condition tends to remain stationary, the support of an elasticbandage is all that is required; but when the condition progresses andcauses serious inconvenience, it may be necessary to cut down and exposethe communication between the artery and vein, and, after separating thevessels, to close the opening in each by suture; this may be difficultor impossible if the parts are matted from former suppuration. If it isimpossible thus to obliterate the communication, the artery should beligated above and below the point of communication; although the risk ofgangrene is considerable unless means are taken to develop thecollateral circulation beforehand (Makins). _Varicose aneurysm_ usually develops in relation to a traumaticaneurysm, the sac becoming adherent to an adjacent vein, and ultimatelyopening into it. In this way a communication between the artery and thevein is established, and the clinical features are those of acombination of aneurysm and aneurysmal varix. As there is little tendency to spontaneous cure, and as the aneurysm isliable to increase in size and finally to rupture, operative treatmentis usually called for. This is carried out on the same lines as foraneurysmal varix, and at the same time incising the sac, turning out theclots, and ligating any branches which open into the sac. If it can beavoided, the vein should not be ligated. ANEURYSMS OF INDIVIDUAL ARTERIES #Thoracic Aneurysm. #--All varieties of aneurysm occur in the aorta, thefusiform being the most common, although a sacculated aneurysmfrequently springs from a fusiform dilatation. The _clinical features_ depend chiefly on the direction in which theaneurysm enlarges, and are not always well marked even when the sac isof considerable size. They consist in a pulsatile swelling--sometimes inthe supra-sternal notch, but usually towards the right side of thesternum--with an increased area of dulness on percussion. With theX-rays a dark shadow is seen corresponding to the sac. Pain is usually aprominent symptom, and is largely referable to the pressure of theaneurysm on the vertebræ or the sternum, causing erosion of these bones. Pressure on the thoracic veins and on the air-passage causes cyanosisand dyspnœa. When the œsophagus is pressed upon, the patient may havedifficulty in swallowing. The left recurrent nerve may be stretched orpressed upon as it hooks round the arch of the aorta, and hoarseness ofthe voice and a characteristic "brassy" cough may result from paralysisof 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 onthe transverse part of the arch, the trachea is pulled down with eachbeat of the heart--a clinical phenomena known as the "tracheal tug. "Aneurysm of the descending aorta may, after eroding the bodies of thevertebræ (Fig. 71) and posterior portions of the ribs, form a swellingin the back to the left of the spine. Inasmuch as obliteration of the sac and the feeding artery is out of thequestion, surgical treatment is confined to causing coagulation of theblood in an extension or pouching of the sac, which, making its waythrough the parietes of the chest, threatens to rupture externally. Thismay be achieved by Macewen's needles or by the introduction of wire intothe sac. We have had cases under observation in which the treatmentreferred to has been followed by such an amount of improvement that thepatient has been able to resume a laborious occupation for one or moreyears. Christopher Heath found that improvement followed ligation of theleft common carotid in aneurysm of the transverse part of the aorticarch. [Illustration: FIG.  74. --Thoracic Aneurysm, threatening to ruptureexternally, but prevented from doing so by Macewen's needling. Theneedles were left in for forty-eight hours. ] #Abdominal Aneurysm. #--Aneurysm is much less frequent in the abdominalthan in the thoracic aorta. While any of the large branches in theabdomen may be affected, the most common seats are in the aorta itself, just above the origin of the cœliac artery and at the bifurcation. The _clinical features_ vary with the site of the aneurysm and with itsrapidity and direction of growth. A smooth, rounded swelling, whichexhibits expansile pulsation, forms, usually towards the left of themiddle line. It may extend upwards under cover of the ribs, downwardstowards the pelvis, or backward towards the loin. On palpation asystolic thrill may be detected, but the presence of a murmur is neitherconstant nor characteristic. Pain is usually present; it may beneuralgic in character, or may simulate renal colic. When the aneurysmpresses on the vertebræ and erodes them, the symptoms simulate those ofspinal caries, particularly if, as sometimes happens, symptoms ofcompression paraplegia ensue. In its growth the swelling may press uponand displace the adjacent viscera, and so interfere with theirfunctions. The _diagnosis_ has to be made from solid or cystic tumours overlyingthe artery; from a "pulsating aorta"; and from spinal caries; much helpis obtained by the use of the X-rays. The condition usually proves fatal, either by the aneurysm bursting intothe peritoneal cavity, or by slow leakage into the retro-peritonealtissue. The Moore-Corradi method has been successfully employed, access to thesac having been obtained by opening the abdomen. Ligation of the aortahas so far been unsuccessful, but in one case operated upon by Keen thepatient survived forty-eight days. #Innominate aneurysm# may be of the fusiform or of the sacculatedvariety, and is frequently associated with pouching of the aorta. Itusually grows upwards and laterally, projecting above the sternum andright clavicle, which may be eroded or displaced (Fig. 75). Symptoms ofpressure on the structures in the neck, similar to those produced byaortic aneurysm, occur. The pulses in the right upper extremity and inthe right carotid and its branches are diminished and delayed. Pressureon the right brachial plexus causes shooting pain down the arm andmuscular paresis on that side. Vaso-motor disturbances and contractionof the pupil on the right side may result from pressure on thesympathetic. Death may take place from rupture, or from pressure on theair-passage. [Illustration: FIG.  75. --Innominate Aneurysm in a woman, æt.  47, eightmonths after treatment by Moore-Corradi method (cf. Fig. 73). ] The available methods of treatment are ligation of the right commoncarotid and third part of the right subclavian (Wardrop's operation), ofwhich a number of successful cases have been recorded. Those mostsuitable for ligation are cases in which the aneurysm is circumscribedand globular (Sheen). If ligation is found to be impracticable, theMoore-Corradi method or Macewen's needling may be tried. #Carotid Aneurysms. #--Aneurysm of the _common carotid_ is more frequenton the right than on the left side, and is usually situated either atthe root of the neck or near the bifurcation. It is the aneurysm mostfrequently met with in women. From its position the swelling is liableto press on the vagus, recurrent and sympathetic nerves, on theair-passage, and on the œsophagus, giving rise to symptoms referable tosuch pressure. There may be cerebral symptoms from interference with theblood supply of the brain. Aneurysm near the origin has to be diagnosed from subclavian, innominate, and aortic aneurysm, and from other swellings--solid orfluid--met with in the neck. It is often difficult to determine withprecision the trunk from which an aneurysm at the root of the neckoriginates, and not infrequently more than one vessel shares in thedilatation. A careful consideration of the position in which theswelling first appeared, of the direction in which it has progressed, ofits pressure effects, and of the condition of the pulses beyond, mayhelp in distinguishing between aortic, innominate, carotid, andsubclavian aneurysms. Skiagraphy is also of assistance in recognisingthe vessel involved. Tumours of the thyreoid, enlarged lymph glands, and fatty andsarcomatous tumours can usually be distinguished from aneurysm by thehistory of the swelling and by physical examination. Cystic tumours andabscesses in the neck are sometimes more difficult to differentiate onaccount of the apparently expansile character of the pulsationtransmitted to them. The fact that compression of the vessel does notaffect the size and tension of these fluid swellings is useful indistinguishing them from aneurysm. _Treatment. _--Digital compression of the vessel against the transverseprocess of the sixth cervical vertebra--the "carotid tubercle"--has beensuccessfully employed in the treatment of aneurysm near the bifurcation. Proximal ligation in the case of high aneurysms, or distal ligation inthose situated at the root of the neck, is more certain. Extirpation ofthe sac is probably the best method of treatment, especially in those oftraumatic origin. These operations are attended with considerable riskof hemiplegia from interference with the blood supply of the brain. The _external carotid_ and the cervical portion of the _internalcarotid_ are seldom the primary seat of aneurysm, although they areliable to be implicated by the upward spread of an aneurysm at thebifurcation of the common trunk. In addition to the ordinary signs ofaneurysm, the clinical manifestations are chiefly referable to pressureon the pharynx and larynx, and on the hypoglossal nerve. Aneurysm of theinternal carotid is of special importance on account of the way in whichit bulges into the pharynx in the region of the tonsil, in some casesclosely simulating a tonsillar abscess. Cases are on record in whichsuch an aneurysm has been mistaken for an abscess and incised, withdisastrous results. _Aneurysmal varix_ may occur in the neck as a result of stabs or bulletwounds. The communication is usually between the common carotid arteryand the internal jugular vein. The resulting interference with thecerebral circulation causes headache, giddiness, and other brainsymptoms, and a persistent loud murmur is usually a source of annoyanceto 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 withsyphilis and with valvular disease of the heart than are externalaneurysms. It gives rise to symptoms similar to those of otherintracranial tumours, and there is sometimes a loud murmur. It usuallyproves fatal by rupture, and intracranial hæmorrhage. The treatment isto 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 toembrace a number of pathological conditions, including aneurysm, inwhich the chief symptoms are pulsation in the orbit and protrusion ofthe eyeball. There may be, in addition, congestion and œdema of theeyelids, and a distinct thrill and murmur, which can be controlled bycompression of the common carotid in the neck. Varying degrees of ocularparalysis and of interference with vision may also be present. These symptoms are due, in the majority of cases, to an aneurysmal varixof the internal carotid artery and cavernous sinus, which is oftentraumatic in origin, being produced either by fracture of the base ofthe skull or by a punctured wound of the orbit. In other cases they aredue to aneurysm of the ophthalmic artery, to thrombosis of the cavernoussinus, 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 menwho follow occupations involving constant use of the shoulder--forexample, dock-porters and coal-heavers. It is more common on the rightside. The aneurysm usually springs from the third part of the artery, andappears as a tense, rounded, pulsatile swelling just above the clavicleand to the outer side of the sterno-mastoid muscle. It occasionallyextends towards the thorax, where it may become adherent to the pleura. The radial pulse on the same side is small and delayed. Congestion andœdema of the arm, with pain, numbness, and muscular weakness, may resultfrom pressure on the veins and nerves as they pass under the clavicle;and pressure on the phrenic nerve may induce hiccough. The aneurysm isof slow growth, and occasionally undergoes spontaneous cure. The conditions most likely to be mistaken for it are a soft, rapidlygrowing sarcoma, and a normal artery raised on a cervical rib. On account of the relations of the artery and of its branches, treatmentis attended with greater difficulty and danger in subclavian than inalmost any other form of external aneurysm. The available operativemeasures are proximal ligation of the innominate, and distal ligation. In some cases it has been found necessary to combine distal ligationwith amputation at the shoulder-joint, to prevent the collateralcirculation maintaining the flow through the aneurysm. Matas' operationhas been successfully performed by Hogarth Pringle. #Axillary Aneurysm. #--This is usually met with in the right arm oflabouring men and sailors, and not infrequently follows an injury in theregion of the shoulder. The vessel may be damaged by the head of adislocated humerus or in attempts to reduce the dislocation, by thefragments of a fractured bone, or by a stab or cut. Sometimes the veinalso is injured and an arterio-venous aneurysm established. Owing to the laxity of the tissues, it increases rapidly, and it maysoon attain a large size, filling up the axilla, and displacing theclavicle upwards. This renders compression of the third part of thesubclavian difficult or impossible. It may extend beneath the clavicleinto the neck, or, extending inwards may form adhesions to the chestwall, and, after eroding the ribs, to the pleura. The usual symptoms of aneurysm are present, and the pressure effects onthe veins and nerves are similar to those produced by an aneurysm of thesubclavian. Intra-thoracic complications, such as pleurisy or pneumonia, are not infrequent when there are adhesions to the chest wall andpleura. Rupture may take place externally, into the shoulder-joint, orinto the pleura. Extirpation of the sac is the operation of choice, but, if this isimpracticable, ligation of the third part of the subclavian may be hadrecourse to. #Brachial aneurysm# usually occurs at the bend of the elbow, is oftraumatic origin, and is best treated by excision of the sac. _Aneurysmal varix_, which was frequently met with in this situation inthe days of the barber-surgeons, --usually as a result of the arteryhaving been accidentally wounded while performing venesection of themedian basilic vein, --may be treated, according to the amount ofdiscomfort it causes, by a supporting bandage, or by ligation of theartery above and below the point of communication. Aneurysms of the vessels of the #forearm and hand# call for no specialmention; they are almost invariably traumatic, and are treated byexcision of the sac. #Inguinal Aneurysm# (_Aneurysm of the Iliac and FemoralArteries_). --Aneurysms appearing in the region of Poupart's ligament mayhave their origin in the external or common iliac arteries or in theupper 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 thesac at the level of Poupart's ligament. The pressure exerted on the nerves and veins of the lower extremitycauses pain, congestion, and œdema of the limb. Rupture may take placeexternally, or into the cellular tissue of the iliac fossa. These aneurysms have to be diagnosed from pulsating sarcoma growing fromthe pelvic bones, and from an abscess or a mass of enlarged lymph glandsoverlying the artery and transmitting its pulsation. The method of treatment that has met with most success is ligation ofthe common or external iliac, reached either by reflecting theperitoneum from off the iliac fossa (extra-peritoneal operation), or bygoing through the peritoneal cavity (trans-peritoneal operation). #Gluteal Aneurysm. #--An aneurysm in the buttock may arise from thesuperior or from the inferior gluteal artery, but by the time it forms asalient swelling it is seldom possible to recognise by externalexamination in which vessel it takes origin. The special symptoms towhich it gives rise are pain down the limb from pressure on the sciaticnerve, and interference with the movements at the hip. Ligation of the hypogastric (internal iliac) by the trans-peritonealroute is the most satisfactory method of treatment. Extirpation of thesac is difficult and dangerous, especially when the aneurysm has spreadinto the pelvis. #Femoral Aneurysm. #--Aneurysm of the femoral artery beyond the origin ofthe profunda branch is usually traumatic in origin, and is more commonin Scarpa's triangle than in Hunter's canal. Any of the methods alreadydescribed is available for their treatment--the choice lying betweenMatas' operation and ligation of the external iliac. Aneurysm of the _profunda femoris_ is distinguished from that of themain trunk by the fact that the pulses beyond are, in the former, unaffected, and by the normal artery being felt pulsating over oralongside the sac. In _aneurysmal varix_, a not infrequent result of a bullet wound or astab, the communication with the vein may involve the main trunk of thefemoral artery. Should operative interference become necessary as aresult of progressive increase in size of the tumour, or progressivedistension of the veins of the limb, an attempt should be made toseparate the vessels concerned and to close the opening in each bysuture. If this is impracticable, the artery is tied above and below thecommunication; gangrene of the limb may supervene, and we have observeda case in which the gangrene extended up to the junction of the middleand lower thirds of the thigh, and in which recovery followed uponamputation of the thigh. #Popliteal Aneurysm. #--This is the most common surgical aneurysm, and isnot infrequently met with in both limbs. It is generally due to diseaseof the artery, and repeated slight strains, which are so liable to occurat the knee, play an important part in its formation. In former times itwas common in post-boys, from the repeated flexion and extension of theknee in riding. The aneurysm is usually of the sacculated variety, and may spring fromthe front or from the back of the vessel. It may exert pressure on thebones and ligaments of the joint, and it has been known to rupture intothe articulation. The pain, stiffness, and effusion into the joint whichaccompany these changes often lead to an erroneous diagnosis of jointdisease. The sac may press upon the popliteal artery or vein and theirbranches, causing congestion and œdema of the leg, and lead to gangrene. Pressure on the tibial and common peroneal nerves gives rise to severepain, 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 thebones entering into the knee joint. The choice of operation lies between ligation of the femoral artery inHunter's canal, and Matas' operation of aneurysmo-arteriorrhaphy. Thesuccess which attends the Hunterian operation is evidenced by the factthat Syme performed it thirty-seven times without a single failure. Ifit fails, the old operation should be considered, but it is a moreserious operation, and one which is more liable to be followed bygangrene of the limb. Experience shows that ligation of the vein, oreven the removal of a portion of it, is not necessarily followed bygangrene. The risk of gangrene is diminished by a course of digitalcompression of the femoral artery, before operating on the aneurysm. _Aneurysmal varix_ is sometimes met with in the region of the poplitealspace. It is characterised by the usual symptoms, and is treated bypalliative measures, or by ligation of the artery above and below thepoint 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--Leucocythæmia--TUMOURS. #Surgical Anatomy and Physiology. #--Lymph is essentially blood plasma, which has passed through the walls of capillaries. After bathingand nourishing the tissues, it is collected by lymph vessels, whichreturn it to the blood stream by way of the thoracic duct. These lymphvessels take origin in the lymph spaces of the tissues and in thewalls of serous cavities, and they usually run alongside bloodvessels--_perivascular lymph vessels_. They have a structure similar tothat of veins, but are more abundantly provided with valves. Along thecourse of the lymph trunks are the _lymph glands_, which possess adefinite capsule and are composed of a reticulated connective tissue, the spaces of which are packed with leucocytes. The glands act asfilters, arresting not only inert substances, such as blood pigmentcirculating in the lymph, but also living elements, such as cancer cellsor bacteria. As it passes through a gland the lymph is brought intointimate contact with the leucocytes, and in bacterial infections thereis always a struggle between the organisms and the leucocytes, so thatthe glands may be looked upon as an important line of defence, retardingor preventing the passage of bacteria and their products into thegeneral circulation. The infective agent, moreover, in order to reachthe blood stream, must usually overcome the resistance of severalglands. Lymph glands are, for the most part, arranged in groups or chains, suchas those in the axilla, neck, and groin. In any given situation theyvary in number and size in different individuals, and fresh glands maybe formed on comparatively slight stimulus, and disappear when thestimulus is withdrawn. The best-known example of this is the increase inthe number of glands in the axilla which takes place during lactation;when this function ceases, many of the glands become involuted and aretransformed into fat, and in the event of a subsequent lactation theyare again developed. After glands have been removed by operation, newones may be formed. The following are the more important groups of glands, and the areasdrained 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 someare partly embedded in the substance of the parotid gland; they drainthe parts about the temple, cheek, eyelids, and auricle, and arefrequently 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. _Theposterior auricular (mastoid) glands_ lie over the mastoid process, anddrain the side of the head and auricle. These three groups pour theirlymph into the superficial cervical glands. _The submaxillary_--two tosix in number--lie along the lower order of the mandible from thesymphysis to the angle, the posterior ones (paramandibular) beingclosely connected with the submaxillary salivary gland. They receivelymph from the face, lips, floor of the mouth, gums, teeth, anteriorpart of tongue, and the alæ nasi, and from the pre-auricular glands. Thelymph passes from them into the deeper cervical glands. They arefrequently infected with tubercle, with epithelioma which has spread tothem from the mouth, and also with pyogenic organisms. _The submentalglands_ lie in or close to the median line between the anterior belliesof the digastric muscles, and receive lymph from the lips. It is rarefor them to be the seat of tubercle, but in epithelioma of the lower lipand floor of the mouth they are infected at an early stage of thedisease. _The supra-hyoid gland_ lies a little farther back, immediatelyabove the hyoid bone, and receives lymph from the tongue. _Thesuperficial cervical (external jugular) glands_, when present, lie alongthe external jugular vein, and receives lymph from the occipital andauricular glands and from the auricle. _The sterno-mastoidglands_--glandulæ concatinatæ--form a chain along the posterior edge ofthe sterno-mastoid muscle, some of them lying beneath the muscle. Theyare commonly enlarged in secondary syphilis. _The superior deep cervical(internal jugular) glands_--from six to twenty in number--form acontinuous chain along the internal jugular vein, beneath thesterno-mastoid muscle. They drain the various groups of glands which lienearer the surface, also the interior of the skull, the larynx, trachea, thyreoid, and lower part of the pharynx, and pour their lymph into themain trunks at the root of the neck. Belonging to this group is onelarge gland (the tonsillar gland) which lies behind the posterior bellyof the digastric, and rests in the angle between the internal jugularand common facial veins. It is commonly enlarged in affections of thetonsil and posterior part of the tongue. In the same group are three orfour glands which lie entirely under cover of the upper end of thesterno-mastoid muscle, and surround the accessory nerve before itperforates the muscle. The deep cervical glands are commonly infected bytubercle and also by epithelioma secondary to disease in the tongue orthroat. _The inferior deep cervical (supra-clavicular) glands_ lie inthe posterior triangle, above the clavicle. They receive lymph from thelowest cervical glands, from the upper part of the chest wall, and fromthe highest axillary glands. They are frequently infected in cancer ofthe breast; those on the left side also in cancer of the stomach. Theremoval of diseased supra-clavicular glands is not to be lightlyundertaken, as difficulties are liable to ensue in connection with thethoracic duct, the pleura, or the junction of the subclavian andinternal jugular veins. _The retro-pharyngeal glands_ lie on each sideof the median line upon the rectus capitis anticus major muscle and infront of the pre-vertebral layer of the cervical fascia. They receivepart of the lymph from the posterior wall of the pharynx, the interiorof the nose and its accessory cavities, the auditory (Eustachian) tube, and the tympanum. When they are infected with pyogenic organisms orwith tubercle bacilli, they may lead to the formation of one form ofretro-pharyngeal abscess. #Upper Extremity. #--_The epi-trochlear and cubital glands_ vary innumber, that most commonly present lying about an inch and a half abovethe medial epi-condyle, and other and smaller glands may lie along themedial (internal) bicipital groove or at the bend of the elbow. Theydrain the ulnar side of the hand and forearm, and pour their lymph intothe axillary group. The epi-trochlear gland is sometimes enlarged insyphilis. _The axillary glands_ are arranged in groups: a central grouplies embedded in the axillary fascia and fat, and is often related to anopening in it; a posterior or subscapular group lies along the line ofthe subscapular vessels; anterior or pectoral groups lie behind thepectoralis minor, along the medial side of the axillary vein, and aninter-pectoral group, between the two pectoral muscles. The axillaryglands receive lymph from the arm, mamma, and side of the chest, andpass it on into the lowest cervical glands and the main lymph trunk. They are frequently the seat of pyogenic, tuberculous, and cancerousinfection, and their complete removal is an essential part of theoperation for cancer of the breast. #Lower Extremity. #--_The popliteal glands_ include one superficial glandat the termination of the small saphenous vein, and several deeper onesin relation to the popliteal vessels. They receive lymph from the toesand foot, and transmit it to the inguinal glands. _The femoral glands_lie vertically along the upper part of the great saphenous vein, andreceive lymph from the leg and foot; from them the lymph passes to thedeep inguinal and external iliac glands. The femoral glands oftenparticipate in pyogenic infections entering through the skin of the toesand sole of the foot. _The superficial inguinal glands_ lie along theinguinal (Poupart's) ligament, and receive lymph from the externalgenitals, anus, perineum, buttock, and anterior abdominal wall. Thelymph passes on to the deep inguinal and external iliac glands. Thesuperficial glands through their relations to the genitals arefrequently the subject of venereal infection, and also of epitheliomawhen this disease affects the genitals or anus; they are rarely the seatof tuberculosis. _The deep inguinal glands_ lie on the medial side ofthe femoral vein, and sometimes within the femoral canal. They receivelymph from the deep lymphatics of the lower limb, and some of theefferent vessels from the femoral and superficial inguinal glands. Thelymph then passes on through the femoral canal to the external iliacglands. The extension of malignant disease, whether cancer or sarcoma, can often be traced along these deeper lymphatics into the pelvis, andas the obstruction to the flow of lymph increases there is acorresponding increase in the swollen dropsical condition of the lowerlimb on the same side. The glands of the _thorax_ and _abdomen_ will be considered with thesurgery of these regions. INJURIES OF LYMPH VESSELS Lymph vessels are divided in all wounds, and the lymph that escapes fromthem is added to any discharge that may be present. In injuries oflarger trunks the lymph may escape in considerable quantity as acolourless, watery fluid--_lymphorrhagia_; and the opening through whichit escapes is known as a _lymphatic fistula_. This has been observedchiefly after extensive operation for the removal of malignant glands inthe groin where there already exists a considerable degree ofobstruction to the lymph stream, and in such cases the lymph, includingthat which has accumulated in the vessels of the limb, may escape insuch abundance as to soak through large dressings and delay healing. Ultimately new lymph channels are formed, so that at the end of fromfour to six weeks the discharge of lymph ceases and the wound heals. _Lymphatic Œdema. _--When the lymphatic return from a limb has beenseriously interfered with, --as, for example, when the axillary contentshas been completely cleared out in operating for cancer of thebreast, --a condition of lymphatic œdema may result, the arm becomingswollen, 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 œdema, the condition is relieved by elevation of the limb, but not nearly tothe same degree; in time the tissues become so hard and tense asscarcely to pit on pressure; this is in part due to the formation of newconnective tissue and hypertrophy of the skin; in advanced cases thereis a gradual transition into one form of elephantiasis. Handley has devised a method of treatment--_lymphangioplasty_--theobject of which is to drain the lymph by embedding a number of silkthreads in the subcutaneous cellular tissue. #Wounds of the Thoracic Duct. #--The thoracic duct usually opens at theangle formed by the junction of the left internal jugular and subclavianveins, but it may open into either of these vessels by one or by severalchannels, or the duct may be double throughout its course. There is asmaller duct on the right side--the right lymphatic duct. The duct orducts may be displaced by a tumour or a mass of enlarged glands, and maybe accidentally wounded in dissections at the root of the neck; jets ofmilky fluid--chyle--may at once escape from it. The jets are rhythmicaland coincide with expiration. The injury may, however, not be observedat the time of operation, but later through the dressings being soakedwith chyle--_chylorrhœa_. If the wound involves the only existing mainduct and all the chyle escapes, the patient suffers from intense thirst, emaciation, and weakness, and may die of inanition; but if, as isusually the case, only one of several collateral channels is implicated, the loss of chyle may be of little moment, as the discharge usuallyceases. If the wound heals so that the chyle is prevented from escaping, a fluctuating swelling may form beneath the scar; in course of time itgradually disappears. An attempt should be made to close the wound in the duct by means of afine suture; failing this, the duct must be occluded by a ligature as ifit were a bleeding artery. The tissues are then stitched over it and theskin wound accurately closed, so as to obtain primary union, firmpressure being applied by dressings and an elastic webbing bandage. Evenif the main duct is obliterated, a collateral circulation is usuallyestablished. A wound of the right lymphatic duct is of less importance. _Subcutaneous rupture of the thoracic duct_ may result from a crush ofthe thorax. The chyle escapes and accumulates in the cellular tissue ofthe posterior mediastinum, behind the peritoneum, in the pleural cavity(_chylo-thorax_), or in the peritoneal cavity (_chylous ascites_). Thereare physical signs of fluid in one or other of these situations, but, asa rule, the nature of the lesion is only recognised when chyle iswithdrawn by the exploring needle. DISEASES OF LYMPH VESSELS #Lymphangitis. #--Inflammation of peripheral lymph vessels usuallyresults from some primary source of pyogenic infection in the skin. Thismay be a wound or a purulent blister, and the streptococcus pyogenes isthe organism most frequently present. _Septic_ lymphangitis is commonlymet with in those who, from the nature of their occupation, handleinfective material. A _gonococcal_ form has been observed in thosesuffering from gonorrhœa. The inflammation affects chiefly the walls of the vessels, and isattended with clotting of the lymph. There is also some degree ofinflammation of the surrounding cellular tissue--_peri-lymphangitis_. One or more abscesses may form along the course of the vessels, or aspreading cellulitis may supervene. The _clinical features_ resemble those of other pyogenic infections, andthere are wavy red lines running from the source of infection towardsthe nearest lymph glands. These correspond to the inflamed vessels, andare the seat of burning pain and tenderness. The associated glands areenlarged and painful. In severe cases the symptoms merge into those ofsepticæmia. When the deep lymph vessels alone are involved, thesuperficial red lines are absent, but the limb becomes greatly swollenand pits on pressure. In cases of extensive lymphangitis, especially when there are repeatedattacks, the vessels are obliterated by the formation of new connectivetissue and a persistent solid œdema results, culminating in one form ofelephantiasis. _Treatment. _--The primary source of infection is dealt with on the usuallines. If the lymphangitis affects an extremity, Bier's elastic bandageis applied, and if suppuration occurs, the pus is let out through one ormore small incisions; in other parts of the body Klapp's suction bellsare employed. An autogenous vaccine may be prepared and injected. Whenthe condition has subsided, the limb is massaged and evenly bandaged topromote the disappearance of œdema. _Tuberculous Lymphangitis. _--Although lymph vessels play an importantrôle in the spread of tuberculosis, the clinical recognition of thedisease in them is exceptional. The infection spreads upwards along thesuperficial lymphatics, which become nodularly thickened; at one or morepoints, larger, peri-lymphangitic nodules may form and break down intoabscesses and ulcers; the nearest group of glands become infected at anearly stage. When the disease is widely distributed throughout thelymphatics of the limb, it becomes swollen and hard--a conditionillustrated by lupus elephantiasis. _Syphilitic lymphangitis_ is observed in cases of primary syphilis, inwhich the vessels of the dorsum of the penis can be felt as induratedcords. In addition to acting as channels for the conveyance of bacterialinfection, _lymph vessels frequently convey the cells of malignanttumours_, and especially cancer, from the seat of the primary disease tothe nearest lymph glands, and they may themselves become the seat ofcancerous growth forming nodular cords. The permeation of cancer by wayof the lymphatics, described by Sampson Handley, has already beenreferred 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 itmay be acquired as the result of any condition which is attended withextensive obliteration or blocking of the main lymph trunks. Aninteresting type of lymphangiectasis is that which results from thepresence of the _filaria Bancrofti_ in the vessels, and is observedchiefly in the groin, spermatic cord, and scrotum of persons who havelived 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 maypartly disappear on pressure and when the patient lies down. The patient gives a history of feverish attacks of the nature oflymphangitis during which the swelling becomes painful and tender. Theseattacks may show a remarkable periodicity, and each may be followed byan increase in the size of the swelling, which may extend along theinguinal canal into the abdomen, or down the spermatic cord into thescrotum. On dissection, the swelling is found to be made up of dilated, tortuous, and thickened lymph vessels in which the parent worm issometimes found, and of greatly enlarged lymph glands which haveundergone fibrosis, with giant-cell formation and eosinophileaggregations. The fluid in the dilated vessels is either clear orturbid, in the latter case resembling chyle. The affection is frequentlybilateral, 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 ashernia, lipoma, or cystic pouching of the great saphenous vein. It isconfirmed by finding the recently dead or dying worms in the inflamedlymph glands. _Treatment. _--When the disease is limited to the groin or scrotum, excision may bring about a permanent cure, but it may result in theformation of lymphatic sinuses and only afford temporary relief. #Lymphangioma. #--A lymphangioma is a swelling composed of a series ofcavities and channels filled with lymph and freely communicating withone another. The cavities result either from the new formation of lymphspaces or vessels, or from the dilatation of those which already exist;their walls are composed of fibro-areolar tissue lined by endotheliumand strengthened by non-striped muscle. They are rarely provided with adefinite capsule, and frequently send prolongations of their substancebetween and into muscles and other structures in their vicinity. Theyare of congenital origin and usually make their appearance at or shortlyafter birth. When the tumour is made up of a meshwork of caverns andchannels, it is called a _cavernous lymphangioma_; when it is composedof one or more cysts, it is called a _cystic lymphangioma_. It isprobable that the cysts are derived from the caverns by breaking downand absorption of the intervening septa, as transition forms between thecavernous 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 hæmangioma, but itis not capable of being emptied by pressure, it does not become tensewhen the blood pressure is raised, as in crying, and if the tumour ispunctured, it yields lymph instead of blood. It also resembles a lipoma, especially the congenital variety which grows from the periosteum, andthe differential diagnosis between these is rarely completed until theswelling is punctured or explored by operation. If treatment is calledfor, it is carried out on the same lines as for hæmangioma, by means ofelectrolysis, igni-puncture, or excision. Complete excision is rarelypossible because of the want of definition and encapsulation, but it isnot 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 cystichygroma_ is most often met with in the neck--_hydrocele of the neck_; itis situated beneath the deep fascia, and projects either in front of orbehind the sterno-mastoid muscle. It may attain a large size, theoverlying skin and cyst wall may be so thin as to be translucent, and ithas been known to cause serious impairment of respiration throughpressing on the trachea. In the axilla also the cystic tumour may attaina 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, bytheir having existed from infancy, and, if necessary, by drawing offsome of the contents of the cyst through a fine needle. They are usuallyremarkably indolent, persisting often for a long term of years withoutchange, and, like the hæmangioma, they sometimes undergo spontaneouscicatrisation and cure. Sometimes the cystic tumour becomes infected andforms an abscess--another, although less desirable, method of cure. Those situated in the neck are most liable to suppurate, probablybecause of pyogenic organisms being brought to them by the lymphaticstaking origin in the scalp, ear, or throat. If operative interference is called for, the cysts may be tapped andinjected with iodine, or excised; the operation for removal may entail aconsiderable dissection amongst the deeper structures at the root of theneck, and should not be lightly undertaken; parts left behind may beinduced to cicatrise by inserting a tube of radium and leaving it for afew days. Lymphangiomas are met with in the abdomen in the form of _omentalcysts_. DISEASES OF LYMPH GLANDS #Lymphadenitis. #--Inflammation of lymph glands results from the adventof an irritant, usually bacterial or toxic, brought to the glands by theafferent lymph vessels. These vessels may share in the inflammation andbe the seat of lymphangitis, or they may show no evidence of the passageof the noxa. It is exceptional for the irritant to reach the glandthrough the blood-stream. A strain or other form of trauma is sometimes blamed for the onset oflymphadenitis, especially in the glands of the groin (bubo), but it isusually possible to discover some source of pyogenic infection which isresponsible for the mischief, or to obtain a history of some antecedentinfection such as gonorrhœa. It is possible for gonococci to lie latentin the inguinal glands for long periods, and only give rise tolymphadenitis if the glands be subsequently subjected to injury. Theglands most frequently affected are those in the neck, axilla, andgroin. The characters of the lymphadenitis vary with the nature of theirritant. Sometimes it is mild and evanescent, as in the glandularenlargement in the neck which attends tonsillitis and other forms ofsore throat. Sometimes it is more persistent, as in the enlargementthat is associated with adenoids, hypertrophied tonsils, carious teeth, eczema of the scalp, and otorrhœa; and it is possible that this indolentenlargement predisposes to tuberculous infection. A similar enlargementis met with in the axilla in cases of chronic interstitial mastitis, andin the groin as a result of chronic irritation about the externalgenitals, such as balanitis. Sometimes the lymphadenitis is of an acute character, and the tendencyis towards the formation of an abscess. This is illustrated in theaxillary glands as a result of infected wounds of the fingers; in thefemoral glands in infected wounds or purulent blisters on the foot; inthe inguinal glands in gonorrhœa and soft sore; and in the cervicalglands in the severer forms of sore throat associated with diphtheriaand scarlet fever. The most acute suppurations result from infectionwith streptococci. Superficial glands, when inflamed and suppurating, become enlarged, tender, fixed, and matted to one another. In the glands of the groin thesuppurative process is often remarkably sluggish; purulent foci form inthe interior of individual glands, and some time may elapse before thepus erupts through their respective capsules. In the deeply placedcervical glands, especially in cases of streptococcal throat infections, the suppuration rapidly involves the surrounding cellular tissue, andthe clinical features are those of an acute cellulitis and deeply seatedabscess. When this is incised the necrosed glands may be found lying inthe pus, and on bacteriological examination are found to be swarmingwith streptococci. In suppuration of the axillary glands the abscess maybe quite superficial, or it may be deeply placed beneath the strongfascia and pectoral muscles, according to the group of glands involved. The _diagnosis_ of septic lymphadenitis is usually easy. The indolentenlargements are not always to be distinguished, however, fromcommencing tuberculous disease, except by the use of the tuberculintest, and by the fact that they usually disappear on removing theperipheral source of irritation. _Treatment. _--The first indication is to discover and deal with thesource of infection, and in the indolent forms of lymphadenitis thiswill usually be followed by recovery. In the acute forms following onpyogenic infection, the best results are obtained from the hyperæmictreatment carried out by means of suction bells. If suppuration is notthereby prevented, or if it has already taken place, each separatecollection of pus is punctured with a narrow-bladed knife and the use ofthe suction bell is persevered with. If there is a large periglandularabscess, as is often the case, in the neck and axilla, the opening mayrequire to be made by Hilton's method, and it may be necessary to inserta drainage-tube. [Illustration: FIG.  77. --Tuberculous Cervical Gland with abscessformation in subcutaneous cellular tissue, in a boy æt.  10. ] #Tuberculous Disease of Glands. #--This is a disease of great frequencyand importance. The tubercle bacilli usually gain access to the glandthrough the afferent lymph vessels, which convey them from some lesionof the surface within the area drained by them. Tuberculous infectionmay supervene in glands that are already enlarged as a result of chronicseptic irritation. While any of the glands in the body may be affected, the disease is most often met with in the cervical groups which derivetheir lymph from the mouth, nose, throat, and ear. _The appearance of the glands on section_ varies with the stage of thedisease. In the early stages the gland is enlarged, it may be to manytimes its natural size, is normal in appearance and consistence, and asthere is no peri-adenitis it is easily shelled out from itssurroundings. On microscopical examination, however, there is evidenceof infection in the shape of bacilli and of characteristic giant andepithelioid cells. At a later stage, the gland tissue is studded withminute yellow foci which tend to enlarge and in time to becomeconfluent, so that the whole gland is ultimately converted into acaseous mass. This caseous material is surrounded by the thickenedcapsule which, as a result of peri-adenitis, tends to become adherent toand fused with surrounding structures, and particularly with layers offascia and with the walls of veins. The caseated tissue often remainsunchanged for long periods; it may become calcified, but more frequentlyit breaks down and liquefies. #Tuberculous disease in the cervical glands# is a common accompanimentor sequel of adenoids, enlarged tonsils, carious teeth, pharyngitis, middle-ear disease, and conjunctivitis. These lesions afford the bacillia chance of entry into the lymph vessels, in which they are carried tothe glands, where they give rise to disease. The enlargement may affect only one gland, usually below the angle ofthe mandible, and remain confined to it, the gland reaching the size ofa hazel-nut, and being ovoid, firm, and painless. More commonly thedisease 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 posteriorauricular and occipital glands are first involved, the spread is tothose along the posterior border of the sterno-mastoid. In many casesall the chains in front of, beneath, and behind this muscle areinvolved, the enlarged glands extending from the mastoid to theclavicle. They are at first discrete and movable, and may even vary insize from time to time; but with the addition of peri-adenitis theybecome fixed and matted together, forming lobulated or nodular masses(Fig. 78). They become adherent not only to one another, but also to thestructures in their vicinity, --and notably to the internal jugularvein, --a point of importance in regard to their removal by operation. At any stage the disease may be arrested and the glands remain for longperiods without further change. It is possible that the tuberculoustissue may undergo cicatrisation. More commonly suppuration ensues, anda cold abscess forms, but if there is a mixed infection, the pyogenicfactor being usually derived from the throat, it may take on activefeatures. [Illustration: FIG.  78. --Mass of Tuberculous Glands removed from Axilla(cf. Fig. 79). ] The transition from the solid to the liquefied stage is attended withpain and tenderness in the gland, which at the same time becomes fixedand globular, and finally fluctuation can be elicited. If left to itself, the softened tubercle erupts through the capsule ofthe gland and infects the cellular tissue. The cervical fascia isperforated and a cold abscess, often much larger than the gland fromwhich 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 withtuberculous abscess. The ulcers and sinuses persist indefinitely, orthey heal and then break out again; sometimes the skin becomes infected, and a condition like lupus spreads over a considerable area. Spontaneoushealing finally takes place after the caseous tubercle has beenextruded; the resulting scars are extremely unsightly, being puckered orbridled, or hypertrophied like keloid. While the disease is most common in childhood and youth, it may be metwith even in advanced life; and although often associated with impairedhealth and unhealthy surroundings, it may affect those who areapparently robust and are in affluent circumstances. _Diagnosis. _--The chief importance lies in differentiating tuberculousdisease from lympho-sarcoma and from lymphadenoma, and this is usuallypossible from the history and from the nature of the enlargement. Signsof liquefaction and suppuration support the diagnosis of tubercle. Ifany doubt remains, one of the glands should be removed and submitted tomicroscopical examination. Other forms of sarcoma, and the enlargementof an accessory thyreoid, are less likely to be confused withtuberculous glands. Calcified tuberculous glands give definite shadowswith the X-rays. Enlargement of the cervical glands from secondary cancer may simulatetuberculosis, but is differentiated by its association with cancer inthe mouth or throat, and by the characteristic, stone-like induration ofepithelioma. The cold abscess which results from tuberculous glands is to bedistinguished from that due to disease in the cervical spine, retro-pharyngeal abscess, as well as from congenital and other cysticswellings in the neck. _Prognosis. _--Next to lupus, glandular disease is of all tuberculouslesions the least dangerous to life; but while it is the rule to recoverfrom tuberculous disease of glands with or without an operation, it isunfortunately quite common for such persons to become the subjects oftuberculosis in other parts of the body at any subsequent period oflife. _Treatment. _--There is considerable difference of opinion regarding thetreatment of glandular tuberculosis. Some authorities, impressed withthe undoubted possibility of natural cure, are satisfied with promotingthis by measures directed towards improving the general health, by theprolonged administration of tuberculin, and by repeated exposures to theX-rays and to sunlight. Others again, influenced by the risk ofextension of the disease and by the destruction of tissue anddisfigurement caused by breaking down of the tuberculous tissue andmixed infection, advocate the removal of the glands by operation. The conditions vary widely in different cases, and the treatment shouldbe adapted to the individual requirements. If the disease remainsconfined to the glands originally infected and there are no signs ofbreaking 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, thequestion of operation should be considered. The undesirable results ofthe breaking down and liquefaction of the diseased gland may be avoidedby 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 mustbe sufficiently extensive to give access to the whole of the affectedarea, and to avoid disfigurement should, whenever possible, be made inthe line of the natural creases of the skin. In exposing the glands thecommon facial and other venous trunks may require to be clamped andtied. Care must be taken not to injure the important nerves, particularly the accessory, the vagus, and the phrenic. Theinframaxillary branches of the facial, the hypoglossal and itsdescending branches, and the motor branches of the deep cervical plexus, are also liable to be injured. The dissection is rendered easier and isattended with less risk of injury to the nerves, if the patient isplaced in the sitting posture so as to empty the veins, and, instead ofa knife, the conical scissors of Mayo are employed. When the glands areextensively affected on both sides of the neck, it is advisable to allowan interval to elapse rather than to operate on both sides at onesitting. (_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 throatbeing 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 thegranulation tissue with the spoon, scraping sinuses, and packing thecavity with iodoform worsted and treating it by the open method andsecondary suture if necessary. Exposure to the sunshine on the seashoreand to the X-rays is often beneficial in these cases. #Tuberculous disease in the axillary glands# may be a result ofextension from those in the neck, from the mamma, ribs, or sternum, ormore rarely from the upper extremity. We have seen it from an infectedwound of a finger. In some cases no source of infection is discoverable. The individual glands attain a considerable size, and they fuse togetherto form a large tumour which fills up the axillary space. The diseaseprogresses more rapidly than it does in the cervical glands, and almostalways goes on to suppuration with the formation of sinuses. Conservative measures need not be considered, as the only satisfactorytreatment 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 ofinoculation tubercle on the toes or sole of the foot. The affectedglands nearly always break down and suppurate, and after destroying theoverlying skin give rise to fungating ulcers. The treatment consists inexcising the glands and the affected skin. The dissection may beattended with troublesome hæmorrhage from the numerous veins thatconverge towards the femoral trunk. Tuberculous disease in the _mesenteric_ and _bronchial glands_ isdescribed with the surgery of regions. #Syphilitic Disease of Glands. #--Enlargement of lymph glands is aprominent feature of acquired syphilis, especially in the form of theindolent or bullet-bubo which accompanies the primary lesion, and thegeneral enlargement of glands that occurs in secondary syphilis. Gummatous disease in glands is extremely rare; the affected glandrapidly enlarges to the size of a walnut, and may then persist for along period without further change; if it breaks down, the overlyingskin is destroyed and the caseated tissue of the gumma exposed. #Lymphadenoma. #--_Hodgkin's Disease_ (Pseudo-leukæmia of Germanauthors). --This is a rare disease, the origin of which is as yetunknown, but analogy would suggest that it is due to infection with aslowly growing micro-organism. It is chiefly met with in young subjects, and is characterised by a painless enlargement of a particular group ofglands, most commonly those in the cervical region (Fig. 80). [Illustration: FIG.  80. --Chronic Hodgkin's Disease in a boy æt.  11. ] The glands are usually larger than in tuberculosis, and they remainlonger discrete and movable; they are firm in consistence, and onsection present a granular appearance due to overgrowth of theconnective-tissue framework. In time the glandular masses may formenormous projecting tumours, the swelling being added to by lymphaticœdema of the overlying cellular tissue and skin. The enlargement spreads along the chain of glands to those above theclavicle, to those in the axilla, and to those of the opposite side(Fig. 81). Later, the glands in the groin become enlarged, and it isprobable that the infection has spread from the neck along themediastinal, bronchial, retro-peritoneal, and mesenteric glands, and hasbranched off to the iliac and inguinal groups. Two clinical types are recognised, one in which the disease progressesslowly and remains confined to the cervical glands for two or moreyears; the other, in which the disease is more rapidly disseminated andcauses death in from twelve to eighteen months. [Illustration: FIG.  81. --Lymphadenoma (Hodgkin's Disease) affecting leftside of neck and left axilla, in a woman æt.  44. Three years' duration. ] In the acute form, the health suffers, there is fever, and the glandsmay vary in size with variations in the temperature; the blood presentsthe characters met with in secondary anæmia. The spleen, liver, testes, and mammæ may be enlarged; the glandular swellings press on importantstructures, such as the trachea, œsophagus, or great veins, and symptomsreferable to such pressure manifest themselves. _Diagnosis. _--Considerable difficulty attends the diagnosis oflymphadenoma at an early stage. The negative results of tuberculin testsmay assist in the differentiation from tuberculous disease, but the morecertain means of excising one of the suspected glands and submitting itto microscopical examination should be had recourse to. The sectionsshow proliferation of endothelial cells, the formation of numerous giantcells quite unlike those of tuberculosis and a progressive fibrosis. Lympho-sarcoma can usually be differentiated by the rapid assumption ofthe local features of malignant disease, and in a gland removed forexamination, a predominance of small round cells with scanty protoplasm. The enlargement associated with leucocythæmia is differentiated by thecharacteristic changes in the blood. _Treatment. _--In the acute form of lymphadenoma, treatment is of littleavail. Arsenic may be given in full doses either by the mouth or bysubcutaneous injection; the intravenous administration of neo-salvarsanmay be tried. Exposure to the X-rays and to radium has been moresuccessful than any other form of treatment. Excision of glands, although sometimes beneficial, seldom arrests the progress of thedisease. The ease and rapidity with which large masses of glands may beshelled out is in remarkable contrast to what is observed in tuberculousdisease. Surgical interference may give relief when important structuresare being pressed upon--tracheotomy, for example, may be required wherelife is threatened by asphyxia. #Leucocythæmia. #--This is a disease of the blood and of theblood-forming organs, in which there is a great increase in the number, and an alteration of the character, of the leucocytes present in theblood. It may simulate lymphadenoma, because, in certain forms of thedisease, the lymph glands, especially those in the neck, axilla, andgroin, are greatly enlarged. TUMOURS OF LYMPH GLANDS #Primary Tumours. #--_Lympho-sarcoma_, which may be regarded as a sarcomastarting in a lymph gland, appears in the neck, axilla, or groin as arapidly growing tumour consisting of one enlarged gland with numeroussatellites. As the tumour increases in size, the sarcomatous tissueerupts through the capsule of the gland, and infiltrates the surroundingtissues, whereby it becomes fixed to these and to the skin. [Illustration: FIG.  82. --Lympho-Sarcoma removed from Groin. It will beobserved that there is one large central parent tumour surrounded bysatellites. ] The prognosis is grave in the extreme, and the only hope is in earlyexcision, followed by the use of radium and X-rays. We have observed acase of lympho-sarcoma above the clavicle, in which excision of all thatwas removable, followed by the insertion of a tube of radium for tendays, was followed by a disappearance of the disease over a period whichextended to nearly five years, when death resulted from a tumour in themediastinum. In a second case in which the growth was in the groin, thepatient, a young man, remained well for over two years and was then lostsight of. #Secondary Tumours. #--Next to tuberculosis, _secondary cancer_ is themost common disease of lymph glands. In the neck it is met with inassociation with epithelioma of the lip, tongue, or fauces. The glandsform tumours of variable size, and are often larger than the primarygrowth, the characters of which they reproduce. The glands are at firstmovable, but soon become fixed both to each other and to theirsurroundings; when fixed to the mandible they form a swelling ofbone-like hardness; in time they soften, liquefy, and burst through theskin, forming foul, fungating ulcers. A similar condition is met with inthe groin from epithelioma of the penis, scrotum, or vulva. In cancer ofthe breast, the infection of the axillary glands is an importantcomplication. In _pigmented_ or _melanotic cancers_ of the skin, the glands are earlyinfected and increase rapidly, so that, when the primary growth is stillof small size--as, for example, on the sole of the foot--the femoralglands may already constitute large pigmented tumours. [Illustration: FIG.  83. --Cancerous Glands in Neck secondary toEpithelioma of Lip. (Mr. G.  L.  Chiene's case. )] The implication of the glands in other forms of cancer will beconsidered with regional surgery. _Secondary sarcoma_ is seldom met with in the lymph glands except whenthe 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 ofnerve fibres surrounded and supported by a framework of connectivetissue. The nerve fibres are chiefly of the medullated type, and theyrun without interruption from a nerve cell or _neuron_ in the brain orspinal medulla to their peripheral terminations in muscle, skin, andsecretory glands. Each nerve fibre consists of a number of nerve fibrils collected into acentral bundle--the axis cylinder--which is surrounded by an envelope, the neurolemma or sheath of Schwann. Between the neurolemma and the axiscylinder is the medullated sheath, composed of a fatty substance knownas myelin. This medullated sheath is interrupted at the nodes ofRanvier, and in each internode is a nucleus lying between the myelin andthe neurolemma. The axis cylinder is the essential conducting structureof the nerve, while the neurolemma and the myelin act as insulatingagents. The axis cylinder depends for its nutrition on the centralneuron with which it is connected, and from which it originallydeveloped, 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 individualnerve fibres. The blood vessels and lymphatics run in theseconnective-tissue sheaths. According to Head and his co-workers, Sherren and Rivers, the afferentfibres in the peripheral nerves can be divided into three systems:-- 1. Those which subserve _deep sensibility_ and conduct the impulsesproduced by pressure as well as those which enable the patient torecognise the position of a joint on passive movement (joint-sensation), and the kinæsthetic sense, which recognises that active contraction ofthe muscle is taking place (active muscle-sensation). The fibres of thissystem run with the motor nerves, and pass to muscles, tendons, andjoints. Even division of both the ulnar and the median nerves above thewrist produces little loss of deep sensibility, unless the tendons arealso cut through. The failure to recognise this form of sensibility hasbeen largely responsible for the conflicting statements as to thesensory phenomena following operations for the repair of divided nerves. 2. Those which subserve _protopathic_ sensibility--that is, are capableof responding to painful cutaneous stimuli and to the extremes of heatand cold. These also endow the hairs with sensibility to pain. They arethe first to regenerate after division. 3. Those which subserve _epicritic_ sensibility, the most highlyspecialised, capable of appreciating light touch, _e. G. _ with a wisp ofcotton wool, as a well-localised sensation, and the finer grades oftemperature, called cool and warm (72°–104° F. ), and of discriminatingas separate the points of a pair of compasses 2 cms. Apart. These arethe last to regenerate. A nerve also exerts a trophic influence on the tissues in which it isdistributed. The researches of Stoffel on the minute anatomy of the larger nerves, and the disposition in them of the bundles of nerve fibres supplyingdifferent groups of muscles, have opened up what promises to be afruitful field of clinical investigation and therapeutics. He has shownthat in the larger nerve-trunks the nerve bundles for special groups ofmuscles are not, as was formerly supposed, arranged irregularly andfortuitously, but that on the contrary the nerve fibres to a particulargroup of muscles have a typical and practically constant position withinthe nerve. In the large nerve-trunks of the limbs he has worked out the exactposition of the bundles for the various groups of muscles, so that in across section of a particular nerve the component bundles can belabelled as confidently and accurately as can be the cortical areas inthe brain. In the living subject, by using a fine needle-like electrodeand a very weak galvanic current, he has been able to differentiate thenerve bundles for the various groups of muscles. In several cases ofspastic paralysis he succeeded in picking out in the nerve-trunk of theaffected limb the nerve bundles supplying the spastic muscles, and, byresecting portions of them, in relieving the spasm. In a case of spasticcontracture of the pronator muscles of the forearm, for example, anincision is made along the line of the median nerve above the bend ofthe elbow. At the lateral side of the median nerve, where it lies incontact with the biceps muscle, is situated a well-defined and easilyisolated bundle of fibres which supplies the pronator teres, the flexorcarpi radialis, and the palmaris longus muscles. On incising the sheathof the nerve this bundle can be readily dissected up and its identityconfirmed by stimulating it with a very weak galvanic current. An inchor 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 commonresult of accidental wounds, especially above the wrist, where theulnar, median, and radial nerves are frequently cut across, and ingun-shot injuries. _Changes in Structure and Function. _--The mere interruption of thecontinuity of a nerve results in degeneration of its fibres, the myelinbeing broken up into droplets and absorbed, while the axis cylindersswell up, disintegrate, and finally disappear. Both the conducting andthe insulating elements are thus lost. The degeneration in the centralend of the divided nerve is usually limited to the immediate proximityof the lesion, and does not even involve all the nerve fibres. In thedistal end, it extends throughout the entire peripheral distribution ofthe nerve, and appears to be due to the cutting off of the fibres fromtheir trophic nerve cells in the spinal medulla. Immediate suturing ofthe ends does not affect the degeneration of the distal segment. Theperipheral end undergoes complete degeneration in from six weeks to twomonths. The physiological effects of complete division are that the musclessupplied by the nerve are immediately paralysed, the area to which itfurnishes the sole cutaneous supply becomes insensitive, and the otherstructures, including tendons, bones, and joints, lose sensation, andbegin to atrophy from loss of the trophic influence. #Nerves divided in Amputation. #--In the case of nerves divided in anamputation, there is an active, although necessarily abortive, attemptat regeneration, which results in the formation of bulbous swellings atthe cut ends of the nerves. When there has been suppuration, andespecially 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 knownas "amputation" or "stump neuromas" (Fig. 84). When the nerves in a stump have not been cut sufficiently short, theymay become involved in the cicatrix, and it may be necessary, on accountof pain, to free them from their adhesions, and to resect enough of theterminal portions to prevent them again becoming adherent. When this isdifficult, a portion may be resected from each of the nerve-trunks at ahigher level; and if this fails to give relief, a fresh amputation maybe performed. When there is agonising pain dependent upon an ascendingneuritis, it may be necessary to resect the corresponding posteriornerve roots within the vertebral canal. [Illustration: FIG.  84. --Stump Neuromas of Sciatic Nerve, excised fortyyears after the original amputation by Mr. A.  G.  Miller. ] #Other Injuries of Nerves. #--_Contusion_ of a nerve-trunk is attendedwith extravasation of blood into the connective-tissue sheaths, and isfollowed by degeneration of the contused nerve fibres. Function isusually restored, the conducting paths being re-established by theformation of new nerve fibres. When a nerve is _torn across_ or badly _crushed_--as, for example, by afractured bone--the changes are similar to those in a divided nerve, andthe ultimate result depends on the amount of separation between the endsand the possibility of the young axis cylinders bridging the gap. _Involvement of Nerves in Scar Tissue. _--Pressure or traction may beexerted upon a nerve by contracting scar tissue, or a process ofneuritis or perineuritis may be induced. When terminal filaments are involved in a scar, it is best to dissectout the scar, and along with it the ends of the nerves pressed upon. When a nerve-trunk, such as the sciatic, is involved in cicatricialtissue, the nerve must be exposed and freed from its surroundings(_neurolysis_), and then stretched so as to tear any adhesions that maybe present above or below the part exposed. It may be advisable todisplace the liberated nerve from its original position so as tominimise the risk of its incorporation in the scar of the original woundor in that resulting from the operation--for example, the radial nervemay be buried in the substance of the triceps, or it may be surroundedby a segment of vein or portion of fat-bearing fascia. _Injuries of nerves resulting from_ #gun-shot wounds# include: (1) thosein which the nerve is directly damaged by the bullet, and (2) those inwhich the nerve-trunk is involved secondarily either by scar tissue inits vicinity or by callus following fracture of an adjacent bone. Theprimary injuries include contusion, partial or complete division, andperforation of the nerve-trunk. One of the most constant symptoms is theearly occurrence of severe neuralgic pain, and this is usuallyassociated with marked hyperæsthesia. #Regeneration. #--_Process of Repair when the Ends are in Contact. _--_Ifthe wound is aseptic_, and the ends of the divided nerve are sutured orremain in contact, they become united, and the conducting paths arere-established by a regeneration of nerve fibres. There is a differenceof opinion as to the method of regeneration. The Wallerian doctrine isthat the axis cylinders in the central end grow downwards, and enter thenerve sheaths of the distal portion, and continue growing until theyreach the peripheral terminations in muscle and skin, and in course oftime acquire a myelin sheath; the cells of the neurolemma multiply andform long chains in both ends of the nerve, and are believed to providefor the nourishment and support of the actively lengthening axiscylinders. Another view is that the formation of new axis cylinders isnot confined to the central end, but that it goes on also in theperipheral segment, in which, however, the new axis cylinders do notattain maturity until continuity with the central end has beenre-established. _If the wound becomes infected_ and suppuration occurs, the young nervefibres are destroyed and efficient regeneration is prevented; theformation of scar tissue also may constitute a permanent obstacle to newnerve fibres bridging the gap. _When the ends are not in contact_, reunion of the divided nerve fibresdoes not take place whether the wound is infected or not. At theproximal end there forms a bulbous swelling, which becomes adherent tothe scar tissue. It consists of branching axis cylinders running in alldirections, these having failed to reach the distal end because of theextent of the gap. The peripheral end is completely degenerated, and isrepresented by a fibrous cord, the cut end of which is often slightlyswollen or bulbous, and is also incorporated with the scar tissue ofthe wound. #Clinical Features. #--The symptoms resulting from division and non-unionof a nerve-trunk necessarily vary with the functions of the affectednerve. 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 ofcotton wool stroked gently across the skin; the capacity ofdiscriminating two points as separate, by a pair of blunt-pointedcompasses; the sensation of pressure, by means of a pencil or otherblunt object; of pain, by pricking or scratching with a needle; and ofsensibility to heat and cold, by test-tubes containing water atdifferent temperatures. While these tests are being carried out, thepatient's eyes are screened off. After division of a nerve containing sensory fibres, there is an area ofabsolute cutaneous insensibility to touch (anæsthesia), to pain(analgesia), and to all degrees of temperature--_loss of protopathicsensibility_; surrounded by an area in which there is loss of sensationto light touch, inability to recognise minor differences of temperature(72°–104° F. ), and to appreciate as separate impressions the contact ofthe two points of a compass--_loss of epicritic sensibility_ (Head andSherren) (Figs. 91, 92). _Motor Phenomena. _--There is immediate and complete loss of voluntarypower in the muscles supplied by the divided nerve. The muscles rapidlywaste, and within from three to five days, they cease to react to thefaradic current. When tested with the galvanic current, it is found thata stronger current must be used to call forth contraction than in ahealthy muscle, and the contraction appears first at the closing of thecircuit when the anode is used as the testing electrode. The loss ofexcitability to the interrupted current, and the specific alteration inthe type of contraction with the constant current, is known as the_reaction of degeneration_. After a few weeks all electric excitabilityis lost. The paralysed muscles undergo fatty degeneration, which attainsits maximum three or four months after the division of the nerve. Further changes may take place, and result in the transformation of themuscle into fibrous tissue, which by undergoing shortening may causedeformity known as _paralytic contracture_. _Vaso-motor Phenomena. _--In the majority of cases there is an initialrise in the temperature of the part (2° to 3° F. ), with redness andincreased vascularity. This is followed by a fall in the localtemperature, which may amount to 8° or 10° F. , the parts becoming paleand cold. Sometimes the hyperæmia resulting from vaso-motor paralysis ismore persistent, and is associated with swelling of the parts fromœdema--the so-called _angio-neurotic œdema_. The vascularity varies withexternal influences, and in cold weather the parts present a bluishappearance. _Trophic Phenomena. _--Owing to the disappearance of the subcutaneousfat, the skin is smooth and thin, and may be abnormally dry. The hair isharsh, dry, and easily shed. The nails become brittle and furrowed, orthick and curved, and the ends of the fingers become club-shaped. Skineruptions, especially in the form of blisters, occur, or there may beactual ulcers of the skin, especially in winter. In aggravated cases thetips of the fingers disappear from progressive ulceration, and in thesole of the foot a perforating ulcer may develop. Arthropathies areoccasionally met with, the joints becoming the seat of a painlesseffusion or hydrops, which is followed by fibrous thickening of thecapsular and other ligaments, and terminates in stiffness and fibrousankylosis. In this way the fingers are seriously crippled and deformed. #Treatment of Divided Nerves. #--The treatment consists in approximatingthe divided ends of the nerve and placing them under the most favourableconditions for repair, and this should be done at the earliest possibleopportunity. (_Op. Surg. _, pp. 45, 46. ) #Primary Suture. #--The reunion of a recently divided nerve is spoken ofas primary suture, and for its success asepsis is essential. As thesuturing of the ends of the nerve is extremely painful, an anæsthetic isrequired. When the wound is healed and while waiting for the restoration offunction, measures are employed to maintain the nutrition of the damagednerve and of the parts supplied by it. The limb is exercised, massaged, and douched, and protected from cold and other injurious influences. Thenutrition of the paralysed muscles is further improved by electricity. The galvanic current is employed, using at first a mild current of notmore than 5 milliampères for about ten minutes, the current being madeto flow downwards in the course of the nerve, with the positiveelectrode applied to the spine, and the negative over the affected nervenear its termination. It is an advantage to have a metronome in thecircuit whereby the current is opened and closed automatically atintervals, so as to cause contraction of the muscles. _The results_ of primary suture, when it has been performed underfavourable conditions, are usually satisfactory. In a series of casesinvestigated by Head and Sherren, the period between the operation andthe first return of sensation averaged 65 days. According to PurvesStewart protopathic sensation commences to appear in about six weeks andis completely restored in six months; electric sensation and motor powerreappear together in about six months, and restoration is complete in ayear. When sensation returns, the area of insensibility to pain steadilydiminishes and disappears; sensibility to extremes of temperatureappears soon after; and last of all, after a considerable interval, there is simultaneous return of appreciation of light touch, moderatedegrees of temperature, and the points of a compass. A clinical means of estimating how regeneration in a divided nerve isprogressing has been described by Tinel. He found that a tinglingsensation, similar to that experienced in the foot, when it isrecovering from the "sleeping" condition induced by prolonged pressureon the sciatic nerve from sitting on a hard bench, can be elicited onpercussing over _growing_ axis cylinders. Tapping over the proximal endof a _newly divided nerve_, _e. G. _ the common peroneal behind the headof the fibula, produces no tingling, but when in about three weeksaxis cylinders begin to grow in the proximal end-bulb, local tingling isinduced by tapping there. The downward growth of the axis cylinders canbe traced by tapping over the distal segment of the nerve, the tinglingsensation being elicited as far down as the young axis cylinders havereached. When the regeneration of the axis cylinders is complete, tapping no longer causes tingling. It usually takes about one hundreddays for this stage to be reached. Tinel's sign is present before voluntary movement, muscular tone, or thenormal 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 regenerationis taking place. Its detection may prevent an unnecessary operationbeing performed. Primary suture should not be attempted so long as the wound shows signsof infection, as it is almost certain to end in failure. The ends shouldbe sutured, however, as soon as the wound is aseptic or has healed. #Secondary Suture. #--The term secondary suture is applied to theoperation of stitching the ends of the divided nerve after the wound hashealed. _Results of Secondary Suture. _--When secondary suture has been performedunder favourable conditions, the prognosis is good, but a longer time isrequired for restoration of function than after primary suture. PurvesStewart says protopathic sensation is sometimes observed much earlierthan in primary suture, because partial regeneration of axis cylindersin the peripheral segment has already taken place. Sensation isrecovered first, but it seldom returns before three or four months. There then follows an improvement or disappearance of any trophicdisturbances that may be present. Recovery of motion may be deferred forlong periods--rather because of the changes in the muscles than fromwant of conductivity in the nerve--and if the muscles have undergonecomplete degeneration, it may never take place at all. While waiting forrecovery, every effort should be made to maintain the nutrition of thedamaged nerve, and of the parts which it supplies. When suture is found to be impossible, recourse must be had to othermethods, known as nerve bridging and nerve implantation. #Incomplete Division of a Mixed Nerve. #--The effects of partial divisionof a mixed nerve vary according to the destination of the nerve bundlesthat have been interrupted. Within their area of distribution theparalysis is as complete as if the whole trunk had been cut across. Theuninjured nerve-bundles continue to transmit impulses with the resultthat there is a _dissociated paralysis_ within the distribution of theaffected nerve, some muscles continuing to act and to respond normallyto electric stimulation, while others behave as if the whole nerve-trunkhad been severed. In addition to vasomotor and trophic changes, there is often severe painof a burning kind (_causalgia_ or _thermalgia_) which comes on about afortnight after the injury and causes intense and continuous sufferingwhich may last for months. Paroxysms of pain may be excited by theslightest touch or by heat, and the patient usually learns for himselfthat the constant application of cold wet cloths allays the pain. Thethermalgic area sweats profusely. Operative treatment is indicated where there is no sign of improvementwithin three months, when recovery is arrested before completerestoration of function is attained, or when thermalgic pain isexcessive. #Subcutaneous Injuries of Nerves. #--Several varieties of subcutaneousinjuries of nerves are met with. One of the best known is thecompression paralysis of the nerves of the upper arm which results fromsleeping with the arm resting on the back of a chair or the edge of atable--the so-called "drunkard's palsy"; and from the pressure of acrutch in the axilla--"crutch paralysis. " In some of these injuries, notably "drunkard's palsy, " the disability appears to be due not todamage of the nerve, but to overstretching of the extensors of the wristand fingers (Jones). A similar form of paralysis is sometimes met withfrom the pressure of a tourniquet, from tight bandages or splints, fromthe pressure exerted by a dislocated bone or by excessive callus, andfrom hyper-extension of the arm during anæsthesia. In all these forms there is impaired sensation, rarely amounting toanæsthesia, marked muscular wasting, and diminution or loss of voluntarymotor power, while--and this is a point of great importance--the normalelectrical reactions are preserved. There may also develop trophicchanges such as blisters, superficial ulcers, and clubbing of the tipsof the fingers. The prognosis is usually favourable, as recovery is therule within from one to three months. If, however, neuritis supervenes, the electrical reactions are altered, the muscles degenerate, andrecovery may be retarded or may fail to take place. Injuries which act abruptly or instantaneously are illustrated in thecrushing of a nerve by the sudden displacement of a sharp-edged fragmentof bone, as may occur in comminuted fractures of the humerus. Thesymptoms include perversion or loss of sensation, motor paralysis, andatrophy of muscles, which show the reaction of degeneration from theeighth day onwards. The presence of the reaction of degenerationinfluences both the prognosis and the treatment, for it implies a lesionwhich is probably incapable of spontaneous recovery, and which can onlybe 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 thenerve, steps must be taken to relieve the pressure, by operation ifnecessary. When there is reason to believe that the nerve is severelycrushed or torn across, it should be exposed by incision, and, afterremoval of the damaged ends, should be united by sutures. When it isimpossible to make a definite diagnosis as to the state of the nerve, itis better to expose it by operation, and thus learn the exact state ofaffairs without delay; in the event of the nerve being torn, the endsshould be united by sutures. #Dislocation of Nerves. #--This injury, which resembles the dislocationof tendons from their grooves, is seldom met with except in the ulnarnerve at the elbow, and is described with injuries of that nerve. DISEASES OF NERVES #Traumatic Neuritis. #--This consists in an overgrowth of theconnective-tissue framework of a nerve, which causes irritation andpressure upon the nerve fibres, sometimes resulting in theirdegeneration. It may originate in connection with a wound in thevicinity of a nerve, as, for example, when the brachial nerves areinvolved in scar tissue subsequent to an operation for clearing out theaxilla for cancer; or in contusion and compression of a nerve--forexample, by the pressure of the head of the humerus in a dislocation ofthe shoulder. Some weeks or months after the injury, the patientcomplains of increasing hyperæsthesia and of neuralgic pains in thecourse of the nerve. The nerve is very sensitive to pressure, and, ifsuperficial, may be felt to be swollen. The associated muscles arewasted and weak, and are subject to twitchings. There are also trophicdisturbances. It is rare to have complete sensory and motor paralysis. The disease is commonest in the nerves of the upper extremity, and thehand may become crippled and useless. _Treatment. _--Any constitutional condition which predisposes toneuritis, such as gout, diabetes, or syphilis, must receive appropriatetreatment. The symptoms may be relieved by rest and by soothingapplications, such as belladonna, ichthyol, or menthol, by the use ofhot-air and electric baths, and in obstinate cases by blistering or bythe application of Corrigan's button. When such treatment fails thenerve may be stretched, or, in the case of a purely sensory trunk, aportion may be excised. Local causes, such as involvement of the nervein a scar or in adhesions, may afford indications for operativetreatment. #Multiple Peripheral Neuritis. #--Although this disease mainly comesunder the cognizance of the physician, it may be attended with phenomenawhich call for surgical interference. In this country it is commonly dueto alcoholism, but it may result from diabetes or from chronic poisoningwith lead or arsenic, or from bacterial infections and intoxicationssuch as occur in diphtheria, gonorrhœa, 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 alcoholicform, for example, mainly affecting the legs, the diphtheritic form thesoft palate and pharynx, and that associated with lead poisoning theforearms. The essential lesion is a degeneration of the conductingfibres of the affected nerves, and the prominent symptoms are the resultof this. In alcoholic neuritis there is great tenderness of the muscles. When the legs are affected the patient may be unable to walk, and thetoes may droop and the heel be drawn up, resulting in one variety of pesequino-varus. Pressure sores and perforating ulcer of the foot are themost important trophic phenomena. Apart from the medical _treatment_, measures must be taken to preventdeformity, especially when the legs are affected. The bedclothes aresupported by a cage, and the foot maintained at right angles to the legby sand-bags or splints. When the disease is subsiding, the nutrition ofthe damaged nerves and muscles should be maintained by massage, baths, passive movements, and the use of the galvanic current. When deformityhas been allowed to take place, operative measures may be required forits correction. NEUROMA[5] [5] We have followed the classification adopted by Alexis Thomson in hiswork _On Neuroma, and Neuro-fibromatosis_ (Edinburgh: 1900). Neuroma is a clinical term applied to all tumours, irrespective of theirstructure, which have their seat in nerves. A tumour composed of newly formed nerve tissue is spoken of as a #trueneuroma#; when ganglionic cells are present in addition to nerve fibres, the name _ganglionic neuroma_ is applied. These tumours are rare, andare chiefly met with in the main cords or abdominal plexuses of thesympathetic system of children or young adults. They are quiteinsensitive, and their removal is only called for if they cause pain orshow signs of malignancy. A #false neuroma# is an overgrowth of the sheath of a nerve. Thisovergrowth may result in the formation of a circumscribed tumour, or maytake the form of a diffuse fibromatosis. _The circumscribed or solitary tumour_ grows from the sheath of a nervewhich is otherwise healthy, and it may be innocent or malignant. _The innocent_ form is usually fibrous or myxomatous, and is definitelyencapsulated. It may become cystic as a result of hæmorrhage or ofmyxomatous degeneration. It grows very slowly, is usually elliptical inshape, and the solid form is rarely larger than a hazel-nut. The nervefibres may be spread out all round the tumour, or may run only on oneside of it. When subcutaneous and related to the smaller unnamedcutaneous nerves, it is known as a _painful subcutaneous nodule_ or_tubercle_. It is chiefly met with about the ankle, and most often inwomen. It is remarkably sensitive, even gentle handling causing intensepain, 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 "subcutaneousnodule, " and rarely gives rise to motor symptoms unless it involves thenerve roots where they pass through bony canals. A trunk-neuroma is recognised clinically by its position in the line ofa nerve, by the fact that it is movable in the transverse axis of thenerve but not in its long axis, and by being unduly painful andsensitive. [Illustration: FIG.  85. --Amputation Stump of Upper Arm, showing bulbousthickening of the ends of the nerves, embedded in scar tissue at theapex of the stamp. ] _Treatment. _--If the tumour causes suffering it should be removed, preferably by shelling it out from the investing nerve sheath orcapsule. In the subcutaneous nodule the nerve is rarely recognisable, and is usually sacrificed. When removal of the tumour is incomplete, atube of radium should be inserted into the cavity, to prevent recurrenceof 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 innocentvariety, only it grows more rapidly, and by destroying the nerve fibrescauses motor symptoms--jerkings followed by paralysis. The sarcoma tendsto spread along the lymph spaces in the long axis of the nerve, as wellas to implicate the surrounding tissues, and it is liable to give riseto secondary growths. The malignant neuroma is met with chiefly in thesciatic and other large nerves of the limbs. The _treatment_ is conducted on the same lines as sarcoma in othersituations; the insertion of a tube of radium after removal of thetumour diminishes the tendency to recurrence; a portion of thenerve-trunk being sacrificed, means must be taken to bridge the gap. Ininoperable cases it may be possible to relieve pain by excising aportion of the nerve above the tumour, or, when this is impracticable, by resecting the posterior nerve roots and their ganglia within thevertebral canal. The so-called _amputation neuroma_ has already been referred to (p. 344). _Diffuse or Generalised Neuro-Fibromatosis--Recklinghausen'sDisease. _--These terms are now used to include what were formerly knownas "multiple neuromata, " as well as certain other overgrowths related tonerves. The essential lesion is an overgrowth of the endoneuralconnective tissue throughout the nerves of both the cerebro-spinal andsympathetic systems. The nerves are diffusely and unequally thickened, so that small twigs may become enlarged to the size of the median, whileat irregular intervals along their course the connective-tissueovergrowth is exaggerated so as to form tumour-like swellings similar tothe trunk-neuroma already described. The tumours, which vary greatly insize and number--as many as a thousand have been counted in onecase--are enclosed in a capsule derived from the perineurium. Thefibromatosis may also affect the cranial nerves, the ganglia on theposterior nerve roots, the nerves within the vertebral canal, and thesympathetic nerves and ganglia, as well as the continuations of themotor nerves within the muscles. The nerve fibres, although mechanicallydisplaced and dissociated by the overgrown endoneurium, undergo nostructural change except when compressed in passing through a bonycanal. The disease probably originates before birth, although it may not makeits appearance till adolescence or even till adult life. It is sometimesmet with in several members of one family. It is recognised clinicallyby the presence of multiple tumours in the course of the nerves, andsometimes by palpable enlargement of the superficial nerve-trunks(Fig. 86). The tumours resemble the solitary trunk-neuroma, are usuallyquite insensitive, and many of them are unknown to the patient. As aresult of injury or other exciting cause, however, one or other tumourmay increase in size and become extremely sensitive; the pain is thenagonising; it is increased by handling, and interferes with sleep. Inthese conditions, a malignant transformation of the fibroma into sarcomais to be suspected. Motor disturbances are exceptional, unless in thecase of tumours within the vertebral canal, which press on the spinalmedulla and cause paraplegia. [Illustration: FIG.  86. --Diffuse enlargement of Nerves in generalisedNeuro-fibromatosis. (After R.  W.  Smith. )] Neuro-fibromatosis is frequently accompanied by _pigmentation of theskin_ in the form of brown spots or patches scattered over the trunk. The disease is often stationary for long periods. In progressive casesthe patient becomes exhausted, and usually dies of some intercurrentaffection, particularly phthisis. The treatment is restricted torelieving symptoms and complications; removal of one of the tumours isto be strongly deprecated. In a considerable proportion of cases one of the multiple tumours takeson the characters of a malignant growth ("secondary malignant neuroma, "Garrè). This malignant transformation may follow upon injury, or on anunsuccessful attempt to remove the tumour. The features are those of arapidly growing sarcoma involving a nerve-trunk, with agonising painand muscular cramps, followed by paralysis from destruction of thenerve fibres. The removal of the tumour is usually followed byrecurrence, so that high amputation is the only treatment to berecommended. Metastasis to internal organs is exceptional. [Illustration: FIG.  87. --Plexiform Neuroma of small Sciatic Nerve, froma girl æt.  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 thedistribution 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 thenerve-trunks and with pigmentation of the skin. The clinical featuresare those of an ill-defined swelling composed of a number of tortuous, convoluted cords, lying in a loose areolar tissue and freely movable onone another. It is rarely the seat of pain or tenderness. It most oftenappears in the early years of life, sometimes in relation to a pigmentedor hairy mole. It is of slow growth, may remain stationary for longperiods, and has little or no tendency to become malignant. It isusually subcutaneous, and is frequently situated on the head or neck inthe distribution of the trigeminal or superficial cervical nerves. Thereis no necessity for its removal, but this may be indicated because ofdisfigurement, especially on the face or scalp or because its bulkinterferes with function. When involving the ophthalmic division of thetrigeminus, for example, it may cause enlargement of the upper lid andproptosis, with danger to the function of the globe. The results ofexcision are usually satisfactory, even if the removal is not complete. [Illustration: FIG.  88. --Multiple Neuro-fibromas of Skin (Molluscumfibrosum, or Recklinghausen's disease). ] _The cutaneous neuro-fibroma_ or _molluscum fibrosum_ has been shown byRecklinghausen to be a soft fibroma related to the terminal filaments ofone of the cutaneous nerves (Fig. 88). The disease appears in the formof multiple, soft, projecting tumours, scattered all over the body, except the palms of the hands and soles of the feet. The tumours are ofall sizes, some being no larger than a pin's head, whilst many are asbig as a filbert and a few even larger. Many are sessile and others aredistinctly pedunculated, but all are covered with skin. They are mobile, soft to the touch, and of the consistence of firm fat. In exceptionalcases one of the skin tumours may attain an enormous size and cause ahideous deformity, hanging down by its own weight in lobulated or foldedmasses (pachy-dermatocele). The treatment consists in removing thelarger swellings. In some cases molluscum fibrosum is associated withpigmentation 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 æt.  28] _Elephantiasis neuromatosa_ is the name applied by Virchow to acondition in which a limb is swollen and misshapen as a result of theextension of a neuro-fibromatosis to the skin and subcutaneous cellulartissue of the extremity as a whole (Fig. 89). It usually begins in earlylife without apparent cause, and it may be associated with multipletumours of the nerve-trunks. The inconvenience caused by the bulk andweight of the limb may justify its removal. SURGERY OF THE INDIVIDUAL NERVES[6] [6] We desire here to acknowledge our indebtedness to Mr. JamesSherren's work on _Injuries of Nerves and their Treatment_. #The Brachial Plexus. #--Lesions of the brachial plexus may be dividedinto those above the clavicle and those below that bone. In the #supra-clavicular injuries#, the violence applied to the head orshoulder causes over-stretching of the anterior branches (primarydivisions) of the cervical nerves, the fifth, or the fifth and sixthbeing those most liable to suffer. Sometimes the traction is exertedupon the plexus from below, as when a man in falling from a heightendeavours to save himself by clutching at some projection, and thelesion then mainly affects the first dorsal nerve. There is tearing ofthe nerve sheaths, with hæmorrhage, but in severe cases partial orcomplete severance of nerve fibres may occur and these give way atdifferent levels. During the healing process an excess of fibrous tissueis formed, which may interfere with regeneration. _Post-anæsthetic paralysis_ occurs in patients in whom, during thecourse of an operation, the arm is abducted and rotated laterally orextended 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 partusually affected being the medial cord, which is made up of fibres fromthe 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 nervesby fragments of bone, but to the violence causing the fracture, and thisis 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 fromthe pressure of the dislocated head of the humerus; occasionally fromattempts made to reduce the dislocation by the heel-in-the-axillamethod, or from fracture of the upper end of the humerus or of the neckof the scapula. The whole plexus may suffer, but more frequently themedial cord is alone implicated. _Clinical Features. _--Three types of lesion result from indirectviolence: the whole plexus; the upper-arm type; and the lower-arm type. _When the whole plexus is involved_, sensibility is lost over the entireforearm and hand and over the lateral surface of the arm in its distaltwo-thirds. All the muscles of the arm, forearm, and hand are paralysed, and, as a rule, also the pectorals and spinati, but the rhomboids andserratus anterior escape. There is paralysis of the sympathetic fibresto the eye and orbit, with narrowing of the palpebral fissure, recessionof the globe, and the pupil is slow to dilate when shaded from thelight. The _upper-arm type_--Erb-Duchenne paralysis--is that most frequentlymet with, and it is due to a lesion of the fifth anterior branch, or, itmay 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 extendedand pronated; the deltoid, spinati, biceps, brachialis, and supinatorsare paralysed, and in some cases the radial extensors of the wrist andthe pronator teres are also affected. The patient is unable to supinatethe 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 isfully pronated, the extensors of the wrist becoming feeble flexors ofthe elbow. There is, as a rule, no loss of sensibility, but complaintmay be made of tickling and of pins-and-needles over the lateral aspectof the arm. The abnormal position of the limb may persist although themuscles regain the power of voluntary movement, and as the conditionfrequently follows a fall on the shoulder, great care is necessary indiagnosis, as the condition is apt to be attributed to an injury to theaxillary (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 affectsthe anterior branch of the first dorsal nerve. In typical cases all theintrinsic muscles of the hand are affected, and the hand assumes theclaw shape. Sensibility is usually altered over the medial side of thearm and forearm, and there is paralysis of the sympathetic. _Infra-clavicular injuries_, as already stated, are most often producedby a sub-coracoid dislocation of the humerus; the medial cord is thatmost frequently injured, and the muscles paralysed are those supplied bythe ulnar nerve, with, in addition, those intrinsic muscles of the handsupplied by the median. Sensibility is affected over the medial surfaceof the forearm and ulnar area of the hand. Injury of the lateral andposterior cords is very rare. _Treatment_ is carried out on the lines already laid down for nerveinjuries in general. It is impossible to diagnose between complete andincomplete rupture of the nerve cords, until sufficient time has elapsedto allow of the establishment of the reaction of degeneration. If thisis 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 tothat employed for the subclavian artery, and the nerves are sought foras they emerge from under cover of the scalenus anterior, and are thentraced until the seat of injury is found. In the case of the firstdorsal 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 becomeover-stretched. The prognosis is less favourable in the supra-clavicularlesions than in those below the clavicle, which nearly always recoverwithout surgical intervention. In the _brachial birth-paralysis_ met with in infants, the lesion is dueto over-stretching of the plexus, and is nearly always of theErb-Duchenne type. The injury is usually unilateral, it occurs withalmost equal frequency in breech and in vertex presentations, and theleft arm is more often affected than the right. The lesion is seldomrecognised at birth. The first symptom noticed is tenderness in thesupra-clavicular region, the child crying when this part is touched orthe arm is moved. The attitude may be that of the Erb-Duchenne type, orthe whole of the muscles of the upper limb may be flaccid, and the armhangs powerless. A considerable proportion of the cases recoverspontaneously. The arm is to be kept at rest, with the affected musclesrelaxed, and, as soon as tenderness has disappeared, daily massage andpassive movements are employed. The reaction of degeneration can rarelybe satisfactorily tested before the child is three months old, but if itis present, an operation should be performed. After operation, theshoulder should be elevated so that no traction is exerted on theaffected cords. #The long thoracic nerve# (nerve of Bell), which supplies the serratusanterior, is rarely injured. In those whose occupation entails carryingweights upon the shoulder it may be contused, and the resultingparalysis of the serratus is usually combined with paralysis of thelower part of the trapezius, the branches from the third and fourthcervical nerves which supply this muscle also being exposed to pressureas they pass across the root of the neck. There is complaint of painabove the clavicle, and winging of the scapula; the patient is unable toraise the arm in front of the body above the level of the shoulder or toperform any forward pushing movements; on attempting either of these thewinging of the scapula is at once increased. If the scapula is comparedwith that on the sound side, it is seen that, in addition to the lowerangle being more prominent, the spine is more horizontal and the lowerangle nearer the middle line. The majority of these cases recover if thelimb is placed at absolute rest, the elbow supported, and massage andgalvanism persevered with. If the paralysis persists, the sterno-costalportion of the pectoralis major may be transplanted to the lower angleof the scapula. The long thoracic nerve may be cut across while clearing out the axillain operating for cancer of the breast. The displacement of the scapulais not so marked as in the preceding type, and the patient is able toperform pushing movements below the level of the shoulder. If thereaction of degeneration develops, an operation may be performed, theends of the nerve being sutured, or the distal end grafted into theposterior cord of the brachial plexus. #The Axillary (Circumflex) Nerve. #--In the majority of cases in whichparalysis of the deltoid follows upon an injury of the shoulder, it isdue to a lesion of the fifth cervical nerve, as has already beendescribed in injuries of the brachial plexus. The axillary nerve itselfas it passes round the neck of the humerus is most liable to be injuredfrom the pressure of a crutch, or of the head of the humerus insub-glenoid dislocation, or in fracture of the neck of the scapula or ofthe humerus. In miners, who work for long periods lying on the side, themuscle may be paralysed by direct pressure on the terminal filaments ofthe nerve, and the nerve may also be involved as a result of disease inthe sub-deltoid bursa. The deltoid is wasted, and the acromion unduly prominent. In recentcases paralysis of the muscle is easily detected. In cases of longstanding it is not so simple, because other muscles, the spinati, theclavicular fibres of the pectoral and the serratus, take its place andelevate the arm; there is always loss of sensation on the lateral aspectof the shoulder. There is rarely any call for operative treatment, asthe paralysis is usually compensated for by other muscles. When the _supra-scapular nerve_ is contused or stretched in injuries ofthe shoulder, the spinati muscles are paralysed and wasted, the spine ofthe scapula is unduly prominent, and there is impairment in the power ofabducting 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 thebrachialis, but no movements are abolished, the forearm being flexed, inthe pronated position, by the brachio-radialis and long radial extensorof the wrist; in the supinated position, by that portion of thebrachialis supplied by the radial nerve. Supination is feebly performedby the supinator muscle. Protopathic and epicritic sensibility are lostover the radial side of the forearm. #Radial (Musculo-Spiral) Nerve. #--From its anatomical relationships thistrunk is more exposed to injury than any other nerve in the body. It isfrequently compressed against the humerus in sleeping with the armresting on the back of a chair, especially in the deep sleep ofalcoholic intoxication (drunkard's palsy). It may be pressed upon by acrutch in the axilla, by the dislocated head of the humerus, or byviolent compression of the arm, as when an elastic tourniquet is appliedtoo tightly. The most serious and permanent injuries of this nerve areassociated with fractures of the humerus, especially those from directviolence attended with comminution of the bone. The nerve may be crushedor torn by one of the fragments at the time of the injury, or at a laterperiod may be compressed by callus. _Clinical Features. _--Immediately after the injury it is impossible totell whether the nerve is torn across or merely compressed. The patientmay complain of numbness and tingling in the distribution of thesuperficial branch of the nerve, but it is a striking fact, that so longas the nerve is divided below the level at which it gives off the dorsalcutaneous nerve of the forearm (external cutaneous branch), there is noloss of sensation. When it is divided above the origin of the dorsalcutaneous branch, or when the dorsal branch of the musculo-cutaneousnerve is also divided, there is a loss of sensibility on the dorsumof the hand. The motor symptoms predominate, the muscles affected being the extensorsof the wrist and fingers, and the supinators. There is a characteristic"drop-wrist"; the wrist is flexed and pronated, and the patient isunable to dorsiflex the wrist or fingers (Fig. 90). If the hand andproximal phalanges are supported, the second and third phalanges may bepartly extended by the interossei and lumbricals. There is alsoconsiderable impairment of power in the muscles which antagonise thosethat are paralysed, so that the grasp of the hand is feeble, and thepatient almost loses the use of it; in some cases this would appear tobe due to the median nerve having been injured at the same time. [Illustration: FIG.  90. --Drop-wrist following Fracture of Shaft ofHumerus. ] 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 undermassage, douching, and electricity. If there is drop-wrist, the hand andforearm are placed on a palmar splint, with the hand dorsiflexed tonearly a right angle, and this position is maintained until voluntarydorsiflexion at the wrist returns to the normal. Recovery is sometimesdelayed for several months. In the more severe injuries associated with fracture of the humerus andattended with the reaction of degeneration, it is necessary to cut downupon the nerve and free it from the pressure of a fragment of bone orfrom callus or adhesions. If the nerve is torn across, the ends must besutured, and if this is impossible owing to loss of tissue, the gap maybe bridged by a graft taken from the superficial branch of the radialnerve, or the ends may be implanted into the median. Finally, in cases in which the paralysis is permanent and incurable, thedisability may be relieved by operation. A fascial graft can be employedto act as a ligament permanently extending the wrist; it is attached tothe third and fourth metacarpal bones distally and to the radius or ulnaproximally. The flexor carpi radialis can then be joined up with theextensor digitorum communis by passing its tendon through an aperture inthe interosseous membrane, or better still, through the pronatorquadratus, as there is less likelihood of the formation of adhesionswhen the tendon passes through muscle than through interosseousmembrane. The palmaris longus is anastomosed with the abductor pollicislongus (extensor ossis metacarpi pollicis), thus securing a fair amountof abduction of the thumb. The flexor carpi ulnaris may also beanastomosed with the common extensor of the fingers. The extensors ofthe wrist may be shortened, so as to place the hand in the position ofdorsal flexion, and thus improve the attitude and grasp of the hand. _The superficial branch of the radial_ (radial nerve) _and the deepbranch_ (posterior interosseous), apart from suffering in lesions of theradial, are liable to be contused or torn is dislocation of the head ofthe radius, and in fracture of the neck of the bone. The deep branch maybe divided as it passes through the supinator in operations on oldfractures and dislocations in the region of the elbow. Division of thesuperficial branch in the upper two-thirds of the forearm produces noloss of sensibility; division in the lower third after the nerve hasbecome associated with branches from the musculo-cutaneous is followedby a loss of sensibility on the radial side of the hand and thumb. Woundson the dorsal surface of the wrist and forearm are often followed byloss of sensibility over a larger area, because the musculo-cutaneousnerve is divided as well, and some of the fibres of the lower lateralcutaneous branch of the radial. [Illustration: FIG.  91. --To illustrate the Loss of Sensation produced byDivision of the Median Nerve. The area of complete cutaneousinsensibility is shaded black. The parts insensitive to light touch andto intermediate degrees of temperature are enclosed within the dottedline. (After Head and Sherren. )] #The Median Nerve# is most frequently injured in wounds made by brokenglass in the region of the wrist. It may also be injured in fractures ofthe 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 lessextent the index finger: the terminal phalanx of the thumb cannot beflexed owing to the paralysis of the flexor pollicis longus, and theindex can only be flexed at its metacarpo-phalangeal joint by theinterosseous muscles attached to it. Pronation of the forearm is feeble, and is completed by the weight of the hand. After _division at thewrist_, the abductor-opponens group of muscles and the two laterallumbricals only are affected; the abduction of the thumb can be feeblyimitated by the short extensor and the long abductor (ext. Ossismetacarpi pollicis), while opposition may be simulated by contraction ofthe long flexor and the short abductor of the thumb; the paralysis ofthe two medial lumbricals produces no symptoms that can be recognised. It is important to remember that when the median nerve is divided at thewrist, deep touch can be appreciated over the whole of the areasupplied by the nerve; the injury, therefore, is liable to be overlooked. If, however, the tendons are divided as well as the nerve, thereis insensibility to deep touch. The areas of epicritic and ofprotopathic insensibility are illustrated in Fig. 91. The division ofthe nerve at the elbow, or even at the axilla, does not increase theextent of the loss of epicritic or protopathic sensibility, but usuallyaffects deep sensibility. [Illustration: FIG.  92. --To illustrate Loss of Sensation produced bycomplete Division of Ulnar Nerve. Loss of all forms of cutaneoussensibility is represented by the shaded area. The parts insensitive tolight touch and to intermediate degrees of heat and cold are enclosedwithin the dotted line. (Head and Sherren. )] #The Ulnar Nerve. #--The most common injury of this nerve is its divisionin transverse accidental wounds just above the wrist. In the arm it maybe contused, along with the radial, in crutch paralysis; in the regionof the elbow it may be injured in fractures or dislocations, or it maybe accidentally divided in the operation for excising the elbow-joint. When it is injured _at or above the elbow_, there is paralysis of theflexor carpi ulnaris, the ulnar half of the flexor digitorum profundus, all the interossei, the two medial lumbricals, and the adductors of thethumb. The hand assumes a characteristic attitude: the index and middlefingers are extended at the metacarpo-phalangeal joints owing toparalysis of the interosseous muscles attached to them; the little andring fingers are hyper-extended at these joints in consequence of theparalysis of the lumbricals; all the fingers are flexed at theinter-phalangeal joints, the flexion being most marked in the little andring fingers--claw-hand or _main en griffe_. On flexing the wrist, thehand is tilted to the radial side, but the paralysis of the flexor carpiulnaris is often compensated for by the action of the palmaris longus. The little and ring fingers can be flexed to a slight degree by theslips of the flexor sublimis attached to them and supplied by the mediannerve; flexion of the terminal phalanx of the little finger is almostimpossible. Adduction and abduction movements of the fingers are lost. Adduction of the thumb is carried out, not by the paralysed adductorpollicis, but the movement may be simulated by the long flexor andextensor muscles of the thumb. Epicritic sensibility is lost over thelittle finger, the ulnar half of the ring finger, and that part of thepalm and dorsum of the hand to the ulnar side of a line drawnlongitudinally through the ring finger and continued upwards. Protopathic sensibility is lost over an area which varies in differentcases. Deep sensibility is usually lost over an area almost as extensiveas that of protopathic insensibility. When the nerve is _divided at the wrist_, the adjacent tendons are alsofrequently severed. If divided below the point at which its dorsalbranch is given off, the sensory paralysis is much less marked, and theinjury is therefore liable to be overlooked until the wasting of musclesand typical _main en griffe_ ensue. The loss of sensibility afterdivision of the nerve before the dorsal branch is given off resemblesthat after division at the elbow, except that in uncomplicated casesdeep sensibility is usually retained. If the tendons are divided aswell, however, deep touch is also lost. Care must be taken in all these injuries to prevent deformity; a splintmust be worn, at least during the night, until the muscles regain theirpower of voluntary movement, and then exercises should be instituted. #Dislocation of the ulnar nerve# at the elbow results from sudden andviolent flexion of the joint, the muscular effort causing stretching orlaceration of the fascia that holds the nerve in its groove; it ispredisposed to if the groove is shallow as a result of imperfectdevelopment of the medial condyle of the humerus, and by cubitus valgus. The nerve slips forward, and may be felt lying on the medial aspect ofthe condyle. It may retain this position, or it may slip backwards andforwards with the movements of the arm. The symptoms at the time of thedisplacement are some disability at the elbow, and pain and tinglingalong the nerve, which are exaggerated by movement and by pressure. Thesymptoms may subside altogether, or a neuritis may develop, with severepain shooting up the nerve. The dislocated nerve is easily replaced, but is difficult to retain inposition. In recent cases the arm may be placed in the extended positionwith a pad over the condyle, care being taken to avoid pressure on thenerve. Failing relief, it is better to make a bed for the nerve bydividing the deep fascia behind the medial condyle and to stitch theedges of the fascia over the nerve. This operation has been successfulin all the recorded cases. #The Sciatic Nerve. #--When this nerve is compressed, as by sitting on afence, there is tingling and powerlessness in the limb as a whole, knownas "sleeping" of the limb, but these phenomena are evanescent. _Injuriesto the great sciatic nerve_ are rare except in war. Partial division ismore common than complete, and it is noteworthy that the fibres destinedfor the peroneal nerve are more often and more severely injured thanthose for the tibial (internal popliteal). After complete division, allthe muscles of the leg are paralysed; if the section is in the upperpart of the thigh, the hamstrings are also paralysed. The limb is atfirst quite powerless, but the patient usually recovers sufficiently tobe able to walk with a little support, and although the hamstrings areparalysed the knee can be flexed by the sartorius and gracilis. Thechief feature is drop-foot. There is also loss of sensation below theknee except along the course of the long saphenous nerve on the medialside of the leg and foot. Sensibility to deep touch is only lost over acomparatively small area on the dorsum of the foot. #The Common Peroneal (external popliteal) nerve# is exposed to injurywhere it winds round the neck of the fibula, because it is superficialand lies against the unyielding bone. It may be compressed by atourniquet, or it may be bruised or torn in fractures of the upper endof the bone. It has been divided in accidental wounds, --by a scythe, forexample, --in incising for cellulitis, and in performing subcutaneoustenotomy of the biceps tendon. Cases have been observed of paralysis ofthe nerve as a result of prolonged acute flexion of the knee in certainoccupations. When the nerve is divided, the most obvious result is "drop-foot"; thepatient is unable to dorsiflex the foot and cannot lift his toes off theground, so that in walking he is obliged to jerk the foot forwards andlaterally. The loss of sensibility depends upon whether the nerve isdivided above or below the origin of the large cutaneous branch whichcomes off just before it passes round the neck of the fibula. In courseof time the foot becomes inverted and the toes are pointed--pesequino-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 thecourse of a nerve, and is not referable to any discoverable cause. Itshould not be applied to pain which results from pressure on a nerve bya tumour, a mass of callus, an aneurysm, or by any similar gross lesion. We shall only consider here those forms of neuralgia which are amenableto surgical treatment. #Brachial Neuralgia. #--The pain is definitely located in thedistribution of one of the branches or nerve roots, is oftenintermittent, and is usually associated with tingling and disturbance oftactile sensation. The root of the neck should be examined to excludepressure as the cause of the pain by a cervical rib, a tumour, or ananeurysm. When medical treatment fails, the nerve-trunks may be injectedwith saline solution or recourse may be had to operative measures, theaffected cords being exposed and stretched through an incision in theposterior triangle of the neck. If this fails to give relief, the moreserious operation of resecting the posterior roots of the affectednerves within the vertebral canal may be considered. _Neuralgia of the sciatic nerve_--#sciatica#--is the most common form ofneuralgia met with in surgical practice. It is chiefly met with in adults of gouty or rheumatic tendencies whosuffer from indigestion, constipation, and oxaluria--in fact, the sametype of patients who are liable to lumbago, and the two affections arefrequently associated. In hospital practice it is commonly met with incoal-miners and others who assume a squatting position at work. Theonset 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 dietor indulgence in beer or wine may contribute to its development. The essential symptom is paroxysmal or continuous pain along the courseof the nerve in the buttock, thigh, or leg. It may be comparativelyslight, or it may be so severe as to prevent sleep. It is aggravated bymovement, so that the patient walks lame or is obliged to lie up. It isaggravated also by any movement which tends to put the nerve on thestretch, as in bending down to put on the shoes, such movements alsocausing tingling down the nerve, and sometimes numbness in the foot. This may be demonstrated by flexing the thigh on the abdomen, the kneebeing kept extended; there is no pain if the same manœuvre is repeatedwith the knee flexed. The nerve is sensitive to pressure, the mosttender points being its emergence from the greater sciatic foramen, thehollow between the trochanter and the ischial tuberosity, and where thecommon peroneal nerve winds round the neck of the fibula. The muscles ofthe thigh are often wasted and are liable to twitch. The clinical features vary a good deal in different cases; the affectionis often obstinate, and may last for many weeks or even months. In the sciatica that results from neuritis and perineuritis, there ismarked tenderness on pressure due to the involvement of the nervefilaments in the sheath of the nerve, and there may be patches ofcutaneous anæsthesia, loss of tendon reflexes, localised wasting ofmuscles, and vaso-motor and trophic changes. The presence of thereaction of degeneration confirms the diagnosis of neuritis. Inlong-standing cases the pain and discomfort may lead to a posturalscoliosis (_ischias-scoliotica_). _Diagnosis. _--Pain referred along the course of the sciatic nerve on oneside, or, as is sometimes the case, on both sides, is a symptom oftumours of the uterus, the rectum, or the pelvic bones. It may resultalso from the pressure of an abscess or an aneurysm either inside thepelvis or in the buttock, and is sometimes associated with disease ofthe spinal medulla, such as tabes. Gluteal fibrositis may be mistakenfor sciatica. It is also necessary to exclude such conditions as diseasein the hip or sacro-iliac joint, especially tuberculous disease andarthritis deformans, before arriving at a diagnosis of sciatica. Adigital examination of the rectum or vagina is of great value inexcluding intra-pelvic tumours. _Treatment_ is both general and local. Any constitutional tendency, suchas gout or rheumatism, must be counteracted, and indigestion, oxaluria, and constipation should receive appropriate treatment. In acute casesthe patient is confined to bed between blankets, the limb is wrapped inthermogene wool, and the knee is flexed over a pillow; in some casesrelief is experienced from the use of a long splint, or slinging the legin a Salter's cradle. A rubber hot-bottle may be applied over the seatof greatest pain. The bowels should be well opened by castor oil or bycalomel followed by a saline. Salicylate of soda in full doses, oraspirin, usually proves effectual in relieving pain, but when this isvery intense it may call for injections of heroin or morphin. Potassiumiodide is of benefit in chronic cases. Relief usually results from bathing, douching, and massage, and fromrepeated gentle stretching of the nerve. This may be carried out bypassive movements of the limb--the hip being flexed while the knee iskept extended; and by active movements--the patient flexing the limb atthe hip, the knee being maintained in the extended position. Theseexercises, which may be preceded by massage, are carried out night andmorning, and should be practised systematically by those who are liableto sciatica. Benefit has followed the injection into the nerve itself, or into thetissues surrounding it, of normal saline solution; from 70–100 c. C. Areinjected at one time. If the pain recurs, the injection may require tobe repeated on many occasions at different points up and down the nerve. Needling or acupuncture consists in piercing the nerve at intervals inthe buttock and thigh with long steel needles. Six or eight needles areinserted 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 thehip flexed to a right angle, and then gradually extending the knee untilit is in a straight line with the thigh (Billroth). A general anæstheticis usually required. A more effectual method is to expose the nervethrough an incision at the fold of the buttock, and forcibly pull uponit. This operation is most successful when the pain is due to the nervebeing involved in adhesions. #Trigeminal Neuralgia. #--A severe form of epileptiform neuralgia occursin the branches of the fifth nerve, and is one of the most painfulaffections to which human flesh is liable. So far as its pathology isknown, it is believed to be due to degenerative changes in the semilunar(Gasserian) ganglion. It is met with in adults, is almost invariablyunilateral, and develops without apparent cause. The pain, which occursin paroxysms, is at first of moderate severity, but gradually becomesagonising. 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 jawsin eating or speaking, touching the face as in washing, or exposure to adraught of cold air. Between the paroxysms the patient is free frompain, but is in constant terror of its return, and the face wears anexpression of extreme suffering and anxiety. When the paroxysm isaccompanied by twitching of the facial muscles, it is called _spasmodictic_. The skin of the affected area may be glazed and red, or may be pale andmoist with inspissated sweat, the patient not daring to touch or washit. There is excessive tenderness at the points of emergence of thedifferent branches on the face, and pressure over one or other of thesepoints may excite a paroxysm. In typical cases the patient is unable totake any active part in life. The attempt to eat is attended with suchsevere pain that he avoids taking food. In some cases the suffering isso 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 painvarying in situation, being frequently bilateral, and being more oftenconstant than paroxysmal. _Treatment. _--Before having recourse to the measures described below, itis advisable to give a thorough trial to the medical measures used inthe treatment of neuralgia. _The Injection of Alcohol into the Nerve. _--The alcohol acts bydestroying the nerve fibres, and must be brought into direct contactwith them; if the nerve has been properly struck the injection isfollowed by complete anæsthesia in the distribution of the nerve. Therelief 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 85per cent. , and the amount injected about 2 c. C. ; a general, orpreferably a local, anæsthetic (novocain) should be employed(Schlösser); the needle is 8 cm. Long, and 0. 7 mm. In diameter. Thesevere pain which the alcohol causes may be lessened, after the needlehas penetrated to the necessary depth, by passing a few cubiccentimetres of a 2 per cent. Solution of _novocain-suprarenin_ throughit before the alcohol is injected. The treatment by injection of alcoholis superior to the resection of branches of the nerve, for thoughrelapses occur after the treatment with alcohol, renewed freedom frompain may be obtained by its repetition. The ophthalmic division shouldnot, however, be treated in this manner, for the alcohol may escape intothe orbit and endanger other nerves in this region. Harris recommendsthe injection of alcohol into the semilunar ganglion. _Operative Treatment. _--This consists in the removal of the affectednerve or nerves, either by resection--_neurectomy_; or by a combinationof resection with twisting or tearing of the nerve from its centralconnections--_avulsion_. To prevent the regeneration of the nerve afterthese operations, the canal of exit through the bone should beobliterated; this is best accomplished by a silver screw-nail drivenhome by an ordinary screw-driver (Charles H.  Mayo). When the neuralgia involves branches of two or of all three trunks, orwhen it has recurred after temporary relief following resection ofindividual branches, the _removal of the semilunar ganglion_, along withthe main trunks of the maxillary and mandibular divisions, should beconsidered. The operation is a difficult and serious one, but the results aresatisfactory so far as the cure of the neuralgia is concerned. There islittle or no disability from the unilateral paralysis of the muscles ofmastication; but on account of the insensitiveness of the cornea, theeye must be protected from irritation, especially during the first monthor two after the operation; this may be done by fixing a largewatch-glass around the edge of the orbit with adhesive plaster. If the ophthalmic branch is not involved, neither it nor the ganglionshould be interfered with; the maxillary and mandibular divisions shouldbe divided within the skull, and the foramen rotundum and foramen ovaleobliterated. 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 cellularlayer--the epidermis, and the corium or true skin. The _epidermis_ isdifferentiated from without inwards into the stratum corneum, thestratum lucidum, the stratum granulosum, and the rete Malpighii orgerminal layer, from which all the others are developed. The _corium_ or_true skin_ consists of connective tissue, in which ramify the bloodvessels, lymphatics, and nerves. That part of the corium immediatelyadjoining the epidermis is known as the papillary portion, and containsthe terminal loops of the cutaneous blood vessels and the terminationsof the cutaneous nerves. The deeper portion of the true skin is known asthe reticular portion, and is largely composed of adipose tissue. #Blisters# result from the exudation of serous fluid beneath the hornylayer of the epidermis. The fluid may be clear, as in the blisters of arecent burn, or blood-stained, as in the blisters commonly accompanyingfractures 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. Wheninfected, the separated horny layer must be cut away with scissors toallow of the necessary purification. #Callosities# are prominent, indurated masses of the horny layer of theepidermis, where it has been exposed to prolonged friction and pressure. They occur on the fingers and hand as a result of certain occupationsand sports, but are most common under the balls of the toes or heel. Abursa may form beneath a callosity, and if it becomes inflamed may causeconsiderable 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 pressureby wearing properly fitting boots, and in applying a ring pad around thecallosity; another method is to fit a sock of spongiopilene with a holecut out opposite the callosity. After soaking in hot water, theovergrown horny layer is pared away, and the part painted daily with asaturated solution of salicylic acid in flexile collodion. [Illustration: FIG.  93. --Callosities and Corns on the Sole and PlantarAspect 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 theepidermis, which grows downwards, pressing upon and displacing thesensitive papillæ of the corium. Corns are due to the friction andpressure of ill-fitting boots, and are met with chiefly on the toes andsole of the foot. A corn is usually hard, dry, and white; but it may besodden from moisture, as in "soft corns" between the toes. A bursa mayform beneath a corn, and if inflamed constitutes one form of bunion. When suppuration takes place in relation to a corn, there is great painand disability, and it may prove the starting-point of lymphangitis. The _treatment_ consists in the wearing of properly fitting boots andstockings, and, if the symptoms persist, the corn should be removed. This is done after the manner of chiropodists by digging out the cornwith a suitably shaped knife. A more radical procedure is to excise, under local anæsthesia, the portion of skin containing the corn andthe underlying bursa. The majority of so-called corn solvents consist ofa solution of salicylic acid in collodion; if this is painted on daily, the epidermis dies and can then be pared away. The unskilful paring ofcorns may determine the occurrence of senile gangrene in those who arepredisposed 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 disturbanceresulting from the alternate action of cold and heat on the distal partsof the body. Chilblains are met with chiefly on the fingers and toes inchildren and anæmic girls. In the mild form there is a sensation ofburning and itching, the part becomes swollen, of a dusky red colour, and the skin is tense and shiny. In more severe cases the burning anditching are attended with pain, and the skin becomes of a violet orwine-red colour. There is a third degree, closely approachingfrost-bite, in which the skin tends to blister and give way, leaving anindolent raw surface popularly known as a "broken chilblain. " Those liable to chilblains should take open-air exercise, nourishingfood, cod-liver oil, and tonics. Woollen stockings and gloves should beworn in cold weather, and sudden changes of temperature avoided. Thesymptoms may be relieved by ichthyol ointment, glycerin and belladonna, or a mixture of Venice turpentine, castor oil, and collodion applied onlint which is wrapped round the toe. Another favourite application isone of equal parts of tincture of capsicum and compound liniment ofcamphor, painted over the area night and morning. Balsam of Peru orresin ointment spread on gauze should be applied to broken chilblains. The most effective treatment is Bier's bandage applied for about sixhours twice daily; it can be worn while the patient is following hisoccupation; in chronic cases this may be supplemented with hot-airbaths. #Boils and Carbuncles. #--These result from infection with thestaphylococcus aureus, which enters the orifices of the ducts of theskin under the influence of friction and pressure, as was demonstratedby the well-known experiment of Garrè, who produced a crop of pustulesand boils on his own forearm by rubbing in a culture of thestaphylococcus aureus. A #boil# results when the infection is located in a hair follicle orsebaceous gland. A hard, painful, conical swelling develops, to which, so long as the skin retains its normal appearance, the term "blindboil" is applied. Usually, however, the skin becomes red, and after atime breaks, giving exit to a drop or two of thick pus. After aninterval of from six to ten days a soft white slough is discharged; thisis known as the "core, " and consists of the necrosed hair follicle orsebaceous gland. After the separation of the core the boil healsrapidly, leaving a small depressed scar. Boils are most frequently met with on the back of the neck and thebuttocks, and on other parts where the skin is coarse and thick and isexposed to friction and pressure. The occurrence of a number or asuccession of boils is due to spread of the infection, the cocci fromthe original boil obtaining access to adjacent hair follicles. Thespread of boils may be unwittingly promoted by the use of a domesticpoultice or the wearing of infected underclothing. While boils are frequently met with in debilitated persons, andparticularly in those suffering from diabetes or Bright's disease, theyalso occur in those who enjoy vigorous health. They seldom provedangerous to life except in diabetic subjects, but when they occur onthe face there is a risk of lymphatic and of general pyogenic infection. Boils may be differentiated from syphilitic lesions of the skin bytheir acute onset and progress, and by the absence of other evidence ofsyphilis; and from the malignant or anthrax pustule by the absence ofthe central black eschar and of the circumstances which attend uponanthrax infection. _Treatment. _--The skin of the affected area should be painted withiodine, and a Klapp's suction bell applied thrice daily. If pus forms, the skin is frozen with ethyl-chloride and a small incision made, afterwhich the application of the suction bell is persevered with. Thefurther treatment consists in the use of diluted boracic or resinointment. In multiple boils on the trunk and limbs, lysol or boracicbaths are of service; the underclothing should be frequently changed, and that which is discarded must be disinfected. In patients withrecurrence of boils about the neck, re-infection frequently takes placefrom the scalp, to which therefore treatment should be directed. Any impaired condition of health should be corrected; when, there issugar or albumen in the urine the conditions on which these depend mustreceive appropriate treatment. When there are successive crops of boils, recourse should be had to vaccines. In refractory cases benefit hasfollowed the subcutaneous injection of lipoid solution containing tin. #Carbuncle# may be looked upon as an aggregation of boils, and ischaracterised by a densely hard base and a brownish-red discoloration ofthe skin. It is usually about the size of a crown-piece, but it maycontinue to enlarge until it attains the size of a dinner-plate. Thepatient is ill and feverish, and the pain may be so severe as to preventsleep. As time goes on several points of suppuration appear, and whenthese burst there are formed a number of openings in the skin, giving ita cribriform appearance; these openings exude pus. The differentopenings ultimately fuse and the large adherent greyish-white slough isexposed. The separation of the slough is a tedious process, and thepatient may become exhausted by pain, discharge, and toxin absorption. When the slough is finally thrown off, a deep gap is left, which takes along time to heal. A large carbuncle is a grave disease, especially in aweakly person suffering from diabetes or chronic alcoholism; we have onseveral occasions seen diabetic coma supervene and the patient diewithout recovering consciousness. In the majority of cases the patientis laid aside for several months. It is most common in male adults overforty years of age, and is usually situated on the back between theshoulders. When it occurs on the face or anterior part of the neck it isespecially dangerous, because of the greater risk of dissemination ofthe infection. A carbuncle is to be differentiated from an ulcerated gumma and fromanthrax pustule. [Illustration: FIG.  95. --Carbuncle of seventeen days' duration in awoman æt.  57. ] _Treatment. _--Pain is relieved by full doses of opium or codein, andthese drugs are specially indicated when sugar is present in the urine. Vaccines may be given a trial. The diet should be liberal and easilydigested, and strychnin and other stimulants may be of service. Locallythe treatment is carried out on the same lines as for boils. In some cases it is advisable to excise the carbuncle or to makeincisions across it in different directions, so that the resulting woundpresents a stellate appearance. #Acute Abscesses of the Skin and Subcutaneous Tissue in YoungChildren. #--In young infants, abscesses are not infrequently met withscattered over the trunk and limbs, and are probably the result ofinfection of the sebaceous glands from dirty underclothing. Theabscesses should be opened, and the further spread of infectionprevented 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 theepidermis, such as a sun blister, the bite of an insect, or a scratch. Apustule forms and bursts, and a brownish-yellow scab forms over it. Whenthis is removed, an ulcer is left which has little tendency to heal. These sores are most common about the hands, arms, neck, and feet, andare 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 primaryforms of tuberculosis of the skin in which the bacilli penetrate fromwithout--inoculation tubercle and lupus. #Inoculation Tubercle. #--The appearances vary with the conditions underwhich the inoculation takes place. As observed on the fingers of adults, the affection takes the form of an indolent painless swelling, theepidermis being red and glazed, or warty, and irregularly fissured. Sometimes the epidermis gives way, forming an ulcer with flabbygranulations. The infection rarely spreads to the lymphatics, but wehave seen inoculation tubercle of the index-finger followed by a largecold abscess on the median side of the upper arm and by a huge mass ofbreaking down glands in the axilla. In children who run about barefooted in towns, tubercle may beinoculated into wounds in the sole or about the toes, and although thelocal appearances may not be characteristic, the nature of the infectionis revealed by its tendency to spread up the limb along the lymphvessels, giving rise to abscesses and fungating ulcers in relation tothe femoral glands. #Tuberculous Lupus. #--This is an extremely chronic affection of theskin. It rarely extends to the lymph glands, and of all tuberculouslesions is the least dangerous to life. The commonest form oflupus--_lupus vulgaris_--usually commences in childhood or youth, and ismost often met with on the nose or cheek. The early and typicalappearance is that of brownish-yellow or pink nodules in the skin, aboutthe size of hemp seed. Healing frequently occurs in the centre of theaffected 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 withcicatricial contraction, which may cause unsightly deformity. When thecheek is affected, the lower eyelid may be drawn down and everted; whenthe lips are affected, the mouth may be distorted or seriouslydiminished in size. When the nose is attacked, both the skin and mucoussurfaces are usually involved, and the nasal orifices may be narrowed oreven obliterated; sometimes the soft parts, including the cartilages, are destroyed, leaving only the bones covered by tightly stretched scartissue. The disease progresses slowly, healing in some places and spreading atothers. The patient complains of a burning sensation, but little ofpain, and is chiefly concerned about the disfigurement. Nothing is morecharacteristic of lupus than the appearance of fresh nodules in partswhich have already healed. In the course of years large tracts of theface and neck may become affected. From the lips it may spread to thegum and palate, giving to the mucous membrane the appearance of araised, bright-red, papillary or villous surface. When the diseaseaffects the gums, the teeth may become loose and fall out. [Illustration: FIG.  96. --Tuberculous Elephantiasis in a woman æt.  35. ] On parts of the body other than the face, the disease is even morechronic, and is often attended with a considerable production of densefibrous tissue--the so-called _fibroid lupus_. Sometimes there is awarty thickening of the epidermis--_lupus verrucosus_. In the fingersand toes it may lead to a progressive destruction of tissue like thatobserved in leprosy, and from the resulting loss of portions of thedigits it has been called _lupus mutilans_. In the lower extremity aremarkable form of the disease is sometimes met with, to which the term_lupus elephantiasis_ (Fig. 96) has been applied. It commences as anordinary lupus of the toes or dorsum of the foot, from which thetuberculous infection spreads to the lymph vessels, and the limb as awhole becomes enormously swollen and unshapely. Finally, a long-standing lupus, especially on the cheek, may become theseat of epithelioma--_lupus epithelioma_--usually of the exuberant orcauliflower type, which, like other epitheliomas that originate in scartissue, presents little tendency to infect the lymphatics. The _diagnosis_ of lupus is founded on the chronic progress and longduration, and the central scarring with peripheral extension of thedisease. On the face it is most liable to be confused with syphilis andwith rodent cancer. The syphilitic lesion belongs to the tertiaryperiod, and although presenting a superficial resemblance totuberculosis, its progress is more rapid, so that within a few months itmay involve an area of skin as wide as would be affected by lupus in asmany years. Further, it readily yields to anti-syphilitic treatment. Incases of tertiary syphilis in which the nose is destroyed, it will benoticed that the bones have suffered most, while in lupus thedestruction of tissue involves chiefly the soft parts. Rodent cancer is liable to be mistaken for lupus, because it affects thesame parts of the face; it is equally chronic, and may partly heal. Itbegins later in life, however, the margin of the ulcer is more sharplydefined, and often presents a "rolled" appearance. _Treatment. _--When the disease is confined to a limited area, the mostrapid and certain cure is obtained by _excision_; larger areas arescraped with the sharp spoon. The _ray treatment_ includes the use ofluminous, Röntgen, or radium rays, and possesses the advantage of beingcomparatively painless and of being followed by the least amount ofscarring and deformity. Encouraging results have also been obtained by the application of carbondioxide snow. #Multiple subcutaneous tuberculous nodules# are met with chiefly inchildren. They are indolent and painless, and rarely attract attentionuntil they break down and form abscesses, which are usually about thesize of a cherry, and when these burst sinuses or ulcers result. If theoverlying skin is still intact, the best treatment is excision. If theabscess has already infected the skin, each focus should be scraped andpacked. #Sporotrichosis# is a mycotic infection due to the sporothrix Shenkii. It presents so many features resembling syphilis and tubercle that it isfrequently mistaken for one or other of these affections. It occurschiefly in males between fifteen and forty-five, who are farmers, fruitand vegetable dealers, or florists. There is usually a history of traumaof the nature of a scratch or a cut, and after a long incubation periodthere develop a series of small, hard, round nodules in the skin andsubcutaneous tissue which, without pain or temperature, soften intocold abscesses and leave indolent ulcers or sinuses. The infection isof slow progress and follows the course of the lymphatics. From thegelatinous pus the organism is cultivated without difficulty, and thisis the essential step in arriving at a diagnosis. The disease yields ina few weeks to full doses of iodide of potassium. #Elephantiasis. #--This term is applied to an excessive enlargement of apart depending upon an overgrowth of the skin and subcutaneous cellulartissue, and it may result from a number of causes, acting independentlyor in combination. The condition is observed chiefly in the extremitiesand in the external organs of generation. _Elephantiasis from Lymphatic or Venous Obstruction. _--Of this thebest-known example is _tropical elephantiasis_ (E.  arabum), which isendemic in Samoa, Barbadoes, and other places. It attacks the lowerextremity or the genitals in either sex (Figs. 97, 98). The disease isusually ushered in with fever, and signs of lymphangitis in the partaffected. After a number of such attacks, the lymph vessels appear tobecome obliterated, and the skin and subcutaneous cellular tissue, beingbathed in stagnant lymph--which possibly contains the products ofstreptococci--take on an overgrowth, which continues until the partassumes gigantic proportions. In certain cases the lymph trunks havebeen found to be blocked with the parent worms of the filaria Bancrofti. Cases of elephantiasis of the lower extremity are met with in thiscountry in which there are no filarial parasites in the lymph vessels, and these present features closely resembling the tropical variety, andusually follow upon repeated attacks of lymphangitis or erysipelas. The part affected is enormously increased in size, and causesinconvenience from its bulk and weight. In contrast to ordinary dropsy, there is no pitting on pressure, and the swelling does not disappear onelevation of the limb. The skin becomes rough and warty, and may hangdown in pendulous folds. Blisters form on the surface and yield anabundant exudate of clear lymph. From neglect of cleanliness, the skinbecomes the seat of eczema or even of ulceration attended with fouldischarge. Samson Handley has sought to replace the blocked lymph vessels byburying in the subcutaneous tissue of the swollen part a number of stoutsilk threads--_lymphangioplasty_. By their capillary action they drainthe lymph to a healthy region above, and thus enable it to enter thecirculation. It has been more successful in the face and upper limb thanin 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 æt.  45. ] A similar type of elephantiasis may occur after extirpation of the lymphglands in the axilla or groin; in the leg in long-standing standingvarix and phlebitis with chronic ulcer; in the arm as a result ofextensive cancerous disease of the lymphatics in the axilla secondarilyto cancer of the breast; and in extensive tuberculous disease of thelymphatics. The last-named is chiefly observed in the lower limb inyoung adult women, and from its following upon lupus of the toes or footit has been called _lupus elephantiasis_. The tuberculous infectionspreads slowly up the limb by way of the lymph vessels, and as these areobliterated the skin and cellular tissues become hypertrophied, and thesurface is studded over with fungating tuberculous masses of a lividblue colour. As the more severe forms of the disease may prove dangerousto life by pyogenic complications inducing gangrene of the limb, thequestion of amputation may have to be considered. [Illustration: FIG.  98. --Elephantiasis of Penis and Scrotum in native ofDemerara. (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_ byamniotic bands. _Elephantiasis occurring apart from lymphatic or venous obstruction_ isillustrated by _elephantiasis nervorum_, in which there is an overgrowthof the skin and cellular tissue of an extremity in association withneuro-fibromatosis of the cutaneous nerves (Fig. 89); and by_elephantiasis Græcorum_--a form of leprosy in which the skin of theface becomes the seat of tumour-like masses consisting of leprousnodules. It is also illustrated by _elephantiasis involving the scrotum_as a result of prolonged irritation by the urine in cases in which thepenis has been amputated and the urine has infiltrated the scrotaltissues over a period of years. #Sebaceous Cysts. #--Atheromatous cysts or wens are formed in relation tothe sebaceous glands and hair follicles. They are commonly met with inadults, on the scalp (Fig. 99), face, neck, back, and external genitals. Sometimes they are multiple, and they may be met with in several membersof the same family. They are smooth, rounded, or discoid cysts, varyingin size from a split-pea to a Tangerine orange. In consistence they arefirm and elastic, or fluctuating, and are incorporated with theoverlying skin, but movable on the deeper structures. The orifice of thepartly blocked sebaceous follicle is sometimes visible, and the contentsof the cyst can be squeezed through the opening. The wall of the cyst iscomposed of a connective-tissue capsule lined by stratified squamousepithelium. The contents consist of accumulated epithelial cells, andare at first dry and pearly white in appearance, but as a result offatty degeneration they break down into a greyish-yellow pultaceous andsemi-fluid material having a peculiar stale odour. It is probable thatthe decomposition of the contents is the result of the presence ofbacteria, and that from the surgical point of view they should beregarded as infective. A sebaceous cyst may remain indefinitely withoutchange, or may slowly increase in size, the skin over it becomingstretched and closely adherent to the cyst wall as a result of frictionand pressure. The contents may ooze from the orifice of the duct and dryon the skin surface, leading to the formation of a sebaceous horn(Fig. 100). As a result of injury the cyst may undergo suddenenlargement from hæmorrhage into its interior. Recurrent attacks of inflammation frequently occur, especially in wensof the face and scalp. Suppuration may ensue and be followed by cure ofthe cyst, or an offensive fungating ulcer forms which may be mistakenfor epithelioma. True cancerous transformation is rare. Wens are to be _diagnosed_ from dermoids, from fatty tumours, and fromcold abscesses. Dermoids usually appear before adult life, and as theynearly always lie beneath the fascia, the skin is movable over them. Afatty tumour is movable, and is often lobulated. The confusion with acold abscess is most likely to occur in wens of the neck or back, and itmay be impossible without the use of an exploring needle todifferentiate between them. [Illustration: FIG.  99. --Multiple Sebaceous Cysts or Wens; the largerones are of many years' duration. ] _Treatment. _--The removal of wens is to be recommended while they aresmall and freely movable, as they are then easily shelled out afterincising the overlying skin; sometimes splitting the cyst makes itsremoval easier. Local anæsthesia is to be preferred. It is importantthat none of the cyst wall be left behind. In large and adherent wens anellipse of skin is removed along with the cyst. When inflamed, it may beimpossible to dissect out the cyst, and the wall should be destroyedwith carbolic acid, the resulting wound being treated by the openmethod. #Moles. #--The term mole is applied to a pigmented, and usually hairy, patch of skin, present at or appearing shortly after birth. The colourvaries from brown to black, according to the amount of melanin pigmentpresent. The lesion consists in an overgrowth of epidermis which oftenpresents an alveolar arrangement. Moles vary greatly in size: some aremere dots, others are as large as the palm of the hand, and occasionallya mole covers half the face. In addition to being unsightly, they bleedfreely when abraded, are liable to ulcerate from friction and pressure, and occasionally become the starting-point of melanotic cancer. Rodentcancer sometimes originates in the slightly pigmented moles met with onthe face. Overgrowths in relation to the cutaneous nerves, especiallythe plexiform neuroma, occasionally originate in pigmented moles. Soldaubelieves that the pigmentation and overgrowth of the epidermis in molesare associated with, and probably result from, a fibromatosis of thecutaneous nerves. _Treatment. _--The quickest way to get rid of a mole is to excise it; ifthe edges of the gap cannot be brought together with sutures, recourseshould be had to grafting. In large hairy moles of the face whose sizeforbids excision, radium or the X-rays should be employed. Excellentresults have been obtained by refrigeration with solid carbon dioxide. In children and women with delicate skin, applications of from ten tothirty seconds suffice. In persons with coarse skin an application ofone minute may be necessary, and it may have to be repeated. #Horns. #--The _sebaceous_ horn results from the accumulation of thedried contents of a wen on the surface of the skin: the sebaceousmaterial after drying up becomes cornified, and as fresh material isadded to the base the horn increases in length (Fig. 100). The _wart_horn grows from a warty papilloma of the skin. _Cicatrix_ horns areformed by the heaping up of epidermis in the scars that result fromburns. _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-pointof epithelioma, and for this reason, as well as for others, horns shouldbe removed. [Illustration: FIG.  100. --Sebaceous Horn growing from Auricle. (Dr. Kenneth Maclachan's case. )] #New Growths in the Skin and Subcutaneous Tissue. #--The _Angioma_ hasbeen described with diseases of blood vessels. _Fibroma. _--Various typesof fibroma occur in the skin. A soft pedunculated fibroma, about thesize of a pea, is commonly met with, especially on the neck and trunk;it is usually solitary, and is easily removed with scissors. Themultiple, soft fibroma known as _molluscum fibrosum_, which depends upona neuro-fibromatosis of the cutaneous nerves, is described with thetumours of nerves. Hard fibromas occurring singly or in groups may bemet with, especially in the skin of the buttock, and may present a localmalignancy, recurring after removal like the "recurrent fibroid" ofPaget. The "painful subcutaneous nodule" is a solitary fibroma relatedto one of the cutaneous nerves. The hard fibroma known as _keloid_ isdescribed with the affections of scars. #Papilloma. #--The _common wart_ or verruca is an outgrowth of thesurface epidermis. It may be sessile or pedunculated hard or soft. Thesurface may be smooth, or fissured and foliated like a cauliflower, orit may be divided up into a number of spines. Warts are met with chieflyon the hands, and are often multiple, occurring in clusters or insuccessive crops. Multiple warts appear to result from some contagion, the nature of which is unknown; they sometimes occur in an epidemic formamong school-children, and show a remarkable tendency to disappearspontaneously. The solitary flat-topped wart which occurs on the faceof old people may, if irritated, become the seat of epithelioma. A wartygrowth of the epidermis is a frequent accompaniment of moles and of thatvariety of lupus known as _lupus verrucosus_. _Treatment. _--In the multiple warts of children the health should bebraced up by a change to the seaside. A dusting-powder, consisting ofboracic acid with 5 per cent. Salicylic acid, may be rubbed into thehands after washing and drying. The persistent warts of young adultsshould be excised after freezing with chloride of ethyl. When cutting isobjected to, they may be painted night and morning with salicyliccollodion, the epidermis being dehydrated with alcohol before eachapplication. _Venereal warts_ occur on the genitals of either sex, and may form largecauliflower-like masses on the inner surface of the prepuce or of thelabia majora. Although frequently co-existing with gonorrhœa orsyphilis, they occur independently of these diseases, being probablyacquired by contact with another individual suffering from warts(C.  W.  Cathcart). They give rise to considerable irritation andsuffering, and when cleanliness is neglected there may be an offensivedischarge. 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 aresnipped off with scissors. In milder cases, the warts usually disappearif the parts are kept absolutely dry and clean. A useful dusting-powderis one consisting of calamine and 5 per cent. Salicylic acid; theexsiccated sulphate of iron, in the form of a powder, may be employed incases which resist this treatment. #Adenoma. #--This is a comparatively rare tumour growing from the glandsof the skin. One variety, known as the "tomato tumour, " which apparentlyoriginates from _the sweat glands_, is met with on the scalp and face inwomen past middle life. These growths are often multiple; the individualtumours vary in size, and the skin, which is almost devoid of hairs, isglistening and tightly stretched over them. A similar tumour may occuron the nose. The _sebaceous adenoma_, which originates from thesebaceous glands, forms a projecting tumour on the face or scalp, andwhen the skin is irritated it may ulcerate and fungate. The treatmentconsists 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 removedby shaving them off with a knife until the normal shape of the nose isrestored Healing takes place with remarkable rapidity. #Cancer. #--There are several types of primary cancer of the skin, themost important being squamous epithelioma, rodent cancer, and melanoticcancer. [Illustration: FIG.  101. --Paraffin Epithelioma. ] #Epithelioma# occurs in a variety of forms. When originating in a smallulcer or wart-for example on the face in old people--it presents thefeatures of a chronic indurated ulcer. A more exuberant and rapidlygrowing form of epithelial cancer, described by Hutchinson as the_crateriform ulcer_, commences on the face as a small red pimple whichrapidly develops into an elevated mass shaped like a bee-hive, andbreaks down in the centre. Epithelioma may develop anywhere on the bodyin relation to long-standing ulcers, especially that resulting from aburn or from lupus; this form usually presents an exuberant outgrowth ofepidermis not unlike a cauliflower. An interesting example ofepithelioma has been described by Neve of Kashmir. The natives in thatprovince are in the habit of carrying a fire-basket suspended from thewaist, which often burns the skin and causes a chronic ulcer, and manyof 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 inthose who follow certain occupations, such as paraffin workers andchimney-sweeps. The most recent member of this group is the _X-raycarcinoma_, which is met with in those who are constantly exposed to theirritation of the X-rays; there is first a chronic dermatitis with wartyovergrowth of the surface epithelium, pigmentation, and the formation offissures and warts. The trade epithelioma varies a good deal inmalignancy, but it tends to cause death in the same manner as otherepitheliomas. Epithelial cancer has also been observed in those who have taken arsenicover long periods for medicinal purposes. [Illustration: FIG.  102. --Rodent Cancer of Inner Canthus. ] #Rodent Cancer# (Rodent Ulcer). --This is a cancer originating in thesweat glands or sebaceous follicles, or in the fœtal residues ofcutaneous glands. The cells are small and closely packed together inalveoli or in reticulated columns; cell nests are rare. It is remarkablyconstant in its seat of origin, being nearly always located on thelateral 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 smallflattened nodule in the skin, the epidermis over it being stretched andshining. The centre becomes depressed, while the margins extend in theform of an elevated ridge. Sooner or later the epidermis gives way inthe 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 awell-defined "rolled" border which consists of the peripheral portion ofthe cancer that has not broken down. The central ulcer may temporarilyheal. There is itching but little pain, and the condition progressesextremely slowly; rodent cancers which have existed for many years arefrequently met with. The disease attacks and destroys every structurewith which it comes in contact, such as the eyelids, the walls of thenasal cavities, and the bones of the face; hence it may produce the mosthideous deformities (Fig. 103). The patient may succumb to hæmorrhage orto infective complications such as erysipelas or meningitis. Secondary growths in the lymph glands, while not unknown, are extremelyrare. We have only seen them once--in a case of rodent cancer in thegroin. _Diagnosis. _--Lupus is the disease most often mistaken for rodentcancer. Lupus usually begins earlier in life, it presents apple-jellynodules, and lacks the rounded, elevated border. Syphilitic lesionsprogress more rapidly, and also lack the characteristic margin. Thedifferentiation from squamous epithelioma is of considerable importance, as the latter affection spreads more rapidly, involves the lymph glandsearly, and is much more dangerous to life. _Treatment. _--In rodent cancers of limited size--say less than one inchin diameter--free excision is the most rapid and certain method oftreatment. The alternative is the application of radium or of theRöntgen rays, which, although requiring many exposures, results in curewith the minimum of disfigurement. If the cancer already covers anextensive area, or has invaded the cavity of the orbit or nose, radiumor X-rays yield the best results. The effect is soon shown by theingrowth of healthy epithelium from the surrounding skin, and at thesame time the discharge is lessened. Good results are also reported fromthe application of carbon dioxide snow, especially when this followsupon a course of X-ray treatment. #Paget's disease# of the nipple is an epithelioma occurring in womenover forty years of age: a similar form of epithelioma is sometimes metwith at the umbilicus or on the genitals. #Melanotic Cancer. #--Under this head are included all new growths whichcontain an excess of melanin pigment. Many of these were formerlydescribed as melanotic sarcoma. They nearly always originate in apigmented mole which has been subjected to irritation. The primarygrowth may remain so small that its presence is not even suspected, orit may increase in size, ulcerate, and fungate. The amount of pigmentvaries: when small in amount the growth is brown, when abundant it is adeep black. The most remarkable feature is the rapidity with which thedisease becomes disseminated along the lymphatics, the first evidence ofwhich is an enlargement of the lymph glands. As the primary growth isoften situated on the sole of the foot or in the matrix of the nail ofthe great toe, the femoral and inguinal glands become enlarged insuccession, 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 thisusually occurs at a comparatively early stage. The secondary growths aredeeply pigmented, being usually of a coal-black colour, and melaninpigment may be present in the urine. When recurrence takes place in ornear the scar left by the operation, the cancer nodules are notnecessarily pigmented. [Illustration: FIG.  104. --Diffuse Melanotic Cancer of Lymphatics of Skinsecondary to a Growth in the Sole of the Foot. ] To extirpate the disease it is necessary to excise the tumour, with azone of healthy skin around it and a somewhat large zone of theunderlying subcutaneous tissue and deep fascia. Hogarth Pringlerecommends that a broad strip of subcutaneous fascia up to and includingthe nearest anatomical group of glands should be removed with the tumourin one continuous piece. #Secondary Cancer of the Skin. #--Cancer may spread to the skin from asubjacent growth by direct continuity or by way of the lymphatics. Bothof these processes are so well illustrated in cases of mammary cancerthat they will be described in relation to that disease. #Sarcoma# of various types is met with in the skin. The fibroma, afterexcision, may recur as a fibro-sarcoma. The alveolar sarcoma commencesas a hard lump and increases in size until the epidermis gives way andan ulcer is formed. [Illustration: FIG.  105. --Melanotic Cancer of Forehead with Metastasesin 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 noduleswhich tend to become confluent. Excision, unless performed early, is oflittle avail, and in any case should be followed up by exposure toradium. AFFECTIONS OF CICATRICES A cicatrix or scar consists of closely packed bundles of white fibrescovered by epidermis; the skin glands and hair follicles are usuallyabsent. The size, shape, and level of the cicatrix depend upon theconditions which preceded healing. A healthy scar, when recently formed, has a smooth, glossy surface of apinkish colour, which tends to become whiter as a result of obliterationof the blood vessels concerned in its formation. _Weak Scars. _--A scar is said to be weak when it readily breaks down asa result of irritation or pressure. The scars resulting from severeburns and those over amputation stumps are especially liable to breakdown from trivial causes. The treatment is to excise the weak portion ofthe scar and bring the edges of the gap together. _Contracted scars_ frequently cause deformity either by displacingparts, such as the eyelid or lip, or by fixing parts and preventing thenormal movements--for example, a scar on the flexor aspect of a jointmay prevent extension of the forearm (Fig. 63). These are treated bydividing the scar, correcting the deformity, and filling up the gap withepithelial grafts, or with a flap of the whole thickness of the skin. When deformity results from _depression of a scar_, as is not uncommonafter the healing of a sinus, the treatment is to excise the scar. Depressed scars may be raised by the injection of paraffin into thesubcutaneous tissue. _Painful Scars. _--Pain in relation to a scar is usually due to nervefibres being compressed or stretched in the cicatricial tissue; and insome cases to ascending neuritis. The treatment consists in excising thescar or in stretching or excising a portion of the nerve affected. _Pigmented or Discoloured Scars. _--The best-known examples are the bluecoloration which results from coal-dust or gunpowder, the brown scarsresulting from chronic ulcer with venous congestion of the leg, and thevariously coloured scars caused by tattooing. The only satisfactorymethod of getting rid of the coloration is to excise the scar; the edgesare brought together by sutures, or the raw surface is covered withskin-grafts according to the size of the gap. _Hypertrophied Scars. _--Scars occasionally broaden out and becomeprominent, and on exposed parts this may prove a source ofdisappointment after operations such as those for goitre or tuberculousglands in the neck. There is sometimes considerable improvement fromexposure to the X-rays. _Keloid. _--This term is applied to an overgrowth of scar tissue whichextends beyond the area of the original wound, and the name is derivedfrom the fact that this extension occurs in the form of radiatingprocesses, suggesting the claws of a crab. It is essentially a fibromaor new growth of fibrous tissue, which commences in relation to thewalls of the smaller blood vessels; the bundles of fibrous tissue arefor the most part parallel with the surface, and the epidermis istightly stretched over them. It is more frequent in the negro and inthose who are, or have been, the subjects of tuberculous disease. [Illustration: FIG.  106. --Recurrent Keloid in scar left by operation fortuberculous glands in a girl æt.  7. ] Keloid may attack scars of any kind, such as those resulting fromleech-bites, acne pustules, boils or blisters; those resulting fromoperation or accidental wounds; and the scars resulting from burns, especially when situated over the sternum, appear to be speciallyliable. The scar becomes more and more conspicuous, is elevated abovethe surface, of a pinkish or brownish-pink pink colour, and sends outirregular prolongations around its margins. The patient may complain ofitching and burning, and of great sensitiveness of the scar, even tocontact with the clothing. There is a natural hesitation to excise keloid because of the fear ofits returning in the new scar. The application of radium is, so far aswe know, the only means of preventing such return. The irritationassociated with keloid may be relieved by the application of salicyliccollodion or of salicylic and creosote plaster. _Epithelioma_ is liable to attack scars in old people, especially thosewhich result from burns sustained early in childhood and have neverreally healed. From the absence of lymphatics in scar tissue, thedisease does not spread to the glands until it has invaded the tissuesoutside the scar; the prognosis is therefore better than in epitheliomain general. It should be excised widely; in the lower extremity whenthere is also extensive destruction of tissue from an antecedent chroniculcer or osteomyelitis, it may be better to amputate the limb. AFFECTION OF THE NAILS _Injuries. _--When a nail is contused or crushed, blood is extravasatedbeneath it, and the nail is usually shed, a new one growing in itsplace. A splinter driven underneath the nail causes great pain, and iforganisms are carried in along with it, may give rise to infectivecomplications. The free edge of the nail should be clipped away to allowof the removal of the foreign body and the necessary disinfection. _Trophic Changes. _--The growth of the nails may be interfered with inany disturbance of the general health. In nerve lesions, such as adivided 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 aroundthe nail or of the matrix beneath it. The commonest form of onychia hasalready been referred to with whitlow. There is a superficial varietyresulting from the extension of a purulent blister beneath the naillifting it up from its bed, the pus being visible through the nail. Thenail as well as the raised horny layer of the epidermis should beremoved. A deeper and more troublesome onychia results from infection atthe nail-fold; the infection spreads slowly beneath the fold until itreaches the matrix, and a drop or two of pus forms beneath the nail, usually in the region of the lunule. This affection entails adisability of the finger which may last for weeks unless it is properlytreated. Treatment by hyperæmia, using a suction bell, should first betried, and, failing improvement, the nail-fold and lunule should befrozen, and a considerable portion removed with the knife; if only asmall portion of the nail is removed, the opening is blocked bygranulations springing from the matrix. A new nail is formed, but it isliable to be misshapen. _Tuberculous onychia_ is met with in children and adolescents. Itappears as a livid or red swelling at the root of the nail and spreadingaround its margins. The epidermis, which is thin and shiny, gives way, and the nail is usually shed. [Illustration: FIG.  107. --Subungual Exostosis growing from DistalPhalanx of Great Toe, showing Ulceration of Skin and Displacement ofNail. _a. _ Surface view. _b. _ On section. ] _Syphilitic_ affections of the nails assume various aspects. A primarychancre at the edge of the nail may be mistaken for a whitlow, especially if it is attended with much pain. Other forms of onychiaoccur during secondary syphilis simultaneously with the skin eruptions, and may prove obstinate and lead to shedding of the nails. They alsooccur in inherited syphilis. In addition to general treatment, anointment containing 5 per cent. Of oleate of mercury should be appliedlocally. _Ingrowing Toe-nail. _--This is more accurately described as anovergrowth of the soft tissues along the edge of the nail. It is mostfrequently met with in the great toe in young adults with flat-footwhose feet perspire freely, who wear ill-fitting shoes, and who cuttheir toe-nails carelessly or tear them with their fingers. Where thesoft tissues are pressed against the edge of the nail, the skin givesway and there is the formation of exuberant granulations and ofdischarge which is sometimes fœtid. The affection is a painful one andmay unfit the patient for work. In mild cases the condition may beremedied by getting rid of contributing causes and by disinfecting theskin and nail; the nail is cut evenly, and the groove between it and theskin packed with an antiseptic dusting-powder, such as boracic acid. Inmore severe cases it may be necessary to remove an ellipse of tissueconsisting of the edge of the nail, together with the subjacent matrixand the redundant nail-fold. _Subungual exostosis_ is an osteoma growing from the terminal phalanx ofthe great toe (Fig. 107). It raises the nail and may be accompanied byulceration of the skin over the most prominent part of the growth. Thesoft parts, including the nail, should be reflected towards the dorsumin the form of a flap, the base of the exostosis divided with thechisel, and the exostosis removed. _Malignant disease_ in relation to the nails is rare. Squamousepithelioma and melanotic cancer are the forms met with. Treatmentconsists in amputating the digit concerned, and in removing theassociated 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 bruisingof its fibres and blood vessels, may be due to violence acting fromwithout, as in a blow, a kick, or a fall; or from within, as by thedisplacement of bone in a fracture or dislocation. The symptoms are those common to all contusions, and the patientcomplains of severe pain on attempting to use the muscle, and maintainsan attitude which relaxes it. If the sheath of the muscle also is torn, there is subcutaneous ecchymosis, and the accumulation of blood mayresult in the formation of a hæmatoma. Restoration of function is usually complete; but when the nervesupplying the muscle is bruised at the same time, as may occur in thedeltoid, wasting and loss of function may be persistent. In exceptionalcases the process of repair may be attended with the formation of bonein the substance of the muscle, and this may likewise impair itsfunction. A contused muscle should be placed at rest and supported by cotton wooland a bandage; after an interval, massage and appropriate exercises areemployed. #Sprain and Partial Rupture of Muscle. #--This lesion consists inoverstretching and partial rupture of the fibres of a muscle or itsaponeurosis. It is of common occurrence in athletes and in those whofollow laborious occupations. It may follow upon a single or repeatedeffort--especially in those who are out of training. Familiar examplesof muscular sprain are the "labourer's" or "golfer's back, " affectingthe latissimus dorsi or the sacrospinalis (erector spinæ); the"tennis-player's elbow, " and the "sculler's sprain, " affecting themuscles and ligaments about the elbow; the "angler's elbow, " affectingthe common origin of the extensors and supinators; the "sprinter'ssprain, " affecting the flexors of the hip; and the "jumper's anddancer's sprain, " affecting the muscles of the calf. The patientcomplains of pain, often sudden in onset, of tenderness on pressure, andof inability to carry out the particular movement by which the sprainwas produced. The disability varies in different cases, and it mayincapacitate the patient from following his occupation or sport forweeks or, if imperfectly treated, even for months. The _treatment_ consists in resting the muscle from the particulareffort concerned in the production of the sprain, in gently exercisingit in other directions, in the use of massage, and the induction ofhyperæmia by means of heat. In neglected cases, that is, where themuscle has not been exercised, the patient shrinks from using it and thedisablement threatens to be permanent; it is sometimes said thatadhesions have formed and that these interfere with the recovery offunction. The condition may be overcome by graduated movements or by asudden forcible movement under an anæsthetic. These cases afford afruitful field for the bone-setter. #Rupture of Muscle or Tendon. #--A muscle or a tendon may be ruptured inits continuity or torn from its attachment to bone. The site of rupturein individual muscles is remarkably constant, and is usually at thejunction of the muscular and tendinous portions. When rupture takesplace through the belly of a muscle, the ends retract, the amount ofretraction depending on the length of the muscle, and the extent of itsattachment to adjacent aponeurosis or bone. The biceps in the arm, andthe sartorius in the thigh, furnish examples of muscles in which theseparation between the ends may be considerable. The gap in the muscle becomes filled with blood, and this in time isreplaced by connective tissue, which forms a bond of union between theends. When the space is considerable the connecting medium consists offibrous tissue, but when the ends are in contact it contains a number ofnewly formed muscle fibres. In the process of repair, one or both endsof the muscle or tendon may become fixed by adhesions to adjacentstructures, and if the distal portion of a muscle is deprived of itsnerve supply it may undergo degeneration and so have its functionimpaired. Rupture of a muscle or tendon is usually the result of a sudden, andoften involuntary, movement. As examples may be cited the rupture ofthe quadriceps extensor in attempting to regain the balance when fallingbackwards; of the gastrocnemius, plantaris, or tendo-calcaneus injumping or dancing; of the adductors of the thigh in gripping a horsewhen it swerves--"rider's sprain"; of the abdominal muscles in vomiting, and of the biceps in sudden movements of the arm. Sometimes the effortis one that would scarcely be thought likely to rupture a muscle, as inthe case recorded by Pagenstecher, where a professional athlete, whilesitting at table, ruptured his biceps in a sudden effort to catch afalling glass. It would appear that the rupture is brought about not somuch by the contraction of the muscle concerned, as by the contractionof the antagonistic muscles taking place before that of the muscle whichundergoes rupture is completed. The violent muscular contractions ofepilepsy, tetanus, or delirium rarely cause rupture. The _clinical features_ are usually characteristic. The patientexperiences a sudden pain, with the sensation of being struck with awhip, and of something giving way; sometimes a distant snap is heard. The limb becomes powerless. At the seat of rupture there is tendernessand swelling, and there may be ecchymosis. As the swelling subsides, agap may be felt between the retracted ends, and this becomes wider whenthe muscle is thrown into contraction. If untreated, a hard, fibrouscord remains at the seat of rupture. _Treatment. _--The ends are approximated by placing the limb in anattitude which relaxes the muscle, and the position is maintained bybandages, splints, or special apparatus. When it is impossible thus toapproximate the ends satisfactorily, the muscle or tendon is exposed byincision, 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 theaccident. Secondary suture after an interval of months is rendereddifficult by the retraction of the ends and by their adhesion toadjacent structures. _Rupture of the biceps of the arm_ may involve the long or the shorthead, or the belly of the muscle. Most interest attaches to rupture ofthe long tendon of origin. There is pain and tenderness in front of theupper end of the humerus, the patient is unable to abduct or to elevatethe arm, and he may be unable to flex the elbow when the forearm issupinated. The long axis of the muscle, instead of being parallel withthe humerus, inclines downwards and outwards. When the patient is askedto contract the muscle, its belly is seen to be drawn towards theelbow. The _adductor longus_ may be ruptured, or torn from the pubes, by aviolent effort to adduct the limb. A swelling forms in the upper andmedial part of the thigh, which becomes smaller and harder when themuscle is thrown into contraction. The _quadriceps femoris_ is usually ruptured close to its insertion intothe patella, in the attempt to avoid falling backwards. The injury issometimes bilateral. The injured limb is rendered useless forprogression, as it suddenly gives way whenever the knee is flexed. Treatment is conducted on the same lines as in transverse fracture ofthe patella; in the majority of cases the continuity of the quadricepsshould be re-established by suture within five or six days of theaccident. The _tendo calcaneus_ (Achillis) is comparatively easily ruptured, andthe symptoms are sometimes so slight that the nature of the injury maybe overlooked. The limb should be put up with the knee flexed and thetoes pointed. This may be effected by attaching one end of an elasticband to the heel of a slipper, and securing the other to the lower thirdof the thigh. If this is not sufficient to bring the ends intoapposition they should be approximated by an open operation. The _plantaris_ is not infrequently ruptured from trivial causes, suchas a sudden movement in boxing, tennis, or hockey. A sharp stinging painlike the stroke of a whip is felt in the calf; there is markedtenderness at the seat of rupture, and the patient is unable to raisethe heel without pain. The injury is of little importance, and if thepatient does not raise the heel from the ground in walking, it isrecovered from in a couple of weeks or so, without it being necessary tolay him up. #Hernia of Muscle. #--This is a rare condition, in which, owing to thefascia covering a muscle becoming stretched or torn, the muscularsubstance is protruded through the rent. It has been observed chiefly inthe adductor longus. An oval swelling forms in the upper part of thethigh, is soft and prominent when the muscle is relaxed, less prominentwhen it is passively extended, and disappears when the muscle is throwninto contraction. It is liable to be mistaken, according to itssituation, for a tumour, a cyst, a pouched vein, or a femoral orobturator hernia. Treatment is only called for when it is causinginconvenience, the muscle being exposed by a suitable incision, theherniated portion excised, and the rent in the sheath closed by sutures. #Dislocation of Tendons. #--Tendons which run in grooves may be displacedas a result of rupture of the confining sheath. This injury is met withchiefly in the tendons at the ankle and in the long tendon of thebiceps. Dislocation of the _peronei tendons_ may occur, for example, from aviolent twist of the foot. There is severe pain and considerableswelling on the lateral aspect of the ankle; the peroneus longus byitself, or together with the brevis, can be felt on the lateral aspector in front of the lateral malleolus; the patient is unable to move thefoot. By a little manipulation the tendons are replaced in theirgrooves, and are retained there by a series of strips of plaster. At theend of three weeks massage and exercises are employed. In other cases there is no history of injury, but whenever the foot iseverted the tendon of the peroneus longus is liable to be jerkedforwards out of its groove, sometimes with an audible snap. The patientsuffers pain and is disabled until the tendon is replaced. Reduction iseasy, but as the displacement tends to recur, an operation is requiredto fix the tendon in its place. An incision is made over the tendon; ifthe sheath is slack or torn, it is tightened up or closed with catgutsutures; or an artificial sheath is made by raising up a quadrilateralflap of periosteum from the lateral aspect of the fibula, and stitchingit over the tendon. Similarly the _tibialis posterior_ may be displaced over the medialmalleolus as a result of inversion of the foot. The _long tendon of the biceps_ may be dislocated laterally--or morefrequently medially--as a result of violent or repeated rotationmovements of the arm, such as are performed in wringing clothes. Thepatient is aware of the displacement taking place, and is unable toextend the forearm until the displaced tendon has been reduced byabducting the arm. In recurrent cases the patient may be able todislocate the tendon at will, but the disability is so inconsiderablethat there is rarely any occasion for interference. #Wounds of Muscles and Tendons. #--When a muscle is cut across in awound, its ends should be brought together with sutures. If the ends areallowed to retract, and especially if the wound suppurates, they becomeunited by scar tissue and fixed to bone or other adjacent structure. Ina limb this interferes with the functions of the muscle; in theabdominal wall the scar tissue may stretch, and so favour thedevelopment of a ventral hernia. Tendons may be cut across accidentally, especially in those wounds socommonly met with above the wrist as a result, for example, of the handbeing thrust through a pane of glass. It is essential that the endsshould be sutured to each other, and as the proximal end is retractedthe original wound may require to be enlarged in an upward direction. When primary suture has been omitted, or has failed in consequence ofsuppuration, the separated ends of the tendon become adherent toadjacent structures, and the function of the associated muscle isimpaired or lost. Under these conditions the operation of secondarysuture is indicated. A free incision is necessary to discover and isolate the ends of thetendon; if the interval is too wide to admit of their being approximatedby sutures, means must be taken to lengthen the tendon, or one from someother part may be inserted in the gap. A new sheath may be provided forthe tendon by resecting a portion of the great saphenous vein. _Injuries of the tendons of the fingers_ are comparatively common. Oneof the best known is the partial or complete rupture of the aponeurosisof the extensor tendon close to its insertion into the terminalphalanx--_drop-_ or _mallet-finger_. This may result from comparativelyslight violence, such as striking the tip of the extended finger againstan object, or the violence may be more severe, as in attempting to catcha cricket ball or in falling. The terminal phalanx is flexed towards thepalm and the patient is unable to extend it. The treatment consists inputting up the finger with the middle joint strongly flexed. Inneglected cases, a perfect functional result can only be obtained byoperation; under a local anæsthetic, the ruptured tendon is exposed andis sutured to the base of the phalanx, which may be drilled for thepassage of the sutures. _Subcutaneous rupture_ of one or other _of the digital tendons_ in thehand or at the wrist can be remedied only by operation. When some timehas elapsed since the accident, the proximal end may be so retractedthat it cannot be brought down into contact with the distal end, inwhich case a slip may be taken from an adjacent tendon; in the case ofone of the extensors of the thumb, the extensor carpi radialis longusmay be detached from its insertion and stitched to the distal end of thetendon of the thumb. Subcutaneous _rupture of the tendon of the extensor pollicis longus_ atthe wrist takes place just after its emergence from beneath the annularligament; the actual rupture may occur painlessly, more frequently asharp pain is felt over the back of the wrist. The prominence of thetendon, which normally forms the ulnar border of the snuff-box, disappears. This lesion is chiefly met with in drummer-boys and is thecause of drummer's palsy. The only chance of restoring function is inuniting the ruptured tendon by open operation. [Illustration: FIG.  108. --Avulsion of Tendon with Terminal Phalanx ofThumb. (Surgical Museum, University of Edinburgh. )] _Avulsion of Tendons. _--This is a rare injury, in which the tendons of afinger or toe are torn from their attachments along with a portion ofthe digit concerned. In the hand, it is usually brought about by thefingers being caught in the reins of a runaway horse, or being seized ina horse's teeth, or in machinery. It is usually the terminal phalanxthat is separated, and with it the tendon of the deep flexor, whichruptures at its junction with the belly of the muscle (Fig. 108). Thetreatment 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 inassociation with other deformities. The pectoralis major, for example, may be absent on one or on both sides, without, however, causing anydisability, as other muscles enlarge and take on its functions. _Atrophy of Muscle. _--Simple atrophy, in which the muscle elements aremerely diminished in size without undergoing any structural alteration, is commonly met with as a result of disuse, as when a patient isconfined to bed for a long period. In cases of joint disease, the muscles acting on the joint becomeatrophied more rapidly than is accounted for by disuse alone, and thisis attributed to an interference with the trophic innervation of themuscles reflected from centres in the spinal medulla. It is more markedin the extensor than in the flexor groups of muscles. Those affectedbecome soft and flaccid, exhibit tremors on attempted movement, andtheir 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, probablybecause vaso-motor and trophic fibres are involved as well as those thatare purely motor in function. It is attended with definite structuralalterations, the muscle elements first undergoing fatty degeneration, and then being absorbed, and replaced to a large extent by ordinaryconnective tissue and fat. At a certain stage the muscles exhibit thereaction of degeneration. In the common form of paralysis resulting frompoliomyelitis, many fibres undergo fatty degeneration and are replacedby fat, while at the same time there is a regeneration of muscle fibres. #Fibrositis# or "#Muscular Rheumatism#. "--This clinical term is appliedto a group of affections of which lumbago is the best-known example. Thegroup includes lumbago, stiff-neck, and pleurodynia--conditions whichhave this in common, that sudden and severe pain is excited by movementof the affected part. The lesion consists in inflammatory hyperplasia ofthe connective tissue; the new tissue differs from normal fibrous tissuein its tendency to contract, in being swollen, painful and tender onpressure, and in the fact that it can be massaged away (Stockman). Itwould appear to involve mainly the fibrous tissue of muscles, althoughit may extend from this to aponeuroses, ligaments, periosteum, and thesheaths of nerves. The term _fibrositis_ was applied to it by Gowers in1904. In _lumbago_--_lumbo-sacral fibrositis_--the pain is usually locatedover the sacrum, the sacro-iliac joint, or the aponeurosis of the lumbarmuscles on one or both sides. The amount of tenderness varies, and solong as the patient is still he is free from pain. The slightestattempt to alter his position, however, is attended by pain, which maybe so severe as to render him helpless for the moment. The pain is mostmarked on rising from the stooping or sitting posture, and may extenddown the back of the hip, especially if, as is commonly the case, lumbago and gluteal fibrosis coexist. Once a patient has suffered fromlumbago, it is liable to recur, and an attack may be determined byerrors of diet, changes of weather, exposure to cold or unwontedexertion. It is met with chiefly in male adults, and is most apt tooccur in those who are gouty or are the subjects of oxaluric dyspepsia. _Gluteal fibrositis_ usually follows exposure to wet, and affects thegluteal muscles, particularly the medius, and their aponeuroticcoverings. When the condition has lasted for some time, induratedstrands or nodules can be detected on palpating the relaxed muscles. Thepatient complains of persistent aching and stiffness over the buttock, and sometimes extending down the lateral aspect of the thigh. The painis aggravated by such movements as bring the affected muscles intoaction. It is not referred to the line of the sciatic nerve, nor isthere tenderness on pressing over the nerve, or sensations of tinglingor numbness in the leg or foot. If untreated, the morbid process may implicate the sheath of the sciaticnerve and cause genuine sciatic neuralgia (Llewellyn and Jones). Asimilar condition may implicate the fascia lata of the thigh, or thecalf muscles and their aponeuroses--_crural fibrositis_. In _painful stiff-neck_, or "rheumatic torticollis, " the pain is locatedin 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 patientcontracting the sterno-mastoid. There may be tenderness over thevertebral spines or in the lines of the cervical nerves, and thesterno-mastoid may undergo atrophy. This affection is more often metwith in children. In _pleurodynia_--_intercostal fibrositis_--the pain is in the line ofthe intercostal nerves, and is excited by movement of the chest, as incoughing, or by any bodily exertion. There is often marked tenderness. A similar affection is met with in the _shoulder and arm_--_brachialfibrositis_--especially on waking from sleep. There is acute pain onattempting to abduct the arm, and there may be localised tenderness inthe region of the axillary nerve. _Treatment. _--The general treatment is concerned with the diet, attention to the stomach, bowels, and kidneys and with the correctionof any gouty tendencies that may be present. Remedies such assalicylates are given for the relief of pain, and for this purpose drugsof the aspirin type are to be preferred, and these may be followed bylarge doses of iodide of potassium. Great benefit is derived frommassage, and from the induction of hyperæmia by means of heat. Cuppingor needling, or, in exceptional cases, hypodermic injections ofantipyrin or morphin, may be called for. To prevent relapses of lumbago, the patient must take systematic exercises of all kinds, especially suchas bring out the movements of the vertebral column and hip-joints. [Illustration: FIG.  109. --Volkmann's Ischæmic Contracture. When thewrist 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 fromthe prolonged approximation of their points of attachment, or fromstructural changes in their substance produced by injury or by disease. It is a frequent accompaniment and sometimes a cause of deformities, inthe treatment of which lengthening of the shortened muscles or theirtendons may be an essential step. #Myositis. #--_Ischæmic Myositis. _--Volkmann was the first to describe aform of myositis followed by contracture, resulting from interferencewith the arterial blood supply. It is most frequently observed in theflexor muscles of the forearm in children and young persons undertreatment for fractures in the region of the elbow, the splints andbandages causing compression of the blood vessels. There is considerableeffusion of blood, the skin is tense, and the muscles, vessels, andnerves are compressed; this is further increased if the elbow is flexedand splints and tight bandages are applied. The muscles acquire aboard-like hardness and no longer contract under the will, and passivemotion is painful and restricted. Slight contracture of the fingers isusually the first sign of the malady; in time the muscles undergofurther contraction, and this brings about a claw-like deformity of thehand. The affected muscles usually show the reaction of degeneration. Insevere cases the median and ulnar nerves are also the seat ofcicatricial changes (ischæmic neuritis). By means of splints, the interphalangeal, metacarpo-phalangeal, andwrist joints should be gradually extended until the deformity isover-corrected (R.  Jones). Murphy advises resection of the radius andulna sufficient to admit of dorsiflexion of the joints and lengtheningof the flexor tendons. Various forms of _pyogenic_ infection are met with in muscle, mostfrequently in relation to pyæmia and to typhoid fever. These may resultin overgrowth of the connective-tissue framework of the muscle anddegeneration of its fibres, or in suppuration and the formation of oneor more abscesses in the muscle substance. Repair may be associated withcontracture. A _gonorrhœal_ 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 seatof dull, aching, nocturnal pains, especially in the neck and back. _Syphilitic contracture_ is a condition which has been observed chieflyin the later secondary period; the biceps of the arm and the hamstringsin the thigh are the muscles more commonly affected. The strikingfeature is a gradually increasing difficulty of extending the limb atthe elbow or knee, and progressive flexion of the joint. The affectedmuscle is larger and firmer than normal, and its electric excitabilityis diminished. In tertiary syphilis, individual muscles may become theseat of interstitial myositis or of gummata, and these affectionsreadily yield to anti-syphilitic remedies. _Tuberculous disease_ in muscle, while usually due to extension fromadjacent tissues, is sometimes the result of a primary infection throughthe blood-stream. Tuberculous nodules are found disseminated throughoutthe muscle; the surrounding tissues are indurated, and central caseationmay take place and lead to abscess formation and sinuses. We haveobserved this form of tuberculous disease in the gastrocnemius and inthe psoas--in the latter muscle apart from tuberculous disease in thevertebræ. #Tendinitis. #--German authors describe an inflammation of tendon asdistinguished from inflammation of its sheath, and give it the nametendinitis. It is met with most frequently in the tendo-calcaneus ingouty and rheumatic subjects who have overstrained the tendon, especially during cold and damp weather. There is localised pain whichis aggravated by walking, and the tendon is sensitive and swollen from alittle above its insertion to its junction with the muscle. Goutynodules may form in its substance. Constitutional measures, massage, anddouching should be employed, and the tendon should be protected fromstrain. #Calcification and Ossification in Muscles, Tendons, andFasciæ. #--_Myositis ossificans. _--Ossifications in muscles, tendons, fasciæ, and ligaments, in those who are the subjects of arthritisdeformans, are seldom recognised clinically, but are frequently met within dissecting-rooms and museums. Similar localised ossifications are metwith in Charcot's disease of joints, and in fractures which haverepaired with exuberant callus. The new bone may be in the form ofspicules, plates, or irregular masses, which, when connected with abone, are called _false exostoses_ (Fig. 110). [Illustration: FIG.  110. --Ossification in Tendon of Ilio-psoas Muscle. ] _Traumatic Ossification in Relation to Muscle. _--Various forms ofossification are met with in muscle as the result of a single or ofrepeated injury. Ossification in the crureus or vastus lateralis musclehas been frequently observed as a result of a kick from a horse. Withina week or two a swelling appears at the site of injury, and becomesprogressively harder until its consistence is that of bone. If the massof new bone moves with the affected muscle, it causes littleinconvenience. If, as is commonly the case, it is fixed to the femur, the action of the muscle is impaired, and the patient complains of painand difficulty in flexing the knee. A skiagram shows the extent of themass and its relationship to the femur. The treatment consists inexcising the bony mass. Difficulty may arise in differentiating such a mass of bone fromsarcoma; the ossification in muscle is uniformly hard, while the sarcomavaries in consistence at different parts, and the X-ray picture shows aclear outline of the bone in the vicinity of the ossification inmuscle, whereas in sarcoma the involvement of the bone is shown byindentations and irregularity in its contour. A similar ossification has been observed in relation to the insertion ofthe brachialis muscle as a sequel of dislocation of the elbow. Afterreduction of the dislocation, the range of movement gradually diminishesand 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 thedisability becomes complete. A radiogram shows a shadow in the muscle, attached at one part as a rule to the coronoid process. During the nextthree or four months, the lump in front of the elbow remains stationaryin size; a gradual decrease then ensues, but the swelling persists, as arule, for several years. [Illustration: FIG.  111. --Calcification and Ossification in Biceps andTriceps. (From a radiogram lent by Dr. C.  A.  Adair Dighton. )] Ossification in the adductor longus was first described by Billrothunder the name of "rider's bone. " It follows bruising and partialrupture of the muscle, and has been observed chiefly in cavalrysoldiers. If it causes inconvenience the bone may be removed byoperation. Ossification in the deltoid and pectoral muscles has been observed infoot-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 therifle. _Progressive Ossifying Myositis. _--This is a rare and interestingdisease, in which the muscles, tendons, and fasciæ throughout the bodybecome the seat of ossification. It affects almost exclusively the malesex, and usually begins in childhood or youth, sometimes after aninjury, 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 ofgeneralised Ossifying Myositis. (Photograph lent by Dr. Rustomjee. )] The affected muscles show swellings which are rounded or oval, firm andelastic, sharply defined, without tenderness and without discolorationof the overlying skin. Skiagrams show that a considerable deposit oflime salts may precede the formation of bone, as is seen in Fig. 111. Incourse of time the vertebral column becomes rigid, the head is bentforward, the hips are flexed, and abduction and other movements of thearms are limited. The disease progresses by fits and starts, until allthe striped muscles of the body are replaced by bone, and all movements, even those of the jaws, are abolished. The subjects of this diseaseusually succumb to pulmonary tuberculosis. There is no means of arresting the disease, and surgical treatment isrestricted to the removal or division of any mass of bone thatinterferes with an important movement. A remarkable feature of this disease is the frequent presence of adeformity of the great toe, which usually takes the form of halluxvalgus, the great toe coming to lie beneath the second one; theshortening is usually ascribed to absence of the first phalanx, but ithas been shown to depend also on a synostosis and imperfect developmentof the phalanges. A similar deformity of the thumb is sometimes metwith. Microscopical examination of the muscles shows that, prior to thedeposition of lime salts and the formation of bone, there occurs aproliferation of the intra-muscular connective tissue and a gradualreplacement and absorption of the muscle fibres. The bone is spongy incharacter, and its development takes place along similar lines to thoseobserved in ossification from the periosteum. #Tumours of Muscle. #--With the exception of congenital varieties, suchas the rhabdomyoma, tumours of muscle grow from the connective-tissueframework and not from the muscle fibres. Innocent tumours, such as thefibroma, lipoma, angioma, and neuro-fibroma, are rare. Malignant tumoursmay be primary in the muscle, or may result from extension from adjacentgrowths--for example, implication of the pectoral muscle in cancer ofthe breast--or they may be derived from tumours situated elsewhere. Thediagnosis of an intra-muscular tumour is made by observing that theswelling is situated beneath the deep fascia, that it becomes firm andfixed when the muscle contracts, and that, when the muscle is relaxed, it becomes softer, and can be moved in the transverse axis of themuscle, but not in its long axis. Clinical interest attaches to that form of slowly growingfibro-sarcoma--_the recurrent fibroid of Paget_--which is mostfrequently met with in the muscles of the abdominal wall. A rarervariety is the ossifying chondro-sarcoma, which undergoes ossificationto such an extent as to be visible in skiagrams. In primary sarcoma the treatment consists in removing the muscle. In thelimbs, the function of the muscle that is removed may be retained bytransplanting 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 synovialmembranes of joints, and are liable to the same diseases. Apart from thetendon sheaths displayed in anatomical dissections, there is a looseperitendinous and perimuscular cellular tissue which is subject to thesame pathological conditions as the tendon sheaths proper. #Teno-synovitis. #--The toxic or infective agent is conveyed to thetendon sheaths through the blood-stream, as in the gouty, gonorrhœal, and tuberculous varieties, or is introduced directly through a wound, asin the common pyogenic form of teno-synovitis. _Teno-synovitis Crepitans. _--In the simple or traumatic form ofteno-synovitis, although the most prominent etiological factor is astrain or over-use of the tendon, there would appear to be some other, probably a toxic, factor in its production, otherwise the affectionwould be much more common than it is: only a small proportion of thosewho strain or over-use their tendons become the subjects ofteno-synovitis. The opposed surfaces of the tendon and its sheath arecovered with fibrinous lymph, so that there is friction when they moveon one another. The _clinical features_ are pain on movement, tenderness on pressureover the affected tendon, and a sensation of crepitation or frictionwhen the tendon is moved in its sheath. The crepitation may be soft likethe friction of snow, or may resemble the creaking of newleather--"saddle-back creaking. " There may be swelling in the long axisof the tendon, and redness and œdema of the skin. If there is aneffusion of fluid into the sheath, the swelling is more marked andcrepitation is absent. There is little tendency to the formation ofadhesions. In the upper extremity, the sheath of the long tendon of the biceps maybe affected, but the condition is most common in the tendons about thewrist, particularly in the extensors of the thumb, and it is mostfrequently met with in those who follow occupations which involveprolonged use or excessive straining of these tendons--for example, washerwomen or riveters. It also occurs as a result of excessivepiano-playing, fencing, or rowing. At the ankle it affects the peronei, the extensor digitorum longus, orthe tibialis anterior. It is most often met with in relation to thetendo-calcaneus--_Achillo-dynia_--and results from the pressure ofill-fitting boots or from the excessive use and strain of the tendon incycling, walking, or dancing. There is pain in raising the heel from theground, and creaking can be felt on palpation. The _treatment_ consists in putting the affected tendon at rest, andwith this object a splint may be helpful; the usual remedies forinflammation are indicated: Bier's hyperæmia, lead and opiumfomentations, and ichthyol and glycerine. The affection readily subsidesunder treatment, but is liable to relapse on a repetition of theexciting cause. _Gouty Teno-synovitis. _--A deposit of urate of soda beneath theendothelial covering of tendons or of that lining their sheaths iscommonly met with in gouty subjects. The accumulation of urates mayresult in the formation of visible nodular swellings, varying in sizefrom a pea to a cherry, attached to the tendon and moving with it. Theymay be merely unsightly, or they may interfere with the use of thetendon. Recurrent attacks of inflammation are prone to occur. We haveremoved such gouty masses with satisfactory results. _Suppurative Teno-synovitis. _--This form usually follows upon infectedwounds of the fingers--especially of the thumb or little finger--and isa 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 withcellulitis. In moderately acute cases the tendon and its sheath becomecovered with granulations, which subsequently lead to the formation ofadhesions; while in more acute cases the tendon sloughs. The pus mayburst into the cellular tissue outside the sheath, and the suppurationis liable to spread to neighbouring sheaths or to adjacent bones orjoints--for example, those of the wrist. The _treatment_ consists in inducing hyperæmia and making smallincisions for the escape of pus. The site of incision is determined bythe point of greatest tenderness on pressure. After the inflammation hassubsided, active and passive movements are employed to prevent theformation of adhesions between the tendon and its sheath. If the tendonsloughs, the dead portion should be cut away, as its separation isextremely slow and is attended with prolonged suppuration. _Gonorrhœal Teno-synovitis. _--This is met with especially in the tendonsheaths about the wrist and ankle. It may occur in a mild form, withpain, impairment of movement, and œdema, and sometimes an elongated, fluctuating swelling, the result of serous effusion into the sheath. This condition may alternate with a gonorrhœal affection of one of thelarger joints. It may subside under rest and soothing applications, butis liable to relapse. In the more severe variety the skin is red, andthe swelling partakes of the characters of a phlegmon with threateningsuppuration; it may result in crippling from adhesions. Even if pusforms in the sheath, the tendon rarely sloughs. The treatment consistsin inducing hyperæmia by Bier's method; and a vaccine may be employedwith satisfactory results. #Tuberculous Disease of Tendon Sheaths. #--This is a comparatively commonaffection, and is analogous to tuberculous disease of the synovialmembrane of joints. It may originate in the sheath, or may spread to itfrom an adjacent bone. The commonest form--hydrops--is that in which the synovial sheath isdistended with a viscous fluid, and the fibrinous material on the freesurface becomes detached and is moulded into melon-seed bodies by themovement of the tendon. The sheath itself is thickened by the growth oftuberculous granulation tissue. The bodies are smooth and of adull-white colour, and vary greatly in size and shape. There may be anovergrowth of the fatty fringes of the synovial sheath, a conditiondescribed as "arborescent lipoma. " The _clinical features_ vary with the tendon sheath affected. In thecommon flexor sheath of the hand an hour-glass-shaped swelling isformed, bulging above and below the transverse carpal (anterior annular)ligament--formerly known as _compound palmar ganglion_. There is littleor no pain, but the fingers tend to be stiff and weak, and to becomeflexed. On palpation, it is usually possible to displace the contents ofthe sheath from one compartment to the other, and this may yieldfluctuation, and, what is more characteristic, a peculiar soft crepitantsensation from the movement of the melon-seed bodies. In the sheath ofthe peronei or other tendons about the ankle, the swelling issausage-shaped, and is constricted opposite the annular ligament. The onset and progress of the affection are most insidious, and thecondition may remain stationary for long periods. It is aggravated byuse or strain of the tendons involved. In exceptional cases the skin isthinned and gives way, resulting in the formation of a sinus. _Treatment. _--In the common flexor sheath of the palm, an attempt may bemade to cure the condition by removing the contents through a smallincision and filling the cavity with iodoform glycerine, followed by theuse 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 sheathbecomes the seat of _a diffuse tuberculous thickening_, not unlike thewhite swelling met with in joints, and with a similar tendency tocaseation. A painless swelling of an elastic character forms in relationto the tendon sheath. It is hour-glass-shaped in the common flexorsheath of the palm, elongated or sausage-shaped in the extensors of thewrist and in the tendons at the ankle. The tuberculous granulationtissue is liable to break down and lead to the formation of a coldabscess and sinuses, and in our experience is often associated withdisease in an adjacent bone or joint. In the peronei tendons, forexample, it may result from disease of the fibula or of the ankle-joint. When conservative measures fail, excision of the affected sheath shouldbe performed; the whole of the diseased area being exposed by freeincision of the overlying soft parts, the sheath is carefully isolatedfrom the surrounding tissues and is cut across above and below. Anytuberculous tissue on the tendon itself is removed with a sharp spoon. Associated bone or joint lesions are dealt with at the same time. In theafter-treatment the functions of the tendons must be preserved byvoluntary and passive movements. #Syphilitic Affections of Tendon Sheaths. #--These closely resemble thesyphilitic affections of the synovial membrane of joints. During thesecondary period the lesion usually consists in effusion into thesheath; gummata are met with during the tertiary period. Arborescent lipoma has been found in the sheaths of tendons about thewrist 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 elongatedswelling of slow development, or over the phalanx of a finger as a smallrounded swelling. The tumour tissue, when exposed by dissection, is of achocolate or chamois-yellow colour, and consists almost entirely ofgiant cells. The treatment consists in dissecting the tumour tissue offthe tendons, and this is usually successful in bringing about apermanent cure. All varieties of _sarcoma_ are met with, but their origin from tendonsheaths is not associated with special features. CHAPTER XIX THE BURSÆ Anatomy--Normal and adventitious bursæ--Injuries: Bursal hæmatoma--DISEASES: Infective bursitis; Traumatic or trade bursitis; Bursal hydrops; Solid bursal tumour; Gonorrhœal and suppurative forms of bursitis; Tuberculous and syphilitic disease--Tumours--_Diseases of individual bursæ 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 thepatella, and that between the aponeurosis of the gluteus maximus and thegreat trochanter. _Adventitious bursæ_ are developed as a result ofabnormal pressure--for example, over the tarsal bones in cases ofclub-foot. #Injuries of Bursæ. #--As a result of contusion, especially in bleeders, hæmorrhage may occur into the cavity of a bursa and give rise to a_bursal hæmatoma_. Such a hæmatoma may mask a fracture of the bonebeneath--for example, fracture of the olecranon. #Diseases of Bursæ. #--The lining membrane of bursæ resembles that ofjoints and tendon sheaths, and is liable to the same forms of disease. #Infective bursitis# frequently follows abrasions, scratches, and woundsof the skin over the prepatellar or olecranon bursa, and in neglectedcases the infection transgresses the wall of the bursa and gives rise toa spreading cellulitis. #Traumatic or Trade Bursitis. #--This term may be conveniently applied tothose affections of bursæ which result from repeated slight traumatismincident to particular occupations. The most familiar examples of theseare the enlargement of the prepatellar bursa met with in housemaids--the"housemaid's knee" (Fig. 113); the enlargement of the olecranonbursa--"miner's elbow"; and of the ischial bursa--"weaver's" or"tailor's bottom" (Fig. 116). These affections are characterised by aneffusion of fluid into the sac of the bursa with thickening of itslining membrane. While friction and pressure are the most evidentfactors in their production, it is probable that there is also sometoxic agent concerned, otherwise these affections would be much morecommon than they are. Of the countless housemaids in whom theprepatellar bursa is subjected to friction and pressure, only a smallproportion become the subjects of housemaid's knee. _Clinical Features. _--As these are best illustrated in the differentvarieties of prepatellar bursitis, it is convenient to take this as thetype. In a number of cases the inflammation is acute and the patient isunable to use the limb; the part is hot, swollen, and tender, andfluctuation can be detected in the bursa. In the majority the conditionis chronic, and the chief feature is the gradual accumulation of fluidconstituting the _bursal hydrops_ or _hygroma_. When the affection haslasted some time, or has frequently relapsed, the wall of the bursabecomes thickened by fibrous tissue, which may be deposited irregularly, so that septa, bands, or fringes are formed, not unlike those met within arthritis deformans. These fringes may be detached and form loosebodies like those met with in joints; less frequently there arefibrinous bodies of the melon-seed type, sometimes moulded into circulardiscs like wafers. The presence of irregular thickenings of the wall, orof loose bodies, may be recognised on palpation, especially insuperficial bursæ, if the sac is not tensely filled with fluid. Thethickening of the wall may take place in a uniform and concentricfashion, resulting in the formation of a fibrous tumour--_the solidbursal tumour_--a small cavity remaining in the centre which serves todistinguish 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 theaffection. In recent cases the symptoms subside under rest and theapplication of fomentations. Hydrops may be got rid of by blistering, by tapping, or by incision and drainage. When the wall is thickened, themost satisfactory treatment is to excise the bursa; the overlying skinbeing reflected in the shape of a horse-shoe flap or being removed alongwith the bursa. #Other Diseases of Bursæ# are associated with _gonorrhœal infection_, and with _rheumatism_, especially that following scarlet fever, and areapt 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 mayresult in the formation of chalky tumours, sometimes of considerablesize (Fig. 114). [Illustration: FIG.  114. --Section through Bursa over external malleolus, showing deposit of urate of soda. (Cf. Fig. 117. )] _Tuberculous disease_ of bursæ closely resembles that of tendon sheaths. It may occur as an independent affection, or may be associated withdisease in an adjacent bone or joint. It is met with chiefly in theprepatellar and subdeltoid bursæ, or in one of the bursæ over the greattrochanter. The clinical features are those of an indolent hydrops, withor without melon-seed bodies, or of uniform thickening of the wall ofthe bursa; the tuberculous granulation tissue may break down into a coldabscess, and give rise to sinuses. The best treatment is to excise theaffected bursa, or, when this is impracticable, to lay it freely open, remove the tuberculous tissue with the sharp spoon or knife, and treatthe cavity by the open method. _Syphilitic disease_ is rarely recognised except in the form of bursaland peri-bursal gummata in front of the knee-joint. _New growths_ include the fibroma, the myxoma, the myeloma orgiant-celled tumour, and various forms of sarcoma. #Diseases of Individual Bursæ. #--The _olecranon bursa_ is frequentlythe seat of pyogenic infection and of traumatic or trade bursitis, thelatter 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 asingle cavity and does not normally communicate with the shoulder-joint, is indispensable in abduction and rotation of the humerus. When the armis abducted, the fixed lower part or floor of the bursa is carried underthe acromion, and the upper part or roof is rolled up in the samedirection, hence tenderness over the inflamed bursa may disappear whenthe arm is abducted (Dawbarn's sign). It is liable to traumaticaffections from a fall on the shoulder, pressure, or over-use of thelimb. Pain, located commonly at the insertion of the deltoid, is aconstant symptom and is especially annoying at night, the patient beingunable to get into a comfortable position. Tenderness may be elicitedover the anatomical limits of the bursa, and is usually most marked overthe great tuberosity, just external to the inter-tubercular (bicipital)groove. When adhesions are present, abduction beyond 10 degrees isimpossible. Demonstrable effusion is not uncommon, but is disguised bythe overlying tissues. If left to himself, the patient tends to maintainthe limb in the "sling position, " and resists movements in the directionof abduction and rotation. In the treatment of this affection the armshould be maintained at a right angle to the body, the arm being rotatedmedially (Codman). When pain does not prevent it, movements of the armand massage are persevered with. In neglected cases, when adhesions haveformed and the shoulder is fixed, it may be necessary to break down theadhesions under an anæsthetic. The bursa is also liable to infective conditions, such as acuterheumatism, gonorrhœa, suppuration, or tubercle. In tuberculous diseasea large fluctuating swelling may form and acquire the characters of acold abscess (Fig. 115). The bursa underneath the tendon of the _subscapularis_ muscle wheninflamed causes alteration in the attitude of the shoulder andimpairment of its movements. An adventitious bursa forms over the _acromion_ process in porters andothers who carry weights on the shoulder, and may be the seat oftraumatic bursitis. The bursa under the _tendon of insertion of the biceps_, when the seatof disease, is attended with pain and swelling about a finger's breadthbelow the bend of the elbow; there is pain and difficulty in effectingthe combined movement of flexion and supination, slight limitation ofextension, and restriction of pronation. In the lower extremity, a large number of normal and adventitious bursæare met with and may be the seat of bursitis. That over the _tuberosityof the ischium_, when enlarged as a trade disease, is known as"weaver's" or "tailor's bottom. " It may form a fluctuating swelling ofgreat size, projecting on the buttock and extending down the thigh, andcausing great inconvenience in sitting (Fig. 116). It sometimes containsa number of loose bodies. There are two bursæ over the _great trochanter_, one superficial to, theother beneath the aponeurosis of the gluteus maximus; the latter is notinfrequently infected by tuberculous disease that has spread from thetrochanter. The bursa _between the psoas muscle and the capsule of the hip-joint_may be the seat of tuberculous disease, and give rise to clinicalfeatures not unlike those of disease of the hip-joint. The limb isflexed, abducted and rotated out; there is a swelling in the upper partof Scarpa's triangle, but the movements are not restricted in directionswhich do not entail putting the ilio-psoas muscle on the stretch. Cartilaginous and partly ossified loose bodies may accumulate in theilio-psoas bursa and distend it, both in a downward direction towardsthe hip-joint, with which it communicates, and upwards, projectingtowards the abdomen. The bursa beneath the quadriceps extensor--_subcrural bursa_--usuallycommunicates with the knee-joint and shares in its diseases. When shutoff from the joint it may suffer independently, and when distended withfluid 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 communicatingwith one another. It is the seat of the affection known as "housemaid'sknee, " which is very common and is sometimes bilateral, and, lessfrequently, of tuberculous disease which usually originates in thepatella. [Illustration: FIG.  116. --Great Enlargement of the Ischial Bursa. (Mr. Scot-Skirving's case. )] The bursa _between the ligamentum patellæ and the tibia_ is rarely theseat of disease. When it is, there is pain and tenderness referred tothe ligament, the patient is unable to extend the limb completely, thetuberosity of the tibia is apparently enlarged, and there is afluctuating swelling on either side of the ligament, most marked in theextended position of the limb. Of the numerous bursæ in the popliteal space, that _between thesemi-membranosus and the medial head of the gastrocnemius_ is mostfrequently the seat of disease, which is usually of the nature of asimple hydrops, forming a fluctuating egg-or sausage-shaped swelling atthe medial side of the popliteal space. It is flaccid in the flexed, andtense in the extended position. As a rule it causes littleinconvenience, and may be left alone. Otherwise it should be dissectedout, and if, as is frequently the case, there is a communication withthe knee-joint, this should be closed with sutures. [Illustration: FIG.  117. --Gouty Disease of Bursæ in a tailor. The bursaltumours were almost entirely composed of urate of soda. (Cf. Fig. 114. )] An adventitious bursa may form over the _lateral malleolus_, especiallyin tailors, giving rise to the condition known as "tailor's ankle"(Fig. 117). The bursa _between the tendo-calcaneus (Achillis) and the upper part ofthe calcaneus_ may become inflamed--especially as a result ofpost-scarlatinal rheumatism or gonorrhœa. The affection is known asAchillo-bursitis. There is severe pain in the region of the insertion ofthe tendo-calcaneus, the movements at the ankle-joint are restricted, and the patient may be unable to walk. There is a tender swelling oneither side of the tendon. When, in spite of palliative treatment, theaffection persists or relapses, it is best to excise the bursa. Thetendo-calcaneus is detached from the calcaneus, the bursa dissected out, and the tendon replaced. If there is a bony projection from thecalcaneus, it should be shaved off with the chisel. The bursa that is sometimes met with on the under aspect of thecalcaneus--_the subcalcanean bursa_--when inflamed, gives rise to painand tenderness in the sole of the foot. This affection may be associatedwith a spinous projection from the bone, which is capable of beingrecognised in a skiagram. The soft parts of the heel are turned forwardsas a flap, the bursa is dissected out, and the projection of bone, ifpresent, is removed. The enlargement of adventitious bursæ over the head of the firstmetatarsal in hallux valgus; over the tarsus, metatarsus, and digits inthe different forms of club-foot; over the angular projection in Pott'sdisease of the spine; over the end of the bone in amputation stumps, andover hard tumours such as chondroma and osteoma, are describedelsewhere. 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 asthe tibia consists of a shaft or _diaphysis_, and two extremities or_epiphyses_. So long as growth continues there intervenes between theshaft and each of the epiphyses a disc of actively growingcartilage--_the epiphysial cartilage_; and at the junction of thiscartilage with the shaft is a zone of young, vascular, spongy bone knownas the _metaphysis_ or _epiphysial junction_. The shaft is a cylinder ofcompact bone enclosing the medullary canal, which is filled with yellowmarrow. The extremities, which include the ossifying junctions, consistof spongy bone, the spaces of which are filled with red marrow. Thearticular aspect of the epiphysis is invested with a thick layer ofhyaline cartilage, known as the _articular cartilage_, which wouldappear to be mainly nourished from the synovia. The external investment--the _periosteum_--is thick and vascular duringthe period of growth, but becomes thin and less vascular when theskeleton has attained maturity. Except where muscles are attached it iseasily separated from the bone; at the extremities it is intimatelyconnected with the epiphysial cartilage and with the epiphysis, and atthe margin of the latter it becomes continuous with the capsule of theadjacent joint. It consists of two layers, an outer fibrous and an innercellular layer; the cells, which are called osteoblasts, are continuouswith those lining the Haversian canals and the medullary cavity. The arrangement of the _blood vessels_ determines to some extent theincidence of disease in bone. The nutrient artery, after entering themedullary canal through a special foramen in the cortex, bifurcates, andone main division runs towards each of the extremities, and terminatesat the ossifying junction in a series of capillary loops projectedagainst the epiphysial cartilage. This arrangement favours the lodgmentof any organisms that may be circulating in the blood, and partlyaccounts for the frequency with which diseases of bacterial origindevelop in the region of the ossifying junction. The diaphysis is alsonourished by numerous blood vessels from the periosteum, which penetratethe cortex through the Haversian canals and anastomose with thosederived from the nutrient artery. The epiphyses are nourished by aseparate system of blood vessels, derived from the arteries which supplythe adjacent joint. The veins of the marrow are of large calibre and aredevoid of valves. The _nerves_ enter the marrow along with the arteries, and, beingderived from the sympathetic system, are probably chiefly concerned withthe innervation of the blood vessels, but they are also capable oftransmitting sensory impulses, as pain is a prominent feature of manybone affections. It has long been believed that _the function of the periosteum_ is toform new bone, but this view has been questioned by Sir William Macewen, who maintains that its chief function is to limit the formation of newbone. His experimental observations appear to show that new bone isexclusively formed by the cellular elements or osteoblasts: these arefound on the surface of the bone, lining the Haversian canals and in themarrow. We believe that it will avoid confusion in the study of thediseases of bone if the osteoblasts on the surface of the bone are stillregarded as forming the deeper layer of the periosteum. The formation of new bone by the osteoblasts may be _defective_ as aresult of physiological conditions, such as old age and disease of apart, and defective formation is often associated with atrophy, or morestrictly speaking, absorption, of the existing bone, as is well seen inthe edentulous jaw and in the neck of the femur of a person advanced inyears. Defective formation associated with atrophy is also illustratedin the bones of the lower limbs of persons who are unable to stand orwalk, and in the distal portion of a bone which is the seat of anununited fracture. The same combination is seen in an exaggerated degreein the bones of limbs that are paralysed; in the case of adults, atrophyof bone predominates; in children and adolescents, defective formationis 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_, theosteoblasts being excited to abnormal activity by stimuli of differentkinds: for example, the secretion of certain glandular organs, such asthe pituitary and thyreoid; the diluted toxins of certainmicro-organisms, such as the staphylococcus aureus and the spirochæte ofsyphilis; a condition of hyperæmia, such as that produced artificiallyby the application of a Bier's bandage or that which accompanies achronic leg-ulcer. The new bone is laid down on the surface, in the Haversian canals, orin the cancellous spaces and medullary canal, or in all threesituations. The new bone on the surface sometimes takes the form of adiffuse _encrustation_ of porous or spongy bone as in secondarysyphilis, sometimes as a uniform increase in the girth of thebone--_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, andis said to be _sclerosed_; in extreme instances this may result inobliteration of the medullary canal. Hyperostosis and sclerosis arefrequently met with in combination, a condition that is well illustratedin the femur and tibia in tertiary syphilis; if the subject of thiscondition is confined to bed for several months before his death, thesclerosis may be undone, and rarefaction may even proceed beyond thenormal, the bone becoming lighter and richer in fat, although retainingits abnormal girth. The _function of the epiphysial cartilage_ is to provide for the growthof the shaft in length. While all epiphysial cartilages contribute tothis result, certain of them functionate more actively and for a longerperiod than others. Those at the knee, for example, contribute more tothe length of limb than do those at the hip or ankle, and they are alsothe last to unite. In the upper limb the more active epiphyses are atthe shoulder and wrist, and these also are the last to unite. The activity of the epiphysial cartilage may be modified as a result ofdisease. In rickets, for example, the formation of new bone may takeplace unequally, and may go on more rapidly in one half of the disc thanin the other, with the result that the axis of the shaft comes todeviate from the normal, giving rise to knock-knee or bow-knee. Inbacterial diseases originating in the marrow, if the epiphysial junctionis directly involved in the destructive process, its bone-formingfunctions may be retarded or abolished, and the subsequent growth of thebone be seriously interfered with. On the other hand, if it is notdirectly involved but is merely influenced by the proximity of aninfective focus, its bone-forming functions may be stimulated by thediluted toxins and the growth of the bone in length exaggerated. Inparalysed limbs the growth from the epiphyses is usually little short ofthe normal. The result of interference with growth is more injurious inthe lower than in the upper limb, because, from the functional point ofview, it is essential that the lower extremities should be approximatelyof equal length. In the forearm or leg, where there are two parallelbones, if the growth of one is arrested the continued growth of theother results in a deviation of the hand or foot to one side. In certain diseases, such as rickets and inherited syphilis, and indevelopmental anomalies such as achondroplasia, _dwarfing_ of theskeleton results from defective growth of bone at the ossifyingjunctions. Conversely, excessive growth of bone at the ossifyingjunctions results in abnormal height of the skeleton or _giantism_ as aresult, for example, of increased activity of the pituitary inadolescents, and in eunuchs who have been castrated in childhood oradolescence; in the latter, union of the epiphyses at the ends of thelong bones is delayed beyond the usual period at which the skeletonattains maturity. #Regeneration of Bone. #--When bone has been lost or destroyed as aresult of injury or disease, it is capable of being reproduced, theextent to which regeneration takes place varying under differentconditions. The chief part in the regeneration of bone is played by theosteoblasts in the adjacent marrow and in the deeper layer of theperiosteum. The shaft of a long bone may be reproduced after having beendestroyed by disease or removed by operation. The flat bones of theskull and the bones of the face, which are primarily developed inmembrane, have little capacity of regeneration; hence, when bone hasbeen lost or removed in these situations, there results a permanentdefect. Wounds or defects in articular cartilage are repaired by fibrous orosseous tissue derived from the subjacent cancellous spaces. _Transplantation of Bone--Bone-grafting. _--Clinical experience isconclusive that a portion of bone which has been completely detachedfrom its surroundings--for example, a trephine circle, or a flap of bonedetached with the saw, or the loose fragments in a compoundfracture--may become, if replaced in position, firmly and permanentlyincorporated with the surrounding bone. Embedded foreign bodies, on theother hand, such as ivory pegs or decalcified bone, exhibit, on removalafter a sufficient interval, evidence of having been eroded, in theshape of worm-eaten depressions and perforations, and do not becomeunited or fused to the surrounding bone. It follows from this that theimplanting of living bone is to be preferred to the implanting of deadbone or of foreign material. We believe that transplanted living bonewhen placed under favourable conditions survives and becomesincorporated with the bone with which it is in contact, and does notmerely act as a scaffolding. We believe also that the retention of theperiosteum on the graft is not essential, but, by favouring theestablishment of vascular connections, it contributes to the survival ofthe graft and the success of the transplantation. Macewen maintains thatbone grafts "take" better if broken up into small fragments; we regardthis as unnecessary. Bone grafts yield better functional results whenthey are immovably fixed to the adjacent bone by suture, pegs, orplates. 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 leadto the same results as do similar processes in other tissues. Thestructural peculiarities of bone, however, and the important changeswhich take place in the skeleton during the period of growth, modifycertain of the clinical and pathological features. _Definition of Terms. _--Any diseased process that affects the periosteumis spoken of as _periostitis_; the term _osteomyelitis_ is employed whenit is located in the marrow. The term _epiphysitis_ has been applied toan inflammatory process in two distinct situations--namely, theossifying nucleus in the epiphysis, and the ossifying junction ormetaphysis between the epiphysial cartilage and the diaphysis. We shallrestrict the term to inflammation in the first of these situations. Inflammation at the ossifying junction is included under the termosteomyelitis. The term _rarefying ostitis_ is applied to any process that is attendedwith excessive absorption of the framework of a bone, whereby it becomesmore porous or spongy than it was before, a condition known as_osteoporosis_. The term _caries_ is employed to indicate any diseased processassociated with crumbling away of the trabecular framework of a bone. Itmay be considered as the equivalent of ulceration or moleculardestruction in the soft parts. The carious process is preceded by theformation of granulation tissue in the marrow or periosteum, which eatsaway and replaces the bone in contact with it. The subsequentdegeneration and death of the granulation tissue under the necroticinfluence of bacterial toxins results in disintegration and crumblingaway of the trabecular framework of the portion of bone affected. Clinically, carious bone yields a soft grating sensation under thepressure of the probe. The macerated bone presents a rough, erodedsurface. The term _dry caries_ (_caries sicca_) is applied to that variety whichis unattended with suppuration. _Necrosis_ is the term applied to the death of a tangible portion ofbone, and the dead portion when separated is called a _sequestrum_. Theterm _exfoliation_ is sometimes employed to indicate the separation orthrowing off of a superficial sequestrum. The edges and deep surface ofthe sequestrum present a serrated or worm-eaten appearance due to theprocess of erosion by which the dead bone has been separated from theliving. BACTERIAL DISEASES The most important diseases in this group are the pyogenic, thetuberculous, and the syphilitic. PYOGENIC DISEASES OF BONE. --These diseases result frominfection with pyogenic organisms, and two varieties or types arerecognised according to whether the organisms concerned reach their seatof action by way of the blood-stream, or through an infection of thesoft parts in contact with the bone. INFECTIONS THROUGH THE BLOOD-STREAM #Diseases caused by the Staphylococcus Aureus. #--As the majority ofpyogenic diseases are due to infection with the staphylococcus aureus, these will be described first. #Acute osteomyelitis# is a suppurative process beginning in the marrowand tending to spread to the periosteum. The disease is common inchildren, but is rare after the skeleton has attained maturity. Boys areaffected more often than girls, in the proportion of three to one, probably because they are more liable to exposure, to injury, and toviolent exertion. _Etiology. _--Staphylococci gain access to the blood-stream in variousways, it may be through the skin or through a mucous surface. Such conditions as, for example, a blow, some extra exertion such as along walk, or exposure to cold, as in wading, may act as localisingfactors. The long bones are chiefly affected, and the commonest sites are: eitherend of the tibia and the lower end of the femur; the other bones of theskeleton are affected in rare instances. _Pathology. _--The disease commences and is most intense in the marrow ofthe ossifying junction at one end of the diaphysis; it may commence atboth ends simultaneously--_bipolar osteomyelitis_; or, commencing at oneend, 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 ismost advanced--that is, at the ossifying junction--there are evidencesof absorption of the framework of the bone; the marrow spaces andHaversian canals undergo enlargement and become filled withgreenish-yellow pus. This rarefaction of the spongy bone is the earliestchange seen with the X-rays. The process may remain localised to the ossifying junction, but usuallyspreads along the medullary canal for a varying distance, and alsoextends to the periosteum by way of the enlarged Haversian canals. Thepus accumulates under the periosteum and lifts it up from the bone. Theextent of spread in the medullary canal and beneath the periosteum is inclose correspondence. The periosteum of the diaphysis is easilyseparated--hence the facility with which the pus spreads along theshaft; but in the region of the ossifying junction it is raised withdifficulty because of its intimate connection with the epiphysialcartilage. Less frequently there is more than one collection of pusunder the periosteum, each being derived from a focus of suppuration inthe subjacent marrow. The pus perforates the periosteum, and makes itsway to the surface by the easiest anatomical route, and dischargesexternally, forming one or more sinuses through which fresh infectionmay take place. The infection may spread to the adjacent joint, eitherdirectly through the epiphysis and articular cartilage, or along thedeep layer of the periosteum and its continuation--the capsularligament. When the epiphysis is intra-articular, as, for example, in thehead of the femur, the pus when it reaches the surface of the bonenecessarily erupts directly into the joint. While the occurrence of purely periosteal suppuration is regarded aspossible, we are of opinion that the embolic form of staphylococcalosteomyelitis always originates in the marrow. The portion of the diaphysis which has sustained the action of theconcentrated toxins has its vitality further impaired as a result of thestripping of the periosteum and thrombosis of the blood vessels of themarrow, so that _necrosis_ of bone is one of the most striking resultsof the disease, and as this takes place rapidly, that is, in a day ortwo, the term _acute necrosis_, formerly applied to the disease, wasamply justified. When there is marked rarefaction of the bone at the ossifying junction, the epiphysis is liable to be separated--_epiphysiolysis_. Theseparation usually takes place through the young bone of the ossifyingjunction, and the surfaces of the diaphysis and epiphysis are opposed toeach other by irregular eroded surfaces bathed in pus. The separatedepiphysis may be kept in place by the periosteum, but when this has beendetached by the formation of pus beneath it, the epiphysis is liable tobe displaced by muscular action or by some movement of the limb, or itis the diaphysis that is displaced, for example, the lower end of thediaphysis 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 growthof the bone in length may be interfered with. Sometimes the separatedand displaced epiphysis dies and constitutes a sequestrum. The adjacent joint may become filled at an early stage with a serouseffusion, which may be sterile. When the cocci gain access to the joint, the lesion assumes the characters of a purulent arthritis, which, fromits frequency during the earlier years of life, has been called _theacute arthritis of infants_. Separation of an epiphysis nearly always results in infection anddestruction of the adjacent joint. Osteomyelitis is rare in the bones of the carpus and tarsus, and theassociated joints are usually infected from the outset. In flat bones, such as the skull, the scapula, or the ilium, suppuration usually occurson both aspects of the bone as well as in the marrow. _Clinical Features. _--The constitutional symptoms, which are due to theassociated toxæmia, vary considerably in different cases. In mild casesthey may be so slight as to escape recognition. In exceptionally severecases the patient may succumb before there are obvious signs of thelocalisation of the staphylococci in the bone marrow. In average casesthe temperature rises rapidly with a rigor and runs an irregular coursewith morning remissions, there is marked general illness accompanied byheadache, vomiting, and sometimes delirium. The local manifestations are pain and tenderness in relation to one ofthe long bones; the pain may be so severe as to prevent sleep and tocause the child to cry out. Tenderness on pressure over the bone is themost valuable diagnostic sign. At a later stage there is an ill-definedswelling in the region of the ossifying junction, with œdema of theoverlying skin and dilatation of the superficial veins. The swelling appears earlier and is more definite in superficial bonessuch as the tibia, than in those more deeply placed such as the upperend 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 ofits shaft towards the end. The maximum thickening and tenderness usuallycorrespond to the junction of the diaphysis with the epiphysis, and theswelling tails off gradually along the shaft. As time goes on there isredness of the skin, especially over a superficial bone, such as thetibia, the swelling becomes softer, and gives evidence of fluctuation. This stage may be reached at the end of twenty-four hours, or not forsome days. Suppuration spreads towards the surface, until, some days later, theskin sloughs and pus escapes, after which the fever usually remits andthe pain and other symptoms are relieved. The pus may contain blood anddroplets of fat derived from the marrow, and in some cases minuteparticles of bone are present also. The presence of fat and bonyparticles in the pus confirms the medullary origin of the suppuration. If an incision is made, the periosteum is found to be raised from thebone; the extent of the bare bone will be found to correspond fairlyaccurately with the extent of the lesion in the marrow. _Local Complications. _--The adjacent joint may exhibit symptoms whichvary from those of a simple effusion to those of a purulent _arthritis_. The joint symptoms may count for little in the clinical picture, or, asin the case of the hip, may so predominate as to overshadow those of thebone lesion from which they originated. _Separation and displacement of the epiphysis_ usually reveals itself byan alteration in the attitude of the limb; it is nearly alwaysassociated with suppuration in the adjacent joint. When _pathological fracture_ of the shaft occurs, as it may do, fromsome muscular effort or strain, it is attended with the usual signs offracture. _Dislocation_ of the adjacent joint has been chiefly observed at thehip; it may result from effusion into the joint and stretching of theligaments, or may be the sequel of a purulent arthritis; the signs ofdislocation are not so obvious as might be expected, but it is attendedwith an alteration in the attitude of the limb, and the displacement ofthe head of the bone is readily shown in a skiagram. _General Complications. _--In some cases a _multiplicity of lesions_ inthe bones and joints imparts to the disease the features of pyæmia. Theoccurrence of endocarditis, as indicated by alterations in the heartsounds and the development of murmurs, may cause widespread infectiveembolism, and metastatic suppurations in the kidneys, heart-wall, andlungs, as well as in other bones and joints than those primarilyaffected. The secondary suppurations are liable to be overlooked unlesssought for, as they are rarely attended with much pain. In these multiple forms of osteomyelitis the toxæmic symptomspredominate; the patient is dull and listless, or he may be restless andtalkative, or actually delirious. The tongue is dry and coated, the lipsand teeth are covered with sordes, the motions are loose and offensive, and may be passed involuntarily. The temperature is remittent andirregular, the pulse small and rapid, and the urine may contain bloodand albumen. Sometimes the skin shows erythematous and purpuric rashes, and the patient may cry out as in meningitis. The post-mortemappearances are those of pyæmia. _Differential Diagnosis. _--Acute osteomyelitis is to be diagnosed frominfections of the soft parts, such as erysipelas and cellulitis, and, inthe case of the tibia, from erythema nodosum. Tenderness localised tothe ossifying junction is the most valuable diagnostic sign ofosteomyelitis. When there is early and pronounced general intoxication, there is likelyto be confusion with other acute febrile illnesses, such as scarletfever. In all febrile conditions in children and adolescents, theossifying junctions of the long bones should be examined for areas ofpain and tenderness. Osteomyelitis has many features in common with acute articularrheumatism, and some authorities believe them to be different forms ofthe same disease (Kocher). In acute rheumatism, however, the jointsymptoms predominate, there is an absence of suppuration, and the painsand temperature yield to salicylates. The _prognosis_ varies with the type of the disease, with itslocation--the vertebræ, skull, pelvis, and lower jaw being speciallyunfavourable--with the multiplicity of the lesions, and with thedevelopment of endocarditis and internal metastases. _Treatment. _--This is carried out on the same lines as in other pyogenicinfections. In the earliest stages of the disease, the induction of hyperæmia isindicated, and should be employed until the diagnosis is definitelyestablished, and in the meantime preparations for operation should bemade. An incision is made down to and through the periosteum, andwhether pus is found or not, the bone should be opened in the vicinityof the ossifying junction by means of a drill, gouge, or trephine. Ifpus is found, the opening in the bone is extended along the shaft as faras the periosteum has been separated, and the infected marrow is removedwith the spoon. The cavity is then lightly packed with rubber dam, or, as recommended by Bier, the skin edges are brought together by sutureswhich are loosely tied to afford sufficient space between them for theexit of discharge, and the hyperæmic treatment is continued. When there is widespread suppuration in the marrow, and the shaft isextensively bared of periosteum and appears likely to die, it may beresected straight away or after an interval of a day or two. Earlyresection of the shaft is also indicated if the opening of the medullarycanal is not followed by relief of symptoms. In the leg and forearm, theunaffected bone maintains the length and contour of the limb; in thecase of the femur and humerus, extension with weight and pulley alongwith some form of moulded gutter splint is employed with a similarobject. Amputation of the limb is reserved for grave cases, in which life isendangered by toxæmia, which is attributed to the primary lesion. It maybe called for later if the limb is likely to be useless, as, forexample, when the whole shaft of the bone is dead without the formationof a new case, when the epiphyses are separated and displaced, and thejoints are disorganised. Flat bones, such as the skull or ilium, must be trephined and the puscleared out from both aspects of the bone. In the vertebræ, operativeinterference is usually restricted to opening and draining theassociated abscess. #Nature's Effort at Repair. #--_In cases which are left to nature_, andin which necrosis of bone has occurred, those portions of the periosteumand marrow which have retained their vitality resume their osteogeneticfunctions, often to an exaggerated degree. Where the periosteum has beenlifted up by an accumulation of pus, or is in contact with bone that isdead, it proceeds to form new bone with great activity, so that the deadshaft becomes surrounded by a sheath or case of new bone, known as the_involucrum_ (Fig. 118). Where the periosteum has been perforated by pusmaking its way to the surface, there are defects or holes in theinvolucrum, called _cloacæ_. As these correspond more or less inposition to the sinuses in the skin, in passing a probe down one of thesinuses it usually passes through a cloaca and strikes the dead bonelying in the interior. If the periosteum has been extensivelydestroyed, new bone may only be formed in patches, or not at all. Thedead bone is separated from the living by the agency of granulationtissue with its usual complements of phagocytes and osteoclasts, so thatthe sequestrum presents along its margins and on its deep surface apitted, grooved, and worm-eaten appearance, except on the periostealaspect, which is unaltered. Ultimately the dead bone becomes loose andlies in a cavity a little larger than itself; the wall of the cavity isformed by the new case, lined with granulation tissue. The separation ofthe sequestrum takes place more rapidly in the spongy bone of theossifying junction than in the compact bone of the shaft. When foci of suppuration have been scattered up and down the medullarycavity, and the bone has died in patches, several sequestra may beincluded 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 newbone by the marrow; the medullary canal is often obliterated, and thebone becomes heavier and denser--sclerosis; and the new bone which isdeposited on the original shaft results in an increase in the girth ofthe bone--hyperostosis. [Illustration: FIG.  118. --Shaft of Femur after Acute Osteomyelitis. Theshaft has undergone extensive necrosis, and a shell of new bone has beenformed 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, andis most frequently met with in the shaft of the femur. Short offracture, there may be bending or curving of the new case, and thisresults in deformity and shortening of the limb (Fig. 119). The _extrusion of a sequestrum_ may occur, provided there is a cloacalarge enough to allow of its escape, but the surgeon has usually tointerfere by performing the operation of sequestrectomy. Displacement orpartial extrusion of the dead bone may cause complications, as when asequestrum derived from the trigone of the femur perforates thepopliteal artery or the cavity of the knee-joint, or a sequestrum of thepelvis perforates the wall of the urinary bladder. The extent to which bone which has been lost is reproduced varies indifferent parts of the skeleton: while the long bones, the scapula, themandible, and other bones which are developed in cartilage are almostcompletely 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 AcuteOsteomyelitis affecting Trigone of Femur; sequestrum partly surroundedby new case; backward displacement of lower epiphysis and implication ofknee-joint. ] It may be instructive to describe _the X-ray appearances of a long bonethat has passed through an attack of acute osteomyelitis_ severe enoughto have caused necrosis of part of the diaphysis. The shadow of the deadbone 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 itsmargins present an irregular contour from the erosion concerned in itsseparation. The sequestrum is separated from the living bone by a clearzone which corresponds to the layer of granulations lining the cavity inwhich it lies. This clear zone separating the shadow of the dead bonefrom that of the living bone by which it is surrounded is conclusiveevidence of a sequestrum. The medullary canal in the vicinity of thesequestrum being obliterated, is represented by a shadow of varyingdensity, continuous with that of the surrounding bone. The shadow of thenew case or involucrum with its wavy contour is also in evidence, withits openings or cloacæ, and is mainly responsible for the increase inthe diameter of the bone. The skiagram may also show separation and displacement of the adjacentepiphysis and destruction of the articular surfaces or dislocation ofthe joint. _Sequelæ of Acute Suppurative Osteomyelitis. _--The commonest sequel isthe presence of a sequestrum with one or more discharging sinuses; owingto the abundant formation of scar tissue these sinuses have rigid edgeswhich are usually depressed and adherent to the bone. _The Recognition and Removal of Sequestra. _--So long as there is deadbone there will be suppuration from the granulations lining the cavityin which it lies, and a discharge of pus from the sinuses, so that themere persistence of discharge after an attack of osteomyelitis, ispresumptive evidence of the occurrence of necrosis. Where there are oneor more sinuses, the passage of a probe which strikes bare bone affordscorroboration of the view that the bone has perished. When the dead bonehas been separated from the living, the X-rays yield the most exactinformation. The traditional practice is to wait until the dead bone is entirelyseparated before undertaking an operation for its removal, from fear, onthe one hand, of leaving portions behind which may keep up thedischarge, and, on the other, of removing more bone than is necessary. This practice need not be adhered to, as by operating at an earlierstage healing is greatly hastened. If it is decided to wait forseparation of the dead bone, drainage should be improved, and theinfective element combated by the induction of hyperæmia. _The operation_ for the removal of the dead bone (_sequestrectomy_)consists in opening up the periosteum and the new case sufficiently toallow of the removal of all the dead bone, including the most minutesequestra. The limb having been rendered bloodless, existing sinuses areenlarged, but if these are inconveniently situated--for example, in thecentre of the popliteal space in necrosis of the femoral trigone--it isbetter to make a fresh wound down to the bone on that aspect of thelimb which affords best access, and which entails the least injury ofthe soft parts. The periosteum, which is thick and easily separable, israised from the new case with an elevator, and with the chisel or gougeenough of the new bone is taken away to allow of the removal of thesequestrum. Care must be taken not to leave behind any fragment of deadbone, as this will interfere with healing, and may determine a relapseof suppuration. The dead bone having been removed, the lining granulations are scrapedaway with a spoon, and the cavity is disinfected. There are different ways of dealing with a _bone cavity_. It may bepacked with gauze (impregnated with "bipp" or with iodoform), which ischanged at intervals until healing takes place from the bottom; it maybe 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 maybe chiselled through at its base, so that it can be brought into contactwith the opposite wall. The method of filling bone cavities devised byMosetig-Moorhof, consists in disinfecting and drying the cavity by acurrent of hot air, and filling it with a mixture of powdered iodoform(60 parts) and oil of sesame and spermaceti (each 40 parts), which isfluid at a temperature of 112° F. ; the soft parts are then broughttogether without drainage. As the cavity fills up with new bone theiodoform is gradually absorbed. Iodoform gives a dark shadow with theX-rays, so that the process of its absorption can be followed inskiagrams taken at intervals. These procedures may be carried out at the same time as the sequestrumis removed, or after an interval. In all of them, asepsis is essentialfor success. The _deformities_ resulting from osteomyelitis are more marked theearlier in life the disease occurs. Even under favourable conditions, and with the continuous effort at reconstruction of the bone by Nature'smethod, the return to normal is often far from perfect, and thereusually remains a variable amount of hyperostosis and sclerosis andsometimes curving of the bone. Under less favourable conditions, thelate results of osteomyelitis may be more serious. _Shortening_ is notuncommon from interference with growth at the ossifying junction. _Exaggerated growth_ in the length of a bone is rare, and has beenobserved chiefly in the bones of the leg. Where there are two parallelbones--as in the leg, for example--the growth of the diseased bone maybe impaired, and the other continuing its normal growth becomesdisproportionately long; less frequently the growth of the diseasedbone is exaggerated, and it becomes the longer of the two. In eithercase, the longer bone becomes curved. An _obliquity_ of the bone mayresult when one half of the epiphysial cartilage is destroyed and theother half continues to form bone, giving rise to such deformities asknock-knee and club-hand. Deformity may also result from vicious union of a pathological fracture, permanent displacement of an epiphysis, contracture, ankylosis, ordislocation of the adjacent joint. #Relapsing Osteomyelitis. #--As the term indicates, the various forms ofrelapsing osteomyelitis date back to an antecedent attack, and theiroccurrence depends on the capacity of staphylococci to lie latent in themarrow. Relapse may take place within a few months of the original attack, ornot for many years. Cases are sometimes met with in which relapses recurat regular intervals for several years, the tendency, however, being forthe attacks to become milder as the virulence of the organisms becomesmore and more attenuated. _Clinical Features. _--Osteomyelitis in a patient over twenty-five isnearly always of the relapsing variety. In some cases the bone becomesenlarged, with pain and tenderness on pressure; in others there are theusual phenomena which attend suppuration, but the pus is slow in comingto the surface, and the constitutional symptoms are slight. The pus mayescape by new channels, or one of the old sinuses may re-open. Radiograms usually furnish useful information as to the condition of thebone, both as it is altered by the original attack and by the changesthat attend the relapse of the infective process. _Treatment. _--In cases of thickening of the bone with persistent andsevere pain, if relief is not afforded by the repeated application ofblisters, the thickened periosteum should be incised, and the boneopened up with the chisel or trephine. In cases attended withsuppuration, the swelling is incised and drained, and if there is asequestrum, it must be removed. #Circumscribed Abscess of Bone--"Brodie's Abscess. "#--The most importantform of relapsing osteomyelitis is the circumscribed abscess of bonefirst described by Benjamin Brodie. It is usually met with in youngadults, but we have met with it in patients over fifty. Several yearsmay intervene between the original attack of osteomyelitis and the onsetof symptoms of abscess. _Morbid Anatomy. _[7]--The abscess is nearly always situated in thecentral axis of the bone in the region of the ossifying junction, although cases are occasionally met with in which it lies nearer themiddle of the shaft. In exceptional cases there is more than one abscess(Fig. 120). The tibia is the bone most commonly affected, but the lowerend of the femur, or either end of the humerus, may be the seat of theabscess. In the quiescent stage the lesion is represented by a smallcavity in the bone, filled with clear serum, and lined by a fibrousmembrane which is engaged in forming bone. Around the cavity the bone issclerosed, and the medullary canal is obliterated. When the infectionbecomes active, the contents of the cavity are transformed into agreenish-yellow pus from which the staphylococcus can be isolated, andthe cavity is lined by a thin film of granulation tissue which erodesthe surrounding bone and so causes the abscess to increase in size. Ifthe erosion proceeds uniformly, the cavity is spherical or oval; if itis more active at some points than others, diverticula or tunnels areformed, and one of these may finally erupt through the shell of the boneor into an adjacent joint. Small irregular sequestra are occasionallyfound within the abscess cavity. In long-standing cases it is common tofind extensive obliteration of the medullary canal, and a considerableincrease in the girth of the bone. [7] Alexis Thomson, _Edin. Med. Journ. _, 1906. [Illustration: FIG.  120. --Segment of Tibia resected for Brodie'sAbscess. The specimen shows two separate abscesses in the centre of theshaft, the lower one quiescent, the upper one active and increasing insize. ] The size of the abscess ranges from that of a cherry to that of awalnut, but specimens in museums show that, if left to Nature, theabscess may attain much greater dimensions. The affected bone is not only thicker and heavier than normal, but mayalso be curved or otherwise deformed as a result of the original attackof osteomyelitis. The _clinical features_ are almost exclusively local. Pain, due totension within the abscess, is the dominant symptom. At first it isvague and difficult to localise, later it is referred to the interior ofthe bone, and is described as "boring. " It is aggravated by use of thelimb, and there are often, especially during the night, exacerbations inwhich the pain becomes excruciating. In the early stages there areperiods of days or weeks during which the symptoms abate, but as theabscess increases these become shorter, until the patient is hardly everfree from pain. Localised tenderness can almost always be elicited bypercussion, or by compressing the bone between the fingers and thumb. The pain induced by the traction of muscles attached to the bone, or bythe weight of the body, may interfere with the function of the limb, andin the lower extremity cause a limp in walking. The limb may be disabledfrom _involvement of the adjacent joint_, in which there may be anintermittent hydrops which comes and goes coincidently withexacerbations of pain; or the abscess may perforate the joint and set upan acute arthritis. The _diagnosis_ of Brodie's abscess from other affections met with atthe 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. Whenthe adjacent joint is implicated, the surgeon may be misled by thepatient referring all the symptoms to the joint. The X-ray picture is usually diagnostic chiefly because all the lesionswhich 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 thecentral clear area is either not seen at all or only faintly (Fig. 121). _Treatment. _--If an abscess is suspected, there should be no hesitationin exploring the interior of the bone. It is exposed by a suitableincision; the periosteum is reflected and the bone is opened up by atrephine or chisel, and the presence of an abscess may be at onceindicated by the escape of pus. If, owing to the small size of theabscess or the density of the bone surrounding it, the pus is notreached by this procedure, the bone should be drilled in differentdirections. [Illustration: FIG.  121. --Radiogram of Brodie's Abscess in Lower End ofTibia. ] #Other Forms of Acute Osteomyelitis. #--Among the less severe forms ofosteomyelitis resulting from the action of attenuated organisms are the_serous_ variety, in which an effusion of serous fluid forms under theperiosteum; and _growth fever_, in which the child complains of vagueevanescent pains (growing pains), and of feeling tired and disinclinedto 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 onto suppuration. _Necrosis without suppuration_, described by Paget under the name "quietnecrosis, " is a rare disease, and would appear to be associated with anattenuated form of staphylococcal infection (Tavel). It occurs inadults, being met with up to the age of fifty or sixty, and ischaracterised by the insidious development of a swelling which involvesa considerable extent of a long bone. The pain varies in intensity, andmay be continuous or intermittent, and there is tenderness on pressure. The shaft is increased in girth as a result of its being surrounded by anew case of bone. The resemblance to sarcoma may be very close, but theswelling is not as defined as in sarcoma, nor does it ever assume thecharacteristic "leg of mutton" shape. In both diseases there is atendency to pathological fracture. It is difficult also in the absenceof skiagrams to differentiate the condition from syphilitic and fromtuberculous disease. If the diagnosis is not established afterexamination with the X-rays, an exploratory incision should be made; ifdead bone is found, it is removed. In typhoid fever the bone marrow is liable to be invaded by _the typhoidbacillus_, which may set up osteomyelitis soon after its lodgment, or itmay lie latent for a considerable period before doing so. The lesionsmay be single or multiple, they involve the marrow or the periosteum orboth, and they may or may not be attended with suppuration. They aremost commonly met with in the tibia and in the ribs at thecosto-chondral junctions. The bone lesions usually occur during the seventh or eighth week of thefever, but have been known to occur much later. The chief complaint isof vague pains, at first referred to several bones, later becominglocalised in one; they are aggravated by movement, or by handling thebone, and are worst at night. There is redness and œdema of theoverlying soft parts, and swelling with vague fluctuation, and onincision there escapes a yellow creamy pus, or a brown syrupy fluidcontaining the typhoid bacillus in pure culture. Necrosis isexceptional. When the abscess develops slowly, the condition resembles tuberculousdisease, 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 relapseis not uncommon. It is usually sufficient to incise the periosteum, but when the diseaseoccurs in a rib it may be necessary to resect a portion of bone. #Pyogenic Osteomyelitis due to Spread of Infection from the SoftParts. #--There still remain those forms of osteomyelitis which resultfrom infection through a wound involving the bone--for example, compoundfractures, gun-shot injuries, osteotomies, amputations, resections, oroperations for un-united fracture. In all of these the marrow is exposedto infection by such organisms as are present in the wound. A similarform of osteomyelitis may occur apart from a wound--for example, infection may spread to the jaws from lesions of the mouth; to theskull, from lesions of the scalp or of the cranial bonesthemselves--such as a syphilitic gumma or a sarcoma which has fungatedexternally; or to the petrous temporal, from suppuration in the middleear. The most common is an osteomyelitis commencing in the marrow exposed ina wound infected with pyogenic organisms. In amputation stumps, fungating granulations protrude from the sawn end of the bone, and ifnecrosis takes place, the sequestrum is annular, affecting thecross-section of the bone at the saw-line; or tubular, extending up theshaft, and tapering off above. The periosteum is more easily detached, is thicker than normal, and is actively engaged in forming bone. In themacerated specimen, the new bone presents a characteristic coral-likeappearance, and may be perforated by cloacæ (Fig. 122). [Illustration: FIG.  122. --Tubular Sequestrum resulting from SepticOsteomyelitis in Amputation Stump. ] Like other pyogenic infections, it may terminate in pyæmia, as a resultof septic phlebitis in the marrow. The _clinical features_ of osteomyelitis in _an amputation stump_ arethose of ordinary pyogenic infection; the involvement of the bone may besuspected from the clinical course, the absence of improvement frommeasures directed towards overcoming the sepsis in the soft parts, andthe persistence of suppuration in spite of free drainage, but it is notrecognised unless the bone is exposed by opening up the stump or thechanges in the bone are shown by the X-rays. The first change is due tothe deposit of new bone on the periosteal surface; later, there is theshadow of the sequestrum. Healing does not take place until the sequestrum is extruded or removedby operation. _In compound fractures_, if a fragment dies and forms a sequestrum, itis apt to be walled in by new bone; the sinuses continue to dischargeuntil the sequestrum is removed. Even after healing has taken place, relapse is liable to occur, especially in gun-shot injuries. Months oryears afterwards, the bone may become painful and tender. The symptomsmay subside under rest and elevation of the limb and the application ofa compress, or an abscess forms and bursts with comparatively littlesuffering. 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 fromAmputation Stump. Osteomyelitis supervened on the amputation, andresulted in necrosis at the sawn section of the bone. (AnatomicalMuseum, University of Edinburgh. )] TUBERCULOUS DISEASE The tuberculous diseases of bone result from infection of the marrow orperiosteum by tubercle bacilli conveyed through the arteries; it isexceedingly rare for tubercle to appear in bone as a primary infection, the bacilli being usually derived from some pre-existing focus in thebronchial glands or elsewhere. According to the observations of JohnFraser, 60 per cent. Of the cases of bone and joint tubercle in childrenare due to the bovine bacillus, 37 per cent. To the human variety, andin 3 per cent. Both types are present. Tuberculous disease in bone is characterised by its insidious onset andslow progress, and by the frequency with which it is associated withdisease of the adjacent joint. #Periosteal tuberculosis# is met with in the ribs, sternum, vertebralcolumn, skull, and less frequently in the long bones of the limbs. Itmay originate in the periosteum, or may spread thence from the marrow, or from synovial membrane. _In superficial bones_, such as the sternum, the formation oftuberculous granulation tissue in the deeper layer of the periosteum, and its subsequent caseation and liquefaction, is attended by theinsidious development of a doughy swelling, which is not as a rulepainful, although tender on pressure. While the swelling often remainsquiescent for some time, it tends to increase in size, to become boggyor fluctuating, and to assume the characters of a cold abscess. The pusperforates the fibrous layer of the periosteum, invading and infectingthe overlying soft parts, its spread being influenced by the anatomicalarrangement of the tissues. The size of the abscess affords noindication of the extent of the bone lesion from which it originates. Asthe abscess reaches the surface, the skin becomes of a dusky red orlivid colour, is gradually thinned out, and finally sloughs, forming asinus. A probe passed into the sinus strikes carious bone. Smallsequestra may be found embedded in the granulation tissue. The sinuspersists as long as any active tubercle remains in the tissues, and isapt to form an avenue for pyogenic infection. _In deeply seated bones_, such as the upper end of the femur, theformation of a cold abscess in the soft parts is often the firstevidence of the disease. _Diagnosis. _--Before the stage of cold abscess is reached, the localisedswelling is to be differentiated from a gumma, from chronic forms ofstaphylococcal osteomyelitis, from enlarged bursa or ganglion, fromsub-periosteal lipoma, and from sarcoma. Most difficulty is met with inrelation to periosteal sarcoma, which must be differentiated either bythe X-ray appearances or by an exploratory incision. _X-ray appearances in periosteal tubercle_: the surface of the corticalbone in the area of disease is roughened and irregular by erosion, andin 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 greaterirregularity in the contour of the cortical bone, and frequently thereis evidence of formation of bone in the form of characteristic spiculesprojecting from the surface at a right angle. The early recognition of periosteal lesions in the articular ends ofbones is of importance, as the disease, if left to itself, is liable tospread to the adjacent joint. The _treatment_ is that of tuberculous lesions in general; ifconservative measures fail, the choice lies between the injection ofiodoform, and removal of the infected tissues with the sharp spoon. Inthe ribs it is more satisfactory to remove the diseased portion of bonealong with the wall of the associated abscess or sinus. If all thetubercle has been removed and there is no pyogenic infection, the woundis stitched up with the object of obtaining primary union; otherwise itis treated by the open method. #Tuberculous Osteomyelitis. #--Tuberculous lesions in the marrow occur asisolated or as multiple foci of granulation tissue, which replace themarrow and erode the trabeculæ of bone in the vicinity (Fig. 124). Theindividual focus varies in size from a pea to a walnut. The changes thatensue resemble in character those in other tissues, and the extent ofthe destruction varies according to the way in which the tuberclebacillus and the marrow interact upon one another. The granulationtissue may undergo caseation and liquefaction, or may becomeencapsulated by fibrous tissue--"encysted tubercle. " [Illustration: FIG.  124. --Tuberculous Osteomyelitis of Os Magnum, excised from a boy æt.  8. Note well-defined caseous focus, with severalminute foci in surrounding marrow. ] Sometimes the tuberculous granulation tissue spreads in the marrow, assuming the characters of a diffuse infiltration--diffuse tuberculousosteomyelitis. The trabecular framework of the bone undergoes erosionand absorption--rarefying ostitis--and either disappears altogether oronly irregular fragments or sequestra of microscopic dimensions remainin the area affected. Less frequently the trabecular framework is addedto by the formation of new bone, resulting in a remarkable degree ofsclerosis, and if, following upon this, there is caseation of thetubercle and death of the affected portion of bone, there results asequestrum often of considerable size and characteristic shape, which, because of the sclerosis and surrounding endarteritis, is exceedinglyslow in separating. When the sequestrum involves an articular surface itis often wedge-shaped; in other situations it is rounded or truncatedand lies in the long axis of the medullary canal (Fig. 125). Finally, the sequestrum lies loose in a cavity lined by tuberculous granulationtissue, and is readily identified in a radiogram. This type of sclerosispreceding 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 fromexcess of new bone. ] _Clinical Features. _--As a rule, it is only in superficially placedbones, such as the tibia, ulna, clavicle, mandible, or phalanges, thattuberculous disease in the marrow gives rise to signs sufficientlydefinite to allow of its clinical recognition. In the vertebræ, or inthe bones of deeply seated joints, such as the hip or shoulder, theexistence of tuberculous lesions in the marrow can only be inferred fromindirect signs--such, for example, as rigidity and curvature in the caseof the spine, or from the symptoms of grave and persistent joint-diseasein the case of the hip or shoulder. With few exceptions, tuberculous disease in the interior of a bone doesnot reveal its presence until by extension it reaches one or other ofthe surfaces of the bone. In the shaft of a long bone its eruption onthe periosteal surface is usually followed by the formation of a coldabscess in the overlying soft parts. When situated in the articular endsof bones, the disease more often erupts in relation to the reflection ofthe synovial membrane or directly on the articular surface--in eithercase giving rise to disease of the joint (Fig. 156). [Illustration: Fig. 126. --Diffuse Tuberculous Osteomyelitis of RightTibia. (Photograph lent by Sir H.  J.  Stiles. )] #Diffuse Tuberculous Osteomyelitis in the shaft of a long bone# iscomparatively rare, and has been observed chiefly in the tibia and theulna in children (Fig. 126). It commences at the growing extremity ofthe diaphysis, and spreads along the medulla to a variable extent; it isattended by the formation of vascular and porous bone on the surface, which causes thickening of the diaphysis; this is most marked at theossifying junction and tapers off along the shaft. The infection notonly spreads along the medulla, but it invades the spongy bonesurrounding this, and then the cortical bone, and is only prevented fromreaching the soft parts by the new bone formed by the periosteum. Thebone is replaced by granulation tissue, and disappears, or part of itmay become sclerosed and in time form a sequestrum. In the maceratedspecimen, the sequestrum appears small in proportion to the large cavityin 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 asequestrum, and the amount of new bone on the surface. Finally theperiosteum gives way, and an abscess forms in the soft parts; and ifleft to itself ruptures externally, leaving a sinus. The mostsatisfactory _treatment_ is to resect sub-periosteally the diseasedportion of the diaphysis. _In cancellous bones, such as those of the tarsus_, there is a similarcaseous infiltration in the marrow, and this may be attended with theformation of a sequestrum either in the interior of the bone orinvolving its outer shell, as shown in Fig. 127. The situation andextent of the disease are shown in X-ray photographs. After thetuberculous granulation tissue erupts through the cortex of the bone, itgives rise to a cold abscess or infects adjacent joints or tendonsheaths. [Illustration: FIG.  127. --Advanced Tuberculous Disease in region ofAnkle. The ankle-joint is ankylosed, and there is a large sequestrum inthe calcaneus. (Specimen in Anatomical Museum, University of Edinburgh. )] If an exact diagnosis is made at an early stage of the disease--and thisis often possible with the aid of X-rays--the affected bone is excisedsub-periosteally or its interior is cleared out with the sharp spoon andgouge, the latter procedure being preferred in the case of the_calcaneus_ to conserve the stability of the heel. When several bonesand joints are simultaneously affected, and there are sinuses withmixed infection, amputation is usually indicated, especially in adults. #Tuberculous dactylitis# is the name applied to a diffuse form of thedisease as it affects the phalanges, metacarpal or metatarsal bones. Thelesion presents, on a small scale, all the anatomical changes that havebeen described as occurring in the medulla of the tibia or ulna, andthey are easily followed in skiagrams. A periosteal type of dactylitisis also met with. The _clinical features_ are those of a spindle-shaped swelling of afinger or toe, indolent, painless, and interfering but little with thefunction of the digit. Recovery may eventually occur withoutsuppuration, but it is common to have the formation of a cold abscess, which bursts and forms one or more sinuses. It may be difficult todifferentiate tuberculous dactylitis from the enlargement of thephalanges in inherited syphilis (syphilitic dactylitis), especially whenthe tuberculous lesion occurs in a child who is the subject of inheritedsyphilis. [Illustration: FIG.  128. --Tuberculous Dactylitis. ] In the syphilitic lesion, skiagrams usually show a more abundantformation of new bone, but in many cases the doubt is only cleared up byobserving the results of the tuberculin test or the effects ofanti-syphilitic treatment. Sarcoma of a phalanx or metacarpal bone may closely resemble adactylitis both clinically and in skiagrams, but it is rare. _Treatment. _--Recovery under conservative measures is not uncommon, andthe functional results are usually better than those following uponoperative treatment, although in either case the affected finger isliable to be dwarfed (Fig. 129). The finger should be immobilised in asplint, and a Bier's bandage applied to the upper arm. Operativeinterference is indicated if a cold abscess develops, if there is apersistent sinus, or if a sequestrum has formed, a point upon whichinformation is obtained by examination with the X-rays. When a toe isaffected, amputation is the best treatment, but in the case of a fingerit is rarely called for. In the case of a metacarpal or metatarsal bone, sub-periosteal resection is the procedure of choice, saving thearticular ends if possible. [Illustration: FIG.  129. --Shortening of Middle Finger of Adult, theresult of Tuberculous Dactylitis in childhood. ] SYPHILITIC DISEASE Syphilitic affections of bone may be met with at any period of thedisease, but the graver forms occur in the tertiary stage of acquiredand inherited syphilis. The virus is carried by the blood-stream to allparts of the skeleton, but the local development of the disease appearsto be influenced by a predisposition on the part of individual bones. Syphilitic diseases of bone are much less common in practice than thosedue to pyogenic and tuberculous infectious, and they show a markedpredilection for the tibia, sternum, and skull. They differ fromtuberculous affections in the frequency with which they attack theshafts of bones rather than the articular ends, and in the comparativerarity of joint complications. _Evanescent periostitis_ is met with in acquired syphilis during theperiod of the early skin eruptions. The patient complains, especially atnight, of pains over the frontal bone, ribs, sternum, tibiæ, or ulnæ. Localised tenderness is elicited on pressure, and there is slightswelling, which, however, rarely amounts to what may be described as a_periosteal node_. In the later stages of acquired syphilis, _gummatous periostitis andosteomyelitis_ occur, and are characterised by the formation in theperiosteum and marrow of circumscribed gummata or of a diffuse gummatousinfiltration. The framework of the bone is rarefied in the areaimmediately involved, and sclerosed in the parts beyond. If thegummatous tissue degenerates and breaks down, and especially if theoverlying skin is perforated and septic infection is superadded, thebone disintegrates and exhibits the condition known as _syphiliticcaries_; sometimes a portion of bone has its blood supply so farinterfered with that it dies--_syphilitic necrosis_. Syphiliticsequestra are heavier and denser than normal bone, because sclerosisusually precedes death of the bone. The bones especially affected bygummatous disease are: the skull, the septum of the nose, the nasalbones, palate, sternum, femur, tibia, and the bones of the forearm. _In the bones of the skull_, gummata may form in the peri-cranium, diploë, or dura mater. An isolated gumma forms a firm elastic swelling, shading off into the surroundings. In the macerated bone there is adepression or an actual perforation of the calvaria; multiple gummatatend to fuse with one another at their margins, giving the appearance ofa combination of circles: these sometimes surround an area of bone andcut it off from its blood supply (Fig. 130). If the overlying skin isdestroyed and septic infection superadded, such an isolated area of boneis apt to die and furnish a sequestrum; the separation of the dead boneis extremely slow, partly from the want of vascularity in the sclerosedbone round about, and partly from the density of the sequestrum. Inexceptional cases the necrosis involves the entire vertical plate of thefrontal bone. Pus is formed between the bone and the dura (suppurativepachymeningitis), and this may be followed by cerebral abscess or bypyæmia. Gummatous disease in the wall of the orbit may causedisplacement of the eye and paralysis of the ocular muscles. [Illustration: FIG.  130. --Syphilitic Disease of Skull, showing asequestrum in process of separation. ] On the inner surface of the skull, the formation of gummatous tissue maycause pressure on the brain and give rise to intense pain in the head, Jacksonian epilepsy, or paralysis, the symptoms varying with the seatand extent of the disease. The cranial nerves may be pressed upon at thebase, especially at their points of exit, and this gives rise tosymptoms of irritation or paralysis in the area of distribution of thenerves affected. _In the septum of the nose, the nasal bones, and the hard palate_, gummatous disease causes ulceration, which, beginning in the mucousmembrane, spreads to the bones, and being complicated with septicinfection leads to caries and necrosis. In the nose, the disease isattended with stinking discharge (ozœna), the extrusion of portions ofdead bone, and subsequently with deformity characterised by loss of thebridge 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 thevoice a characteristic nasal tone. _Syphilitic disease of the tibia_ may be taken as the type of theaffection as it occurs _in the long bones_. Gummatous disease in theperiosteum may be localised and result in the formation of awell-defined node, or the whole shaft may become the seat of anirregular nodular enlargement (Fig. 132). If the bone is macerated, itis found to be heavier and bulkier than normal; there is diffusesclerosis with obliteration of the medullary canal, and the surface isuneven from heaping up of new bone--hyperostosis (Fig. 131). If aperiosteal gumma breaks down and invades the skin, a syphilitic ulcer isformed with carious bone at the bottom. A central gumma may eat away thesurrounding bone to such an extent that the shaft undergoes pathologicalfracture. In the rare cases in which it attacks the articular end of along bone, gummatous disease may implicate the adjacent joint and giverise to syphilitic arthritis. [Illustration: FIG.  131. --Syphilitic Hyperostosis and Sclerosis ofTibia, on section and on surface view. ] _Clinical Features. _--There is severe boring pain--as if a gimlet werebeing driven into the bone. It is worst at night, preventing sleep, andhas been ascribed to compression of the nerves in the narrowed Haversiancanals. The _periosteal gumma_ appears as a smooth, circumscribed swelling whichis soft and elastic in the centre and firm at the margins, and shadesoff into the surrounding bone. The gumma may be completely absorbed orit may give place to a hard node. In some cases the gumma softens in thecentre, the skin becomes adherent, thin, and red, and finally gives way. The opening in the skin persists as a sinus, or develops into a typicalulcer with irregular, crescentic margins; in either case a probe revealsthe presence of carious bone or of a sequestrum. The health may beimpaired as a result of mixed infection, and the absorption of toxinsand waxy degeneration in the viscera may ultimately be induced. A _central gumma_ in a long bone may not reveal its presence until iterupts through the shell and reaches the periosteal surface or invadesan adjacent joint. Sometimes the first manifestation is a fracture ofthe bone produced by slight violence. In radiograms the appearance of syphilitic bones is usuallycharacteristic. When there is hyperostosis and sclerosis, the shaftappears denser and broader than normal, and the contour is uneven orwavy. When there is a central gumma, the shadow is interrupted by arounded clear area, like that of a chondroma or myeloma, but there issclerosis round about. _Diagnosis. _--The conditions most liable to be mistaken for syphiliticdisease of bone are chronic staphylococcal osteomyelitis, tuberculosis, and sarcoma; and the diagnosis is to be made by the history and progressof the disease, the result of examination with the X-rays, and theresults of specific tests and treatment. _Treatment. _--The general health is to be improved by open air, bynourishing food, and by the administration of cod-liver oil, iron, andarsenic. Anti-syphilitic remedies should be given, and if they areadministered before there is any destruction of tissue, the benefitderived from them is usually marked. Radiograms show the rapid absorption of the new bone both on the surfaceand in the marrow, and are of value in establishing the therapeuticdiagnosis. In certain cases, and particularly when there are destructive changes inthe bone complicated with pyogenic infection, specific remedies havelittle effect. In cases of persistent or relapsing gummatous diseasewith ulceration of skin, it is often necessary to remove the diseasedsoft parts with the sharp spoon and scissors, and to gouge or chiselaway the unhealthy bone, on the same lines as in tuberculous disease. When hyperostosis and sclerosis of the bone is attended with severe painwhich does not yield to blistering, the periosteum may be incised andthe sclerosed bone perforated with a drill or trephine. #Lesions of Bone in Inherited Syphilis. #--_Craniotabes_, in which theflat bones of the skull undergo absorption in patches, was formerlyregarded as syphilitic, but it is now known to result from prolongedmalnutrition from any cause. _Bossing of the skull_ resulting in theformation of Parrot's nodes is also being withdrawn from the category ofsyphilitic affections. The lesions in infancy--epiphysitis, bossing ofthe skull, and craniotabes--have been referred to in the chapter oninherited syphilis. _Epiphysitis or Syphilitic Perichondritis. _--The first of these terms ismisleading, because the lesion involves the ossifying junction and theshaft of the bone, and the epiphysis only indirectly. The young bone isreplaced by granulation tissue, so that large clear areas are seen withthe X-rays. The symptoms are referred to the joint, because it is therethat the muscles are inserted and drag on the perichondrium whenmovement 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 tocry when touched. The mother discovers that the pain is caused by movinga particular limb, usually the arm, as the humerus, radius, and ulna arethe bones most commonly affected; the limb, moreover, hangs useless atthe 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 ofthe acquired disease, but as they affect bones which are still activelygrowing, the effects are more striking. Gummatous disease may come andgo over periods of many years, with the result that the externalappearance and architectural arrangement of a long bone come to beprofoundly altered. In the tibia, for example, the shaft is bowedforward in a gentle curve, which is compared to the curve of asabre--"sabre-blade" deformity (Fig. 132). The diffuse thickening allround the bone obscures the sharp margins so that the bone becomescircular in section and the anterior and mesial edges are blunted, andthe comparison to a cucumber is deserved. In some cases the tibia isactually increased in length as well as in girth. [Illustration: FIG.  132. --Sabre-blade Deformity of Left Tibia inInherited Syphilis. (From a photograph lent by Sir George T. Beatson. )] The contrast between the grossly enlarged and misshapen tibia and thenormal or even attenuated fibula is a striking one. _Treatment_ is carried out on lines similar to those recommended in theacquired disease. When curving of the tibia causes disability inwalking, the bone may be straightened by a cuneiform resection. _Syphilitic dactylitis_ is met with chiefly in children. It may affectany of the fingers or toes, but is commonest in the first phalanx of theindex-finger or of the thumb. Several fingers may be attacked at thesame time or in succession. The lesion consists in a gummatousinfiltration of the soft parts surrounding the phalanx, or a gummatousosteomyelitis, but there is practically no tendency to break down anddischarge, or to the formation of a sequestrum as is so common intuberculous dactylitis. The finger becomes the seat of a swelling, which is more evident on thedorsal aspect, and, according to the distribution and extent of thedisease, it is acorn-shaped, fusiform, or cylindrical. It is firm andelastic, and usually painless. The movements are impaired, especially ifthe joints are involved. In its early stages the disease is amenable toanti-syphilitic treatment, and complete recovery is the rule. HYDATID DISEASE This rare disease results from the lodgment of the embryos of the tæniaechinoccus, which are conveyed to the marrow by the blood-stream. Thecysts are small, usually about the size of a pin-head, and they arepresent in enormous numbers scattered throughout the marrow. The partsof the skeleton most often affected are the articular ends of the longbones, the bodies of the vertebræ, and the pelvis. As the cysts increase in number and in size, the framework of the boneis gradually absorbed, and there result excavations or cavities. Themarrow and spongy bone first disappear, the compact tissue then becomesthin, and pathological fracture may result. The bone becomes expanded, and the cysts may escape through perforations into the surroundingcellular tissue, and when thus freed from confinement may attainconsiderable dimensions. Suppuration from superadded pyogenic infectionmay be attended with extensive necrosis, and lead to disorganisation ofthe adjacent joint. _Clinical Features. _--The patient complains of deep-seated pains. Insuperficial bones, such as the tibia, there is enlargement, and it maybe possible to recognise egg-shell crackling, or unequal consistence ofthe bone, which is hard in some parts, and doughy and elastic in others. The disease may pursue an indolent course during months or years untilsome complication occurs, such as suppuration or fracture. With theoccurrence of suppuration the disease becomes more active, and abscessesmay form in the soft parts and in the adjacent joint. In the vertebralcolumn, hydatids give rise to angular deformity and paraplegia. In thepelvis, there is usually great enlargement of the bones, and whensuppuration occurs it is apt to infect the hip-joint and to terminatefatally. Examination with the X-rays shows the characteristic excavations of thebone caused by the cysts. The disease is liable to be mistaken forcentral tumour, gumma, tuberculosis, or abscess of bone. The _treatment_ consists in thorough eradication of the parasite byoperation. The bone is laid open and scraped or resected according tothe extent of the disease, and the raw surfaces swabbed with 1 per cent. Formalin. In advanced cases complicated with spontaneous fracture orwith 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 nervoussystem. RICKETS Rickets or rachitis is a constitutional disease associated withdisturbance of nutrition, and attended with changes in the skeleton. The disease is most common and most severe among the children of thepoorer classes in large cities, who are improperly fed and are broughtup in unhealthy surroundings. There is evidence that the most importantfactors in the causation of rickets are ill-health of the mother duringpregnancy, and the administration to the child after its birth of foodwhich is defective in animal fat, proteids, and salts of lime, or whichcontains these in such a form that they are not readily assimilated. Theoccurrence of the disease is favoured, and its features are aggravated, by imperfect oxygenation of the blood as the result of a deficiency offresh air and sunlight, want of exercise, and by other conditions whichprevail 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 ofossification. The affected bones lose their rigidity, so that they arebent under the weight of the body, by the traction of muscles, and byother mechanical forces. The _periosteum_ is thick and vascular, and when detached carries withit plates and spicules of soft porous bone. The new bone may be soabundant that it forms a thick crust on the surface, and in the flatbones of the skull this may be heaped up in the form of bosses or ridgesresembling those ascribed to inherited syphilis. In the epiphysial cartilages and at the ossifying junctions, all theprocesses concerned in ossification, excepting the deposition of limesalts, occur to an exaggerated degree. The cartilage of the epiphysialdisc proliferates actively and irregularly, so that it becomes softer, thicker, and wider, and gives rise to a visible swelling, best seen atthe lower end of the radius and lower end of the tibia, and at thecosto-chondral junctions where the series of beaded swellings is knownas the "rickety rosary. " The ossifying zone is increased in depth; the marrow is abnormallyvascular; and the new bone that is formed is imperfectly calcified. Theresult is that the bones may never attain their normal length, and theyremain stunted throughout life as in rickety dwarfs (Fig. 133), or theshafts may grow unequally and come to deviate from their normal axes asin 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 thewell-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 ofbone, the cortex becomes porous, the spongy bone is rarefied, and thebones readily bend or break under mechanical influences. When thedisease is arrested, a process of repair sets in which often results inthe bones becoming denser and heavier than normal. In the flat bones ofthe skull, the absorption may result in the entire disappearance ofareas of bone, leaving a membrane which dimples like thin cardboardunder the pressure of the finger--a condition known as _craniotabes_. _Changes in the Skeleton before the Child is able to walk. _--Thefontanelles remain open until the end of the second year or longer, andthe frontal and parietal eminences are unduly prominent. There issometimes hydrocephalus, and the head is characteristically enlarged. The jaws are altered so that while the upper jaw is contracted into theshape 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 chieffeature may be the beading at the costo-chondral junctions, principallyof the fifth and sixth ribs or its walls may be contracted, particularly if respiration is interfered with as a result of bronchialcatarrh or adenoids. The contraction may take the form of a verticalgroove on each side, or of a horizontal groove at the level of the upperend of the xiphi-sternum; when the sternum and cartilages form aprojection in front, the deformity is known as "pigeon-breast. " The _spine_ may be curved backwards--_kyphosis_--throughout itswhole extent or only in one part; or it may be curved to oneside--_scoliosis_. In the _limbs_, the prominent features are the deficient growth inlength of the long bones, the enlargements at the epiphysial junctions, and the bending, and occasional greenstick fracture, of the shafts. Thedegree of enlargement of the epiphysial junctions is directlyproportionate to the amount of movement to which the bone is subjected(John Thomson). The curves at this stage depend on the attitude of thechild while sitting or being carried--for example, the arm bones becomebent 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, theweight of the limb may lead to curvature of the neck of the femur--coxavara. The clavicle or humerus may sustain greenstick fracture from thechild being lifted by the arms; the femur, by a fall. From the extremelaxity of the ligaments, the joints can be moved beyond the normallimits, and the child is often observed to twist its limbs into abnormalattitudes. _In Children who have walked. _--In these children the most importantdeformities occur in the spine, pelvis, and lower extremities, andresult for the most part from yielding of the softened bones under theweight of the body. Scoliosis is the usual type of spinal curvature, andin extreme cases it may lead to a pronounced form of hump-back. Thepelvis may remain small (_justo-minor pelvis_), or it may be contractedin the sagittal plane (_flat pelvis_); when the bones are unusuallysoft, the acetabular portions are pushed inwards by the femora bearingthe 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 forwardsand laterally; the bones of the leg laterally as in bow-leg, orforwards, or forwards and laterally just above the ankle. Thedeformities at the knee (genu valgum, genu varum, and genu recurvatum), and at the hip (coxa vara), will be described in the volume dealing withthe Extremities. The majority of cases seen in surgical practice suffer from thedeformities resulting from rickets rather than from the active disease. The examination of a large series of children at different ages showsthat the deformities become less and less frequent with each year. Thosewho recover may ultimately show no trace of rickets, and this isespecially true of children who grow at the average rate; in those, however, in whom growth is retarded, especially from the fifth to theseventh year, the deformities are apt to be permanent. It may be notedthat the scoliosis due to rickets has little tendency towards recovery. _Treatment. _--The treatment of the disease consists in regulating thediet, improving the surroundings, and preventing deformity. Phosphorusin doses of 100th grain may be given dissolved in cod-liver oil, andpreparations of iron and lime may be added with advantage. To avoidthose postures which predispose to deformities, the child should lie asmuch as possible. In the well-to-do classes this is readily accomplishedby the aid of a nurse and the use of a perambulator. In hospitalout-patients the child is kept off its feet by the use of a light woodensplint applied to the lateral aspect of each lower extremity, andextending from the pelvis to 6 inches beyond the sole. When deformities are already present, the treatment depends upon whetheror not there is any prospect of the bone straightening naturally. Underfive years of age this may, as a rule, be confidently expected; thechild should be kept off its feet, and the limbs bathed and massaged. Inchildren of five or six and upwards, the prospect of naturalstraightening is a diminishing one, and it is more satisfactory tocorrect the deformity by operation. In rickety curvature of the spine, the child should lie on a firm mattress, or, to allow of its being takeninto the open air, upon a double Thomas' splint extending from theocciput to the heels; the muscles acting on the trunk should be bracedup by massage and appropriate exercises. #Late Rickets# or #Rachitis Adolescentium# is met with at any age fromnine to seventeen, and is generally believed to be due to arecrudescence of rickets which had been present in childhood. Thedisease is not attended with any disturbance of the general health; thepathological changes are the same as in infantile rickets, but are forthe most part confined to the ossifying junctions, especially thosewhich are most active during adolescence, for example at the knee-joint. The patient is easily tired, complains of pain in the bones, and, unlesscare is taken, deformity is liable to ensue. There can be no doubt thatadolescent rickets plays an important part in the production of thedeformities which occur at or near puberty, especially knock-knee andbow-knee. #Scurvy-Rickets# or #Infantile Scurvy#. --This disease, described byBarlow and Cheadle, is met with in infants under two years who have beenbrought up upon sterilised or condensed milk and other proprietaryfoods, and is most common in the well-to-do classes. The hæmorrhages, which are so characteristic of the disease, are usually preceded forsome weeks by a cachectic condition, with listlessness and debility anddisinclination for movement. Very commonly the child ceases to move oneof his lower limbs--pseudo-paralysis--and screams if it is touched; aswelling is found over one of the bones, usually the femur, accompaniedby exquisite tenderness; the skin is tense and shiny, and there may besome œdema. These symptoms are due to a sub-periosteal hæmorrhage, andassociated with this there may be crepitus from separation of anepiphysis, rarely from fracture of the shaft of the bone. X-rayphotographs show enlargement of the bone, the periosteum being raisedfrom the shaft and new bone formed in relation to it. Hæmorrhages alsooccur into the skin, presenting the appearance of bruises, into theorbit and conjunctiva, and from the mucous membranes. The _treatment_ consists in correcting the errors in diet. The infantshould have a wet nurse or a plentiful supply of cow's milk in itsnatural state. Anti-scorbutics in the form of orange, lemon, or grapejuice, 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 andyielding, so that they are unduly liable to bend or break. One form occurs in _pregnant and puerperal women_, affecting mostcommonly the pelvis and lumbar vertebræ, but sometimes the entireskeleton. The lime salts are absorbed, the bones lose their rigidity andbend under the weight of the body and other mechanical influences, withthe result that gross deformities are produced, particularly in thepelvis, the lumbar spine, and the hip-joints. _Neuropathic_ forms occur in certain chronic diseases of the brain andcord; in some cases the bones lose their lime salts and bend, in othersthey become brittle. _Osteomalacia associated with New Growths in the Skeleton. _--When_secondary cancer_ is widely distributed throughout the skeleton, it isassociated with softening of the bones, as a result of which theyreadily bend or break, and after death are easily cut with a knife. Inthe disease known as _multiple myeloma_, the interior of the ribs, sternum, and bodies of the vertebræ is occupied by a reddish gelatinouspulp, the structure of which resembles sarcoma; the bones are reduced toa mere shell, and may break on the slightest pressure; the urinecontains albumose, a substance resembling albumen but coagulating at acomparatively low temperature (140° F. ), and the coagulum isre-dissolved on boiling, and it is readily precipitated by hydrochloricacid (Bence-Jones). #Ostitis Deformans--Paget's Disease of Bone. #--This rare disease wasfirst described by Sir James Paget in 1877. In the early stages, themarrow is transformed into a vascular connective tissue; its bone-eatingfunctions are exaggerated, and the framework of the bone becomesrarefied, so that it bends under pressure as in osteomalacia. In courseof time, however, new bone is formed in great abundance; it is at firstdevoid of lime salts, but later becomes calcified, so that the bonesregain their rigidity. This formation of new bone is much in excess ofthe normal, the bones become large and bulky, their surfaces rough anduneven, their texture sclerosed in parts, and the medullary canal isfrequently obliterated. These changes are well brought out in X-rayphotographs. The curving of the long bones, which is such a strikingfeature of the disease, may be associated with actual lengthening, andthe changes are sometimes remarkably symmetrical (Fig. 135). The bonesforming the cranium may be enormously thickened, the sutures areobliterated, the distinction into tables and diploë is lost, and, whilethe general texture is finely porous, there may be areas as dense asivory (Fig. 134). [Illustration: FIG.  134. --Changes in the Skull resulting from OstitisDeformans. (Anatomical Museum, University of Edinburgh. )] _Clinical Features. _--The disease is usually met with in persons overfifty years of age. It is insidious in its onset, and, the patient'sattention may be first attracted by the occurrence of vague pains in theback or limbs; by the enlargement and bending of such bones as the tibiaor femur; or by a gradual increase in the size of the head, necessitating the wearing of larger hats. When the condition is fullydeveloped, the attitude and general appearance are eminentlycharacteristic. The height is diminished, and, owing to the curving ofthe lower limbs and spine, the arms appear unnaturally long; the headand 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; thewhole appearance suggests that of one of the large anthropoid apes. Themuscles 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 themajority of cases the bones of the lower extremities are much earlierand more severely affected than those of the upper extremity, but thecapacity of walking is usually maintained even in the presence of greatdeformity. In a case observed by Byrom Bramwell, the patient sufferedfrom a succession of fractures over a period of years. [Illustration: FIG.  135. --Cadaver, illustrating the alterations in theLower Limbs resulting from Ostitis Deformans. ] The disease may last for an indefinite period, the general healthremaining long unaffected. In a considerable number of the recordedcases one of the bones became the seat of sarcoma. #Osteomyelitis Fibrosa. #--This comparatively rare disease, which wasfirst described by Recklinghausen, presents many interesting features. Because of its causing deformities of the bones and an undue liabilityto fracture, and being chiefly met with in adolescents, it is regardedby some authors as a juvenile form of Paget's disease. It may bediffused throughout the skeleton--we have seen it in the skull and inthe bones of the extremities--or it may be confined to a single bone, usually the femur, or, what is more remarkable, the condition may affecta portion only of the shaft of a long bone and be sharply defined fromthe normal bone in contact with it. [Illustration: FIG.  136. --Osteomyelitis Fibrosa affecting Femora in aman æt.  19. The curving of the bones is due to multiple fractures. ] On longitudinal section of a long bone during the active stage of thedisease, the marrow is seen to be replaced by a vascular youngconnective tissue which encroaches on the surrounding spongy bone, reducing it to the slenderest proportions; the formation of bone fromthe periosteum does not keep pace with the absorption and replacementgoing on in the interior, and the cortex may be reduced to a thin shellof imperfectly calcified bone which can be cut with a knife. The youngconnective tissue which replaces the marrow is not unlike that seen inosteomalacia; it is highly vascular and may show hæmorrhages of variousdate; there are abundant giant cells of the myeloma type, anddegeneration and liquefaction of tissue may result in the formation ofcysts, which, when they constitute a prominent feature, are responsiblefor the name--_osteomyelitis fibrosa cystica_--sometimes applied to thecondition. It would appear that most of the recorded cases of _cysts of bone_ owetheir origin to this disease, while the abundance of giant cells withoccasional islands of cartilage in the wall of such cysts is responsiblefor the view formerly held that they owed their origin to theliquefaction of a solid tumour, such as a myeloma, a chondroma, or evena sarcoma. Although the tissue elements in this disease resemble thoseof a new growth arising in the marrow, they differ in their arrangementand in their method of growth; there is no tendency to erupt through thecortex of the bone, to invade the soft parts, or to give rise tosecondary growths. _Clinical Features. _--The onset of the disease is insidious, andattention is usually first directed to it by the occurrence of fractureof the shaft of one of the long bones--usually the femur--from violencethat 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 unevencontour are sufficiently remarkable to suggest examination with theX-rays, by means of which the condition is at once recognised. Asystematic examination of the other long bones will often reveal thepresence of the disease at a stage before the bone is alteredexternally. Symmetrical bossing of the skull was present in the case shown inFigs. 136 and 137, and there were also scattered patches of brownpigmentation of the skin of the face, neck, and trunk, similar to thosemet with in generalised neuro-fibromatosis. Apart from fracture, thedisease is recognised by the thickening and usually also by the curvingof the shafts of the long bones. It is easy to understand the curvatureof bones that have passed through a soft stage and also of those thathave been broken and badly united, but it is difficult to account forthe curvatures that have no such cause; for example, we have seenmarked curve of the radius in a forearm of which the ulna was quitestraight. The curvature probably resulted from exaggerated growth inlength. [Illustration: FIG.  137. --Radiogram of Upper End of Femur showingappearances in Osteomyelitis Fibrosa. ] The X-ray appearances vary with the stage of the malady, not estimatedin time, for the condition is chronic and may become stationary, butaccording to whether it is progressive or undergoing repair. The shadowof the bone presents a poor contrast to the soft parts, and no trace ofits original architecture; in extreme cases the shadow of the femurresembles an unevenly filled sausage (Fig. 137); there is no corticallayer, the interior shows no trabecular structure, and some of the manyclear areas are probably cysts. The condition extends right up to thearticular cartilage, or, in the case of adolescent bones, up to theepiphysial cartilage. _Prognosis. _--The condition does not appear to affect the generalhealth. The future is concerned with the local conditions, and, especially in the case of the femur, with its liability to fracture; sofar as we know there is no time limit to this. _Treatment_ is confined to protecting the affected bone--usually thefemur--from injury. Operative treatment may be required for lameness dueto a badly united fracture. #Neuropathic Atrophy of Bone. #--The conditions included under thisheading occur in association with diseases of the nervous system. Most importance attaches to the fragility of the bones met with ingeneral paralysis of the insane, locomotor ataxia, and other chronicdiseases of the brain and spinal cord. The bones are liable to befractured by forces which would be insufficient to break a healthy bone. In _locomotor ataxia_ the fractures affect especially the bones of thelower extremity, and may occur before there are any definite nervesymptoms, but they are more often met with in the ataxic stage, when theabrupt and uncontrolled movements of the limbs may play a part in theircausation. They may be unattended with pain, and may fail to unite; whenrepair does take place, it is sometimes attended with an excessiveformation of callus. Joint lesions of the nature of Charcot's diseasemay occur simultaneously with the alterations in the bones. In_syringomyelia_ pathological fracture is not so frequent as in locomotorataxia; it is more likely to occur in the bones of the upper extremity, and especially in the humerus. In some cases of _epilepsy_ the bonesbreak when the patient falls in a fit, and there is usually anexaggerated amount of comminution. In these affections the bones present no histological or chemicalalterations, and the X-ray shadow does not differ from the normal. It ismaintained, therefore, that the disposition to fracture does not dependupon a fragility of the bone, but on the loss of the muscular sense andof common sensation in the bones, as a result of which there is aninability properly to throw the muscles into action and dispose thelimbs so as to place them under the most favourable conditions to meetexternal violence. #Osteogenesis Imperfecta#, #Fragilitas Ossium#, or #CongenitalOsteopsathyrosis#. --These terms are used to describe a condition inwhich an undue fragility of the bones dates from intra-uterine life. Itmay occur in several members of the same family. In severe cases, intra-uterine fractures occur, and during parturition fresh fracturesare almost sure to be produced, so that at birth there is a combinationof recent fractures and old fractures united and partly united, withbendings and thickenings of the bones. Large areas of the cranial vaultmay remain membranous. After birth the predisposition to fracture continues, the bones areeasily broken, the fractures are attended with little or no pain, thecrepitus is soft, and although union may take place, it may be delayedand be attended with excess of callus. Cases have been observed in whicha child has sustained over a hundred fractures. The bones show a feeble shadow with the X-rays, and appear thin andatrophied; the medullary canal is increased at the expense of thecortex. In young infants in whom multiple fractures occur the prognosis as tolife is unfavourable, and no satisfactory treatment of the disease hasbeen formulated. If the patient survives, the tendency to fracturegradually disappears. #Hypertrophic Pulmonary Osteo-Arthropathy. #--This condition, which wasdescribed by Marie in 1890, is secondary to disease in the chest, suchas 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 theterminal segments of the digits hypertrophied. The fingers come toresemble drum-sticks, and the thumb the clapper of a bell. The nails areconvex, and incurved at their free ends, suggesting a resemblance to thebeak of a parrot. There is also enlargement of the lower ends of thebones of the forearm and leg, and effusion into the wrist andankle-joints. Skiagrams of the hands and feet show a deposit of new bonealong the shafts of the phalanges. TUMOURS OF BONE New growths which originate in the skeleton are spoken of as _primarytumours_; those which invade the bones, either by metastasis from otherparts of the body or by spread from adjacent tissues, as _secondary_. Atumour 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 usuallysolitary, although certain forms, such as the chondroma, may be multiplefrom the outset. _Periosteal tumours_ are at first situated on one side of the bone, butas they grow they tend to surround it completely. Innocent periostealtumours retain the outer fibrous layer as a capsule. Malignant tumourstend to perforate the periosteal capsule and invade the soft parts. _Central_ or _medullary tumours_ as they increase in size replace thesurrounding bone, and simultaneously new bone is formed on the surface;as this is in its turn absorbed, further bone is formed beneath theperiosteum, so that in time the bone is increased in girth, and is saidto be "expanded" by the growth in its interior. #Primary Tumours--Osteoma. #--When the tumour projects from the surfaceof a bone it is called an _exostosis_. When growing from bones developedin membrane, such as the flat bones of the skull, it is usually denselike ivory, and the term _ivory exostosis_ is employed. When derivedfrom hyaline cartilage--for example, at the ends of the long bones--itis known as a _cartilaginous exostosis_. This is invested with a cap ofcartilage from which it continues to grow until the skeleton attainsmaturity. An exostosis forms a rounded or mushroom-shaped tumour of limited size, which may be either sessile or pedunculated, and its surface is smoothor nodulated (Figs. 138 and 139). A cartilaginous exostosis in thevicinity of a joint may be invested with a synovial sac or bursa--theso-called _exostosis bursata_. The bursa may be derived from thesynovial membrane of the adjacent joint with which its cavity sometimescommunicates, or it may be of adventitious origin; when it is the seatof bursitis and becomes distended with fluid, it may mask the underlyingexostosis, which then requires a radiogram for its demonstration. [Illustration: FIG.  138. --Radiogram of Right Knee showing MultipleExostoses. ] _Clinically_, the osteoma forms a hard, indolent tumour attached to abone. The symptoms to which it gives rise depend on its situation. Inthe vicinity of a joint, it may interfere with movement; on the medialside of the knee it may incapacitate the patient from riding. Whengrowing from the dorsum of the terminal phalanx of the greattoe--_subungual exostosis_--it displaces the nail, and may projectthrough its matrix at the point of the toe, while the soft parts over itmay be ulcerated from pressure (Fig. 107). It incapacitates the patientfrom wearing a boot. When it presses on a nerve-trunk it causes painsand cramps. In the orbit it displaces the eyeball; in the nasal fossæand in the external auditory meatus it causes obstruction, which may beattended with ulceration and discharge. In the skull it may projectfrom the outer table, forming a smooth rounded swelling, or it mayproject from the inner table and press upon the brain. The diagnosis is to be made by the slow growth of the tumour, itshardness, 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 ceasesto grow when the skeleton is mature and has no tendency to change itsbenign character. If causing symptoms, it is removed by dividing theneck or base of the tumour with a chisel, care being taken to remove thewhole of the overlying cartilage. The dense varieties met with in thebones of the skull present greater difficulties; if it is necessary toremove them, the base or neck of the tumour is perforated in manydirections 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 placedin 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 thefunction of the glands of internal secretion, the thyreoid being the onewhich is most likely to be at fault (Arthur Keith). The disorder ofgrowth is confined to those elements of the skeleton where a core ofbone formed in cartilage comes to be encased in a sheath of bone formedbeneath the periosteum. To indicate this abnormality the name_diaphysial aclasis_ has been employed by Arthur Keith at the suggestionof Morley Roberts. Bones formed entirely in cartilage are exempt, namely, the tarsal andcarpal bones, the epiphyses of the long bones, the sternum, and thebodies of the vertebræ. Bones formed entirely in membrane, that is, those of the face and of the cranial vault, are also exempt. Thedisorder mainly affects the ossifying junctions of the long bones of theextremities, the vertebral border of the scapula, and the cristal borderof the ilium. _Clinically_ the disease is attended with the gradual and painlessdevelopment during childhood or adolescence of a number of tumours orirregular projections of bone, at the ends of the long bones, thevertebral border of the scapula, and the cristal border of the ilium. They exhibit a rough symmetry; they rarely attain any size; and theyusually cease growing when the skeleton attains maturity--the conversionof cartilage into bone being then completed. While they originate fromthe ossifying junctions of the long bones, they tend, as the shaftincreases in length, to project from the surface of the bone at somedistance from the ossifying junction and to "point" away from it. Theymay cause symptoms by "locking" the adjacent joint or by pressing uponnerve-trunks or blood vessels. In a considerable proportion of cases, the disturbance of growth isfurther manifested by dwarfing of the long bones; these are not onlydeficient in length but are sometimes also curved and misshapen, whichaccounts for the condition being occasionally confused with thedisturbances of growth resulting from rickets. In about one-third of therecorded cases there is a dislocation of the head of the radius on oneor on both sides, a result of unequal growth between the bones of theforearm. [Illustration: FIG.  140. --Multiple Cartilaginous Exostoses in aman æt.  27. The scapular tumour projecting above the right clavicle hastaken on active growth and pressed injuriously on the cords of thebrachial plexus. ] In early adult life, one of the tumours, instead of undergoingossification, may take on active growth and exhibit the features of achondro-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 strikingcharacter; apart from the outgrowths of bone or "tumours" there isevident a widespread alteration in the internal architecture of thebones, which suggests analogies with other disturbances of ossificationsuch as achondroplasia and osteomyelitis fibrosa. The condition is onethat runs in families, sometimes through several generations; we havemore than once seen a father and son together in the hospitalwaiting-room. As regards _treatment_, there is no indication for surgical interferenceexcept when one or other tumour is a source of disability as by pressingupon a nerve-trunk or by locking a joint, in which case it is easilyremoved by chiselling through its neck. [Illustration: FIG.  141. --Multiple Cartilaginous Exostoses in aman æt.  27, the same as in Fig. 140. ] _Diffuse Osteoma, Leontiasis Ossea. _--This rare affection was describedby Virchow, and named leontiasis ossea because of the disfigurement towhich it gives rise. It usually commences in adolescence as a diffuseovergrowth first of one and then of both maxillæ; these bones areenlarged in all directions and project on the face, and the nasal fossæand the maxillary and frontal sinuses become filled up with bone, whichencroaches also on the orbital cavities. In addition to the hideousdeformity, the patient suffers from blocking of the nose, loss of smell, and protrusion of the eyes, sometimes followed by loss of sight. Thecondition is liable to spread to the zygomatic and frontal bones, thevault of the skull, and to the mandible. The base of the skull is notaffected. The disease is of slow progress and may become arrested; lifemay be prolonged for many years, or may be terminated by braincomplications or by intercurrent affections. In certain cases it ispossible to remove some of the more disfiguring of the bony masses. A less aggressive form, confined to the maxilla on one side, issometimes met with, and, in a case of this variety under our ownobservation, the disfigurement, which was the only subject of complaint, was removed, after reflecting the soft parts, by paring away the excessof bone; this is easily done as the bone is spongy, and at an earlystage, imperfectly calcified. A remarkable form of _unilateral hypertrophy and diffuse osteoma of theskull_, following the distribution of the fifth nerve, has seendescribed by Jonathan Hutchinson and Alexis Thomson. #Chondroma. #--Cartilaginous tumours, apart from those giving rise tomultiple 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 ofa bone, the so-called _enchondroma_. The hyaline cartilage composing the tumour frequently undergoesmyxomatous degeneration, resulting in the formation of a glairy, semi-fluid jelly, and if this change takes place throughout the tumourit comes to resemble a cyst. On the other hand, the cartilage mayundergo calcification or ossification. The most important transition ofall 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 giverise to secondary growths, especially in the lungs. Cases have been met with in which certain parts of the skeleton--onlythose developed in cartilage--were so uniformly permeated with cartilagethat the condition has been described as a "chondromatosis" and isregarded as dating from an early period of fœtal life. Unlike thecondition known as multiple cartilaginous exostoses, it is a malignantdisease. [Illustration: FIG.  142. --Multiple Chondromas of Phalanges andMetacarpals in a boy æt.  10 (cf. Fig. 143). ] The chondroma is met with as a slowly growing tumour which is speciallycommon in the bones of the hand, often in a multiple form (Figs. 142 and144). The surface is smooth or lobulated, and in consistence the tumourmay be dense and elastic like normal cartilage, or may present areas ofsoftening, or of bony hardness. The skin moves freely over it, except inrelation to the bones of the fingers, where it may become adherent andulcerate, simulating the appearance of a malignant tumour. Large tumoursgrowing from the bones of the extremities may implicate the mainvessels and nerves, either surrounding them or pressing on them. Portions of a chondroma, which have undergone calcification orossification, throw a dark shadow with the X-rays; unaltered cartilageand myxomatous tissue appear as clear areas. [Illustration: FIG.  143. --Skiagram of Multiple Chondromas shownin Fig. 142. ] _Treatment. _--It is necessary to remove the whole tumour, and inchondromas growing from the surface of the bone, especially if they arepedunculated, this is comparatively easy. When a bone, such as thescapula or mandible, is involved, it is better to excise the bone, or atleast the part of it which bears the tumour. In the case of centraltumours the shell of bone is removed over an area sufficient to allow ofthe enucleation of the tumour, or the affected portion of bone isresected. Should there be evidence of malignancy, such as increased rateof growth, a tube of radium should be inserted, and in advanced caseswith destruction of tissue, amputation may be called for. [Illustration: FIG.  144. --Multiple Chondromas in Hand of boy æt.  8] In multiple chondromas of the hand in young subjects, it was formerlythe custom to amputate the limb; an attempt should be made to avoid thisby shelling out the larger tumours individually, and persevering withthe application of the X-rays or of radium to inhibit the growth of thesmaller ones. Chondromas springing from the pelvic bones usually arise in the regionof the sacro-iliac joint; they project into the pelvis and press on thebladder and rectum, and on the sciatic and obturator nerves; sometimesalso on the iliac veins, causing œdema of the legs. They are liable totake on malignant characters, and rarely lend themselves to completeremoval by operation. #Fibroma# is met with chiefly as a periosteal growth in relation to themouth and pharynx, the _simple epulis_ of the alveolar margin and the_naso-pharyngeal polypus_ being the most common examples. We have metwith a fibroma in the interior of the lower end of the femur of anadult, causing expansion of the bone with decided increase in girth andliability to pathological fracture; it is possible that this representsthe cured stage of osteomyelitis fibrosa. _Myxoma_, _lipoma_, and _angioma_ of bone are all rare. #Myeloma. #--The myeloid tumour, which is sometimes classified with thesarcomas, contains as its chief elements large giant cells, like thosenormally present in the marrow. On section these tumours present abrownish-red or chocolate colour, and, being highly vascular, are liableto hæmorrhages, and therefore also to pigmentation, and to the formationof blood cysts. Sometimes the arterial vessels are so dilated as toimpart to the tumour an aneurysmal pulsation and bruit. The enlargementor "expansion" of the bone results in the cortex being represented by athin shell of bone, which may crackle on pressure--parchment oregg-shell crackling. The myeloma is most often met with between the ages of twenty-five andforty in the upper end of the tibia or lower end of the femur. It growsslowly and causes little pain, and may long escape recognition unless anexamination is made with the X-rays. Although these tumours have beenknown to give rise to metastases, they are, as a rule, innocent and areto 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 ofmyeloma is made with the aid of the X-rays: the typical appearance isthat of a rounded or oval clear area bounded by a shell of bone ofdiminishing thickness (Fig. 145). The inflammatory lesions at the endsof the long bones--tubercle, syphilitic gumma, and Brodie's abscess, that resemble myeloma, are all attended with the formation of new bonein greater or lesser amount. The myeloma is also to be diagnosed fromchondroma, 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 accessto the tumour tissue, which is scraped out with the spoon. Bloodgoodadvises the use of Esmarch's tourniquet, and that the curetting befollowed by painting with pure carbolic acid and then rinsing withalcohol; a rod of bone is inserted to fill the gap. In advanced casesthe segment of bone is resected and a portion of the tibia or fibulafrom the other limb inserted into the gap; a tube of radium should alsobe 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 alveolarprocess, and is described elsewhere. #Sarcoma# and #endothelioma# are the commonest tumours of bone, andpresent 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 formedfibrous tissue, cartilage, or bone. (1) The _soft cellular tumours_ are composed mainly of spindle or roundcells; they grow from the marrow of the spongy ends or from theperiosteum of the long bones, the diploë of the skull, the pelvis, vertebræ, and jaws. As they grow they may cause little alteration in thecontour of the bone, but they eat away its framework and replace it, sothat the continuity of the bone is maintained only by tumour tissue, andpathological fracture is a frequent result. The small round-celledsarcomas are among the most malignant tumours of bone, growing withgreat 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 fullyformed tissues or attempts at fully formed tissues predominate over thecellular elements. They grow chiefly from the deeper layer of theperiosteum, and at first form a projection on the surface, but latertend to surround the bone (Fig. 150), and to invade its interior, filling up the marrow spaces with a white, bone-like substance; in theflat bones of the skull they may traverse the diploë and erupt on theinner table. The tumour tissue next the shaft consists of a dense, white, homogeneous material, from which there radiate into the softerparts of the tumour, spicules, needles, and plates, often exhibiting afan-like arrangement (Fig. 151). The peripheral portion consists of softsarcomatous tissue, which invades the overlying soft parts. Thearticular cartilage long resists destruction. The ossifying sarcoma ismet with most often in the femur and tibia, less frequently in thehumerus, skull, pelvis, and jaws. In the long bones it may grow from theshaft, while the chondro-sarcoma more often originates at theextremities. Sometimes they are multiple, several tumours appearingsimultaneously or one after another. Secondary growths are met withchiefly in the lungs, metastasis taking place by way of the veins. [Illustration: FIG.  146. --Periosteal Sarcoma of Femur in a youngsubject. ] [Illustration: FIG.  147. --Periosteal Sarcoma of Humerus, aftermaceration. (Anatomical Museum, University of Edinburgh. )] _Clinical Features. _--Sarcoma is usually met with before the age ofthirty, and is comparatively common in children. Males suffer oftenerthan females, in the proportion of two to one. In _periosteal sarcoma_ the presence of a swelling is usually the firstsymptom; the tumour is fusiform, firm, and regular in outline, and whenit occurs near the end of a long bone the limb frequently assumes acharacteristic "leg of mutton" shape (Fig. 146). The surface may beuniform or bossed, the consistence varies at different parts, and theswelling gradually tapers off along the shaft. On firm pressure, finecrepitation may be felt from crushing of the delicate framework of newbone. [Illustration: FIG.  148. --Chondro-Sarcoma of Scapula in a man æt.  63;removal of the scapula was followed two years later by metastases anddeath. ] In _central sarcoma_ pain is the first symptom, and it is usuallyconstant, dull, and aching; is not obviously increased by use of thelimb, but is often worse at night. Swelling occurs late, and is due toexpansion of the bone; it is fusiform or globular, and is at firstdensely hard, but in time there may be parchment-like or egg-shellcrackling from yielding of the thin shell. The swelling may pulsate, anda bruit may be heard over it. In advanced cases it may be impossible todifferentiate between a periosteal and a central tumour, eitherclinically or after the specimen has been laid open. Pathological fracture is more common in central tumours, and sometimesis the first sign that calls attention to the condition. Consolidationrarely takes place, although there is often an attempt at union by theformation 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 Thirdof Femur, after maceration. ] The soft parts over the tumour for a long time preserve their normalappearance; or they become œdematous, and the subcutaneous venousnetwork is evident through the skin. Elevation of the temperature overthe tumour, which may amount to two degrees or more, is a point ofdiagnostic significance, as it suggests an inflammatory lesion. The adjacent joint usually remains intact, although its movements may beimpaired by the bulk of the tumour or by effusion into the cavity. Enlargement of the neighbouring lymph glands does not necessarily implythat they have become infected with sarcoma for the enlargement maydisappear after removal of the primary growth; actual infection of theglands, however, does sometimes occur, and in them the histologicalstructure of the parent tumour is reproduced. To obtain a reasonable prospect of cure, the _diagnosis_ must be made atan early stage. Great reliance is to be placed on information gained byexamination with the X-rays. [Illustration: FIG.  151. --Radiogram of Osteo-Sarcoma of Upper Thirdof Femur. ] _X-ray Appearances. _--In periosteal tumours that do not ossify, there ismerely erosion of bone, and the shadow is not unlike that given bycaries; in ossifying tumours, the arrangement of the new bone on thesurface is characteristic, and when it takes the form of spicules atright angles to the shaft, it is pathognomic. In soft central tumours, there is disappearance of bone shadow in thearea of the tumour, while above and below or around this, the shadow isthat of normal bone right up to the clear area. In many respects theX-ray appearances resemble those of myeloma. In tumours in which thereis a considerable amount of imperfectly formed new bone, this gives ashadow which barely replaces that of the original bone, in parts it mayeven add to it--the resulting picture differing widely in differentcases; but it is usually possible to differentiate it from that causedby bacterial infections of the bone and from lesions of the adjacentjoint. [Illustration: FIG.  152. --Radiogram of Chondro-Sarcoma of Upper End ofHumerus in a woman æt.  29. ] Skiagraphy is not only of assistance in differentiating new growths fromother diseases of bone, but may also yield information as to thesituation and nature of the tumour, which may have important bearings onits treatment by operation. When fracture of a long bone takes place in an adolescent or young adultfrom comparatively slight violence, disease of the bone should besuspected and an X-ray examination made. In difficult cases the final appeal is to exploratory incision andmicroscopical examination of a portion of the tumour; this should bedone when the major operation has been arranged for, the surgeon waitinguntil the examination is completed. The _prognosis_ varies widely. In general, it may be said thatperiosteal tumours are less favourable than central ones, because theyare more liable to give rise to metastases. Permanent cures areunfortunately the exception. _Treatment. _--When one of the bones of a limb is involved, the usualpractice has been to perform amputation well above the growth, and thismay still be recommended as a routine procedure. There are reasons, however, which may be urged against its continuance. High amputation isunnecessary in the more benign sarcomas, and in the more malignant formsis usually unavailing to prevent a fatal issue either from localrecurrence or from metastases in the lungs or elsewhere. Followingthe lead of Mikulicz, a considerable number of permanent cures have beenobtained by resecting the portion of bone which is the seat of thetumour, and substituting for it a corresponding portion from the tibiaor fibula of the other limb. In a cellular sarcoma of the humerus of aboy we resected the shaft and inserted his fibula ten years ago, and heshows no sign of recurrence. When resection is impracticable, asubcapsular enucleation is performed, followed by the insertion ofradium. #Pulsating Hæmatoma# or #Aneurysm of Bone#. --A limited number of theseare innocent cavernous tumours dating from a congenital angioma. Themajority would appear to be the result of changes in a sarcoma, endothelioma, or myeloma. The tumour tissue largely disappears, whilethe vessels and vascular spaces undergo a remarkable development. Thetumour may come to be represented by one large blood-containing spacecommunicating with the arteries of the limb; the walls of the spaceconsist of the remains of the original tumour, plus a shell of bone ofvarying thickness. The most common seats of the condition are the lowerend of the femur, the upper end of the tibia, and the bones of thepelvis. The _clinical features_ are those of a pulsating tumour of slowdevelopment, and as in true aneurysm, the pulsation and bruit disappearon compression of the main artery. The origin of the tumour from bonemay be revealed by the presence of egg-shell crackling, and byexamination with the X-rays. If the condition is believed to be innocent, the treatment is the sameas for aneurysm--preferably by ligation of the main artery; ifmalignant, 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 andthose which spread to bone by direct continuity. _Metastatic Tumours. _--Excepting certain cancers which give rise tometastases by lymphatic permeation (Handley), the common metastasesarising in the bone-marrow reach their destination through theblood-stream. [Illustration: FIG.  153. --Epitheliomatous Ulcer of Leg with directextension to Tibia. (Lord Lister's specimen. Anatomical Museum, University of Edinburgh. )] Secondary cancer is a comparatively common disease, and, as inmetastases in other tissues, the secondary growths resemble the parenttumour. The soft forms grow rapidly, and eat away the bone, withoutaltering its shape or form. In slowly growing forms there may beconsiderable formation of imperfectly formed bone, often deficient inlime salts; this condition may be widely diffused throughout theskeleton, and, as it is associated with softening and bending of thebones, it is known as _cancerous osteomalacia_. Secondary cancer of boneis attended with pain, or it suddenly attracts notice by the occurrenceof pathological fracture--as, for example, in the shaft of the femur orhumerus. In the vertebræ, it is attended with a painful form ofparaplegia, which may involve the lower or all four extremities. On theother 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 ofthe breast, liver, uterus, prostate, colon, and rectum; hyper-nephromaof the kidney may also give rise to metastases in bone. _Secondary tumours derived from the thyreoid gland_ require specialmention, because they are peculiar in that neither the primary growth inthe thyreoid nor the secondary growth in the bones is necessarilymalignant. They are therefore amenable to operative treatment. _Secondary sarcoma_, whether derived from a primary growth in the boneor in the soft parts, is much rarer than secondary cancer. Its removalby operation is usually contra-indicated, but we have known of casesterminating 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-raysgives valuable information and often disclose unsuspected metastases. _Cancer of Bone resulting from Direct Extension from Soft Parts. _--Inthis group there are also two clinical types. The first is met with inrelation 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 asinus_, the sequel of suppurative osteomyelitis, compound fracture, ortuberculous disease. The patient has usually had a discharging sinus fora great number of years: we have known it to last as many as fifty. Theepithelioma originates at the skin orifice of the sinus, and spreads tothe bone and into its interior, where the progress of the cancer isresisted by dense bone, which obliterates the medullary canal. Althoughits progress is slow, the infiltration of the bone is usually moreextensive than appears externally. It is recognised clinically by thecharacteristic cauliflower growth at the orifice of the sinus, and bythe offensive nature of the discharge. A similar epithelioma may arisein connection with a _chronic ulcer of the leg_. The cancer may infectthe femoral lymph glands. The operative treatment is influenced by theextent of the disease in the soft parts overlying the bone, and consistsin wide removal of the diseased tissues and resection of the bone, or inamputation. #Cysts of Bone. #--With the exception of hydatid cysts, cysts in theinterior of bone are the result of the liquefaction of solid tissue;this may be that of chondroma, myeloma, or sarcoma, but more commonly ofthe marrow in osteomyelitis fibrosa. CHAPTER XXI DISEASES OF JOINTS Definition of terms--Ankylosis. DISEASES: Errors of development--Bacterial diseases: _Pyogenic_; _Gonorrhœal_; _Tuberculous_; _Syphilitic_; _Acute rheumatism_--Diseases associated with certain constitutional conditions: _Gout_; _Chronic articular rheumatism_; _Arthritis deformans_; _Hæmophilia_--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 reactionwhich affects the synovial membrane of a joint. It is usually associatedwith effusion of fluid, and this may be serous, sero-fibrinous, orpurulent. As the term synovitis merely refers to the tissue involved, itshould always be used with an adjective--such as gouty, gonorrhœal, ortuberculous--which indicates its pathological nature. The terms _hydrops_, _hydrarthrosis_, and _chronic serous synovitis_ aresynonymous, and are employed when a serous effusion into the joint isthe prominent clinical feature. Hydrops may occur apart fromdisease--for example, in the knee-joint from repeated sprains, or whenthere is a loose body in the joint--but is met with chiefly in thechronic forms of synovitis which result from gonorrhœa, tuberculosis, syphilis, arthritis deformans, or arthropathies of nerve origin. _Arthritis_ is the term applied when not only the synovial membrane butthe articular surfaces, and it may be also the ends of the bones, areinvolved, and it is necessary to prefix a qualifying adjective whichindicates its nature. When effusion is present, it may be serous, as inarthritis deformans, or sero-fibrinous or purulent, as in certain formsof pyogenic and tuberculous arthritis. Wasting of the muscles, especially the extensors, in the vicinity of the joint is a constantaccompaniment of arthritis. On account of the involvement of thearticular surfaces, arthritis is apt to be followed by ankylosis. The term _empyema_ is sometimes employed to indicate that the cavity ofthe joint contains pus. This is observed chiefly in chronic disease ofpyogenic or tuberculous origin, and is usually attended with theformation of abscesses outside the joint. _Ulceration of cartilage_ and _caries of the articular surfaces_ arecommon accompaniments of the more serious and progressive forms of jointdisease, especially those of bacterial origin. The destruction ofcartilage may be secondary to disease of the synovial membrane or of thesubjacent bone. When the disease begins as a synovitis, the synovialmembrane spreads over the articular surface, fuses with the cartilageand eats into it, causing defects or holes which are spoken of asulcers. When the disease begins in the bone, the marrow is convertedinto granulation tissue, which eats into the cartilage and separates itfrom the bone. Following on the destruction of the cartilage, thearticular surface of the bone undergoes disintegration, a conditionspoken of as _caries of the articular surface_. The occurrence ofulceration of cartilage and of articular caries is attended with theclinical signs of fixation of the joint from involuntary muscularcontraction, wasting of muscles, and starting pains. These _startingpains_ are the result of sudden involuntary movements of the joint. Theyoccur most frequently as the patient is dropping off to sleep; themuscles becoming relaxed, the sensitive ulcerated surfaces jar on oneanother, which causes sudden reflex contraction of the muscles, and theresulting movement being attended with severe pain, wakens the patientwith a start. Advanced articular caries is usually associated with someabnormal attitude and with shortening of the limb. It may be possible tofeel the bony surfaces grate upon one another. When all its constituentelements are damaged or destroyed, a joint is said to be _disorganised_. Should recovery take place, repair is usually attended with union of theopposing articular surfaces either by fibrous tissue or by bone. #Conditions of Impaired Mobility of Joints. #--There are four conditionsof impaired mobility in joints: rigidity, contracture, ankylosis, andlocking. _Rigidity_ is the fixation of a joint by involuntarycontraction of muscles, and is of value as a sign of disease indeep-seated joints, such as the hip. It disappears under anæsthesia. _Contracture_ is the term applied when the fixation is due to permanentshortening of the soft parts around a joint--muscles, tendons, ligaments, fasciæ, or skin. As the structures on the flexor aspect aremore liable to undergo such shortening, contracture is nearly alwaysassociated with flexion. Contracture may result from disease of thejoint, or from conditions outside it--for example, disease in one ofthe adjacent bones, or lesions of the nerves. _Ankylosis_ is the term applied when impaired mobility results fromchanges involving the articular surfaces. It is frequently combined withcontracture. Three anatomical varieties of ankylosis arerecognised--(a) The _fibrous_, in which there are adhesions betweenthe opposing surfaces, which may be in the form of loose isolated bandsof fibrous tissue, or may bind the bones so closely together as toobliterate the cavity of the joint. The resulting stiffness, therefore, varies from a mere restriction of the normal range of movement, up to aclose union of the bones which prevents movement. Fibrous ankylosis mayfollow upon injury, especially dislocation or fracture implicating ajoint, or it may result from any form of arthritis. (b) _Cartilaginousankylosis_ implies the fusion of two apposed cartilaginous surfaces. Itis often found between the patella and the trochlear surface of thefemur in tuberculous disease of the knee. The fusion of thecartilaginous surfaces is preceded by the spreading of a vascularconnective tissue, derived from the synovial membrane, over thearticular cartilage. Clinically, it is associated with absoluteimmobility, (c) _Bony ankylosis_ or _synostosis_ is an osseous unionbetween articulating surfaces (Figs. 154 and 155). It may follow uponfibrous or cartilaginous ankylosis, or may result from the fusion of twoarticular surfaces which have lost their cartilage and become coveredwith granulations. In the majority of cases it is to be regarded as areparative process, presenting analogies with the union of fracture. [Illustration: FIG.  154. --Osseous Ankylosis of Femur and Tibia inposition of flexion. ] The term _arthritis ossificans_ has been applied by Joseph Griffiths toa condition in which the articular surfaces become fused without evidentcause. The occurrence of ankylosis in a joint before the skeleton has attainedmaturity does not appear to impair the growth in length of the bonesaffected; ankylosis of the temporo-maxillary joints, however, greatlyimpairs the growth of the mandible. When there is arrest of growthaccompanying ankylosis, it usually depends on changes in the ossifyingjunctions caused by the original disease. To differentiate by manipulation between muscular fixation andankylosis, it may be necessary to anæsthetise the patient. The natureand extent of ankylosis may be learned by skiagraphy; in osseousankylosis the shadow of the two bones is a continuous one. In fibrous ascontrasted with osseous ankylosis mobility may be elicited, althoughonly to a limited extent; while in osseous ankylosis the joint isrigidly fixed, and attempts to move it are painless. [Illustration: FIG.  155. --Osseous Ankylosis of Knee in the flexedposition following upon Tuberculous Arthritis. (Anatomical Museum, University of Edinburgh. )] The _treatment_ is influenced by the nature of the original lesion, thevariety of the ankylosis, and the attitude of the joint. When there isrestriction of movement due to fibrous adhesions, these may be elongatedor ruptured. Elongation of the adhesions may be effected bymanipulations, exercises, and the use of special forms ofapparatus--such as the application of weights to the limb. It may benecessary to administer an anæsthetic before rupturing strong fibrousadhesions, and this procedure must be carried out with caution, in viewof such risks as fracture of the bone--which is often rarefied--orseparation of an epiphysis. There is also the risk of fat embolism, andof re-starting the original disease. The giving way of adhesions may beattended with an audible crack; and the procedure is often followed byconsiderable pain and effusion into the joint, which necessitate restfor some days before exercises and manipulations can be resumed. _Operative treatment_ may be called for in cases in which the bones areclosely bound to one another by fibrous or by osseous tissue. _Arthrolysis_, which consists in opening the joint and dividing thefibrous adhesions, is almost inevitably followed by their reunion. _Arthroplasty. _--Murphy of Chicago devised this operation for restoringmovement to an ankylosed joint. It consists in transplanting between thebones a flap of fat-bearing tissue, from which a bursal cavity linedwith endothelium and containing a fluid rich in mucin is ultimatelyformed. Arthroplasty is most successful in ankylosis following upon injury; whenthe ankylosis results from some infective condition such as tuberculosisor gonorrhœa, it is liable to result in failure either because of afresh outbreak of the infection or because the ankylosis recurs. When arthroplasty is impracticable, and a movable joint is desired--forexample at the elbow--a considerable amount of bone, and it may be alsoof periosteum and capsular ligament, is resected to allow of theformation of a false joint. When bony ankylosis has occurred with the joint in an undesirableattitude--for example flexion at the hip or knee--it can sometimes beremedied by osteotomy or by a wedge-shaped resection of the bone, withor without such additional division of the contracted soft parts as willpermit of the limb being placed in the attitude desired. Bony ankylosis of the joints of a finger, whether the result of injuryor disease, is difficult to remedy by any operative procedure, for whileit is possible to restore mobility, the new joint is apt to beflail-like. _Locking. _--A joint is said to lock when its movements are abruptlyarrested by the coming together of bony outgrowths around the joint. Itis best illustrated in arthritis deformans of the hip in which new boneformed round the rim of the acetabulum mechanically arrests theexcursions of the head of the femur. The new bone, which limits themovements, is readily demonstrated in skiagrams; it may be removed byoperative means. Locking of joints is more often met with as a result ofinjuries, especially in fractures occurring in the region of the elbow. In certain injuries of the semilunar menisci of the knee, also, thejoint is liable to a variety of locking, which differs, however, in manyrespects from that described above. #Errors of Development. #--These include congenital dislocations andother deformities of intra-uterine origin, such as abnormal laxity ofjoints, absence, displacement, or defective growth of one or other ofthe essential constituents of a joint. The more important of these aredescribed along with the surgery of the Extremities. DISEASES OF JOINTS #Bacterial Diseases. #--In most bacterial diseases the organisms arecarried to the joint in the blood-stream, and they lodge either in thesynovial membrane or in one of the bones, whence the diseasesubsequently spreads to the other structures of the joint. Organisms mayalso be introduced through accidental wounds. It has been shownexperimentally that joints are among the most susceptible parts of thebody to infection, and this would appear to be due to the viscidcharacter of the synovial fluid, which protects organisms frombactericidal agents in the tissues and fluids. PYOGENIC DISEASES The commoner pyogenic diseases are the result of infection of one orother of the joint structures with _staphylococci_ or _streptococci_, which may be demonstrated in the exudate in the joint and in thesubstance of the synovial membrane. The mode of infection is the same asin the pyogenic diseases of bone, the metastasis occurring mostfrequently from the mucous membrane of the pharynx (J.  B.  Murphy). Thelocalisation of the infection in a particular joint is determined byinjury, exposure to cold, antecedent disease of the joint, or otherfactors, the nature of which is not always apparent. The effects on the joint vary in severity. In the milder forms, there isengorgement and infiltration of the synovial membrane, and an effusioninto the cavity of the joint of serous fluid mixed with flakes offibrin--_serous synovitis_. In more severe infections the exudateconsists of pus mixed with fibrin, and, it may be, red bloodcorpuscles--_purulent_ or _suppurative synovitis_; the synovial membraneand the ligaments are softened, and the surface of the membrane presentsgranulations resembling those on an ulcer; foci of suppuration maydevelop in the peri-articular cellular tissue and result in abscesses. In _acute arthritis_, all the structures of the joint are involved; thearticular cartilage is invaded by granulation tissue derived from thesynovial membrane, and from the marrow of the subjacent bone; itpresents a worm-eaten or ulcerated appearance, or it may undergonecrosis and separate, exposing the subjacent bone and leading todisintegration of the osseous trabeculæ--_caries_. With the destructionof the ligaments, the stability of the joint is lost, and it becomesdisorganised. The _clinical features_ vary with the extent of the infection. Whenthis is confined to the synovial and peri-synovial tissues--_acuteserous_ and _purulent synovitis_--there is the usual general reaction, associated with pyrexia and great pain in the joint. The part is hot andswollen, the swelling assuming the shape of the distended synovial sac, fluctuation can usually be elicited, and the joint is held in the flexedposition. When the joint is infected by extension from the surrounding cellulartissue, the joint lesion may not be recognised at an early stage becauseof the swollen condition of the limb, and because there are alreadysymptoms of toxæmia. We have observed a case in which both the hip andknee joints were infected from the cellular tissue. If the infection involves all the joint structures--_acutearthritis_--the general and local phenomena are intensified, thetemperature rises quickly, often with a rigor, and remains high; thepatient looks ill, and is either unable to sleep or the sleep isdisturbed by starting pains. The joint is held rigid in the flexedposition, and the least attempt at movement causes severe pain; theslightest jar--even the shaking of the bed--may cause agony. The jointis hot, tensely distended, and there may be œdema of the peri-articulartissues or of the limb as a whole. If the pus perforates the jointcapsule, there are signs of abscess or of diffuse suppuration in thecellular tissue. The final disorganisation of the joint is indicated byabnormal mobility and grating of the articular surfaces, or byspontaneous displacement of the bones, and this may amount todislocation. In the acute arthritis of infants, the epiphysis concernedmay be separated and displaced. When the _joint is infected through an external wound_, the anatomicalfeatures are similar to those observed when the infection has reachedthe joint by the blood-stream, but the destructive changes tend to bemore severe and are more likely to result in disorganisation. The _terminations_ vary with the gravity of the infection and with thestage at which treatment is instituted. In the milder forms recovery isthe rule, with more or less complete restoration of function. In moresevere forms the joint may be permanently damaged as a result of fibrousor bony ankylosis, or from displacement or dislocation. From changes inthe peri-articular structures there may be contracture in an undesirableposition, and in young subjects the growth of the limb may be interferedwith. The persistence of sinuses is usually due to disease in one orother of the adjacent bones. In the most severe forms, and especiallywhen several joints are involved, death may result from toxæmia. The _treatment_ is carried out on the same principles as in otherpyogenic infections. The limb is immobilised in such an attitude thatshould stiffness occur there will be the least interference withfunction. Extension by weight and pulley is the most valuable means ofallaying muscular spasm and relieving intra-articular tension and ofcounteracting the tendency to flexion; as much as 15 or 20 pounds may berequired to relieve the pain. The induction of hyperæmia is sometimes remarkably efficacious inrelieving pain and in arresting the progress of the infection. If thefluid in the joint is in sufficient quantity to cause tension, if itpersists, or if there is reason to suspect that it is purulent, itshould be withdrawn without delay; an exploring syringe usuallysuffices, the skin being punctured with a tenotomy knife, and, aspractised by Murphy, 5 to 15 c. C. Of a 2 per cent. Solution of formalinin glycerin are injected and the wound is closed. In virulent infectionsthe injection may be repeated in twenty-four hours. Drainage by tube orotherwise is to be condemned (Murphy). A vaccine may be prepared fromthe fluid in the joint and injected into the subcutaneous cellulartissue. Suppuration in the peri-articular soft parts or in one of the adjacentbones must be looked for and dealt with. When convalescence is established, attention is directed to therestoration of the functions of the limb, and to the prevention ofstiffness and deformity by movements and massage, and the use of hot-airand other baths. At a later stage, and especially in neglected cases, operative and othermeasures may be required for deformity or ankylosis. #Metastatic Forms of Pyogenic Infection# In #pyæmia#, one or more joints may fill with pus without markedsymptoms or signs, and if the pus is aspirated without delay the jointoften recovers without impairment of function. In #typhoid fever#, joint lesions result from infection with the typhoidbacillus alone or along with pyogenic organisms, and run their coursewith or without suppuration; there is again a remarkable absence ofsymptoms, and attention may only be called to the condition by theoccurrence of dislocation. Joint lesions are comparatively common in #scarlet fever#, and wereformerly described as scarlatinal rheumatism. The most frequent clinicaltype is that of a serous synovitis, occurring within a week or ten daysfrom the onset of the fever. Its favourite seat is in the hand andwrist, the sheaths of the extensor tendons as well as the synovialmembrane of the joints being involved. It does not tend to migrate toother joints, and rarely lasts longer than a few days. It is probablydue to the specific virus of scarlet fever. At a later stage, especially in children and in cases in which thethroat lesion is severe, an arthritis is sometimes observed that isbelieved to be a metastasis from the throat; it may be acute andsuppurative, affect several joints, and exhibit a septicæmic or pyæmiccharacter. The joints of the lower extremity are especially apt to suffer; thechild is seriously ill, is delirious at night, develops bed-sores overthe sacrum and, it may happen that, not being expected to recover, thelegs are allowed to assume contracture deformities with ankylosis ordislocation at the hip and flexion ankylosis at the knees; should thechild survive, the degree of crippling may be pitiable in the extreme;prolonged orthopædic treatment and a series of operations--arthroplasty, osteotomies, and resections--may be required to restore even a limitedcapacity of locomotion. #Pneumococcal affections of joints#, the result of infection with thepneumococcus of Fraenkel, are being met with in increasing numbers. Thelocal lesion varies from a _synovitis_ with infiltration of the synovialmembrane and effusion of serum or pus, to an _acute arthritis_ witherosion of cartilage, caries of the articular surfaces, anddisorganisation of the joint. The knee is most frequently affected, butseveral joints may suffer at the same time. In most cases the jointaffection makes its appearance a few days after the commencement of apneumonia, but in a number of instances, especially among children, thelung is not specially involved, and the condition is an indication of ageneralised pneumococcal infection, which may manifest itself byendocarditis, empyema, meningitis, or peritonitis, and frequently has afatal termination. The differential diagnosis from other forms ofpyogenic infection is established by bacteriological examination of thefluid withdrawn from the joint. The treatment is carried out on the samelines as in other pyogenic infections, considerable reliance beingplaced 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 "rheumaticfever" are believed to be due to a diplococcus. In the course of ageneral 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 bedhelpless, dreading the slightest movement. From day to day fresh jointsare attacked, while those first affected subside, often with greatrapidity. Affections of the heart-valves and of the pericardium arecommonly present. On recovery from the acute illness, it may be foundthat the joints have entirely recovered, but in a small proportion ofcases certain of them remain stiff and pass into the crippled conditiondescribed under chronic rheumatism. There is no call for operativeinterference. #Gonococcal Affections of Joints. #--These include all forms of jointlesion occurring in association with gonorrhœal urethritis, vulvo-vaginitis, or gonorrhœal ophthalmia. They may develop at any stageof the urethritis, but are most frequently met with from the eighteenthto the twenty-second day after the primary infection, when the organismshave reached the posterior urethra; they have been observed, however, after the discharge has ceased. There is no connection between theseverity of the gonorrhœa and the incidence of joint disease. In women, the gonorrhœal nature of the discharge must be established bybacteriological examination. As a complication of ophthalmia, the joint lesions are met with ininfants, and occur more commonly towards the end of the second or duringthe third week. The gonococcus is carried to the joint in the blood-stream and is firstdeposited in the synovial membrane, in the tissues of which it canusually be found; it may be impossible to find it in the exudate withinthe joint. The joint lesions may be the only evidence of metastasis, orthey 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 gonorrhœal rheumatism, which in some cases istrifling and evanescent, and in others is persistent and progressive, and results in stiffness of the affected joints and permanent cripplingof the hand and fingers. (2) The commonest type is a _chronic synovitis_ or _hydrops_, in whichthe joint--very often the knee--becomes filled with a serous orsero-fibrinous exudate. There are no reactive changes in the synovialmembrane, cellular tissue, or skin, nor is there any fever ordisturbance of health. The movements are free except in so far as theyare restricted by the amount of fluid in the joint. It usually subsidesin two or three weeks under rest, but tends to relapse. (3) An _acute synovitis_ with peri-articular phlegmon is most often metwith in the elbow, but it occurs also in the knee and ankle. There is asudden onset of severe pain and swelling in and around the joint, withconsiderable fever and disturbance of health. The slightest movementcauses pain, and the part is sensitive to touch. The skin is hot andtense, and in the case of the elbow may be red and fiery as inerysipelas. The deposit of fibrin on the synovial membrane and on the articularsurfaces may lead to the formation of adhesions, sometimes in the formof isolated bands, sometimes in the form of a close fibrous unionbetween the bones. (4) A _suppurative arthritis_, like that caused by ordinary pusmicrobes, may be the result of gonococcal infection alone or of a mixedinfection. Usually only one joint is affected, but the condition may bemultiple. The articular cartilages are destroyed, the ends of the bonesare covered with granulations, extra-articular abscesses form, andcomplete osseous ankylosis results. The _diagnosis_ is often missed because the possibility of gonorrhœa isnot suspected. The denial of the disease by the patient is not always to be reliedupon, especially in the case of women, as they may be ignorant of itspresence. The chief points in the differential diagnosis from acutearticular rheumatism are, that the gonorrhœal affection is more oftenconfined to one or two joints, has little tendency to wander from jointto joint, and its progress is not appreciably influenced by salicylates, although these drugs may relieve pain. The conclusive point is therecognition of a gonorrhœal discharge or of threads in the urine. The disease may persist or may relapse, and the patient may be laid upfor weeks or months, and may finally be crippled in one or in severaljoints. The _treatment_--besides that of the urethral disease or of theophthalmia--consists in rest until all pain and sensitiveness havedisappeared. The pain is relieved by salicylates, but most benefitfollows weight extension, the induction of hyperæmia by the rubberbandage and hot-air baths; if the joint is greatly distended, the fluidmay be withdrawn by a needle and syringe. Detoxicated vaccines should begiven from the first, and in afebrile cases the injection of a foreignprotein, such as anti-typhoid vaccine, is beneficial (Harrison). Murphy has found benefit from the introduction into the joint, in theearly stages, of from 5 to 15 c. C. Of a 2 per cent. Solution of formalinin glycerin. This may be repeated within a week, the patient being keptin bed with light weight extension. In the chronic hydrops the fluid iswithdrawn, and about an ounce of a 1 per cent. Solution of protargolinjected; the patient should be warned of the marked reaction whichfollows. After all symptoms have settled down, but not till then, for fear ofexciting relapse or metastasis, the joint is massaged and exercised. Stiffness from adhesions is most intractable, and may, in spite of everyattention, terminate in ankylosis even in cases where there has been nosuppuration. Forcible breaking down of adhesions under anæsthesia isnot recommended, as it is followed by great suffering and the adhesionsre-form. Operation for ankylosis--arthroplasty--should not beundertaken, as the ankylosis recurs. TUBERCULOUS DISEASE Tuberculous disease of joints results from bacillary infection throughthe arteries. The disease may commence in the synovial membrane or inthe marrow of one of the adjacent bones, and the relative frequency ofthese two seats of infection has been the subject of considerabledifference of opinion. The traditional view of König is that in the kneeand most of the larger joints the disease arises in the bone and in thesynovial membrane in about equal proportion, and that in the hip thenumber of cases beginning in the bones is about five times greater thanthat originating in the membrane. This estimate, so far as the actualfrequency of bone lesions is concerned, has been generally accepted, butrecent observers, notably John Fraser, do not accept the presence ofbone lesions as necessarily proving that the disease commenced in thebones; he maintains, and we think with good grounds, that in many casesthe disease having commenced in the synovial membrane, slowly spreads tothe bone by way of the blood vessels and lymphatics, and gives rise tolesions in the marrow. #Morbid Anatomy. #--Tuberculous disease in the articular end of a longbone may give rise to _reactive changes_ in the adjacent joint, characterised by effusion and by the extension of the synovial membraneover the articular surfaces. This may result in the formation ofadhesions which obliterate the cavity of the joint or divide it intocompartments. These lesions are comparatively common, and are notnecessarily due to actual tuberculous infection of the joint. The _infection of the joint_ by tubercle originating in the adjacentbone may take place at the periphery, the osseous focus reaching thesurface 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 ofthe membrane. Or it may take place in the central area, by theprojection of tuberculous granulation tissue into the joint followingupon erosion of the cartilage (Fig. 156). [Illustration: FIG.  156. --Section of Upper End of Fibula, showingcaseating focus in marrow, erupting on articular surface and infectingjoint. ] _Changes in the Synovial Membrane. _--In the majority of cases there is a_diffuse thickening of the synovial membrane_, due to the formation ofgranulation tissue, or of young connective tissue, in its substance. This new tissue is arranged in two layers--the outer composed of fullyformed connective or fibrous tissue, the inner of embryonic tissue, usually permeated with miliary tubercles. On opening the joint, thesetubercles may be seen on the surface of the membrane, or the surface maybe covered with a layer of fibrinous or caseating tissue. Where there isgreater resistance on the part of the tissues, there is active formationof young connective tissue which circumscribes or encapsulates thetubercles, so that they remain embedded in the substance of themembrane, and are only seen on cutting into it. The thickened synovial membrane is projected into the cavity of thejoint, filling up its pouches and recesses, and spreading over thesurface of the articular cartilage "like ivy growing on a wall. "Wherever the synovial tissue covers the cartilage it becomes adherent toand fused with it. The morbid process may be arrested at this stage, andfibrous adhesions form between the opposing articular surfaces, or itmay progress, in which case further changes occur, resulting indestruction of the articular cartilage and exposure of the subjacentbone. In rare instances the synovial membrane presents nodular masses orlumps, resembling the tuberculous tumours met with in the brain; theyproject into the cavity of the joint, are often pedunculated, and maygive rise to the symptoms of loose body. The fringes of synovialmembrane may also undergo a remarkable development, like that observedin arthritis deformans, and described as arborescent lipoma. Both thesetypes are almost exclusively met with in the knee. _The Contents of Tuberculous Joints. _--In a large proportion of cases ofsynovial tuberculosis the joint is entirely filled up by the diffusethickening of the synovial membrane. In a small number there is anabundant serous exudate, and with this there may be a considerableformation of fibrin, covering the surface of the membrane and floatingin the fluid as flakes or masses; under the influence of movement it mayassume the shape of melon-seed bodies. More rarely the joint containspus, and the surface of the synovial membrane resembles the wall of acold abscess. _Ulceration and Necrosis of Cartilage. _--The synovial tissue coveringthe cartilage causes pitting and perforation of the cartilage and makesits way through it, and often spreads widely between it and thesubjacent bone; the cartilage may be detached in portions ofconsiderable size. It may be similarly ulcerated or detached as a resultof disease in the bone. _Caries of Articular Surfaces. _--Tuberculous infiltration of the marrowin the surface cancelli breaks up the spongy framework of the bone intominute irregular fragments, so that it disintegrates or crumblesaway--caries. When there is an absence of caseation and suppuration, thecondition is called _caries sicca_. The pressure of the articular surfaces against one another favours theprogress of ulceration of cartilage and of articular caries. Theseprocesses are usually more advanced in the areas most exposed topressure--for example, in the hip-joint, on the superior aspect of thehead of the femur, and on the posterior and upper segment of theacetabulum. The occurrence of _pathological dislocation_ is due to softening andstretching of the ligaments which normally retain the bones in position, and to some factor causing displacement, which may be the accumulationof fluid or of granulations in the joint, the involuntary contraction ofmuscles, or some movement or twist of the limb. The occurrence ofdislocation is also favoured by destructive changes in the bones. _Peri-articular tubercle and abscess_ may result from the spread ofdisease from the bone or joint into the surrounding tissues, eitherdirectly or by way of the lymphatics. A peri-articular abscess mayspread in several directions, sometimes invading tendon sheaths orbursæ, and finally reaching the skin surface by tortuous sinuses. Reactive changes in the vicinity of tuberculous joints are of commonoccurrence, and play a considerable part in the production of what isclinically known as _white swelling_. New connective tissue forms in theperi-articular fat and between muscles and tendons. It may be tough andfibrous, or soft, vascular, and œdematous, and the peri-articular fatbecomes swollen and gelatinous, constituting a layer of considerablethickness. The fat disappears and is replaced by a mucoid effusionbetween the fibrous bundles of connective tissue. This is what wasformerly known as _gelatinous degeneration_ of the synovial membrane. Inthe case of the wrist the newly formed connective tissue may fix thetendons in their sheaths, interfering with the movements of the fingers. In relation to the bones also there may be reactive changes, resultingin the formation of spicules of new bone on the periosteal surfaces andat the attachment of the capsular and other ligaments; these are onlymet with where pyogenic infection has been superadded. _Terminations and Sequelæ. _--A natural process of cure may occur at anystage, the tuberculous tissue being replaced by scar tissue. Recovery isapt to be attended with impairment of movement due to adhesions, ankylosis, or contracture of the peri-articular structures. Caseous fociin the interior of the bones may become encapsulated, and a cure be thuseffected, or they may be the cause of a relapse of the disease at alater date. Interference with growth is comparatively common, and mayinvolve only the epiphysial junctions in the immediate vicinity of thejoint affected, or those of all the bones of the limb. This is well seenin adults who have suffered from severe disease of the hip inchildhood--the entire limb, including the foot, being shorter andsmaller than the corresponding parts of the opposite side. Atrophic conditions are also met with, the bones undergoing fattyatrophy, so that in extreme cases they may be cut with a knife or beeasily fractured. These atrophic conditions are most marked in bedriddenpatients, and are largely due to disuse of the limb; they are recoveredfrom if it is able to resume its functions. #Clinical Features. #--These vary with the different anatomical forms ofthe disease, and with the joint affected. Sometimes the disease is ushered in by a febrile attack attended withpains in several joints--described by John Duncan as _tuberculousarthritic fever_. This is liable to be mistaken for rheumatic fever, from which, however, it differs in that there is no real migration fromjoint to joint; there is an absence of sweating and of cardiaccomplications; and no benefit follows the administration of salicylates. In exceptional cases, tuberculous joint disease follows an acute courseresembling that of the pyogenic arthritis of infants. This has beenobserved in children, especially in the knee, the lesion being in thesynovial membrane, and attended with an accumulation of pus in thejoint. 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 moreoften insidious, and are attended with so few symptoms that the diseasemay have obtained a considerable hold before it attracts notice. It isnot uncommon for patients or their friends to attribute the condition toinjury, as it often first attracts attention after some slight trauma orexcessive use of the limb. The symptoms usually subside under rest, onlyto relapse again with use of the limb. The initial local symptoms may be due to the presence of a focus in theneighbouring bone, perhaps causing neuralgic pains in the joint, orweakness, tiredness, stiffness, and inability to use the limb, thesesymptoms improving with rest and being aggravated by exertion. It is rarely possible by external examination to recognise deep-seatedosseous foci in the vicinity of joints; but if they are near the surfacein a superficial bone--such as the head of the tibia--there may be localthickening of the periosteum, œdema, pain, and tenderness on pressureand on percussion. _X-ray Appearances of Tuberculous Joints. _--Gross lesions such ascaseous foci in the marrow of the adjacent bone show as clear areas withan ill-defined margin; a sclerosed focus gives a denser shadow than thesurrounding bone, and a sequestrum presents a dark shadow of irregularcontour, and a clear interval between it and the surrounding bone. Caries of the articular surface imparts a woolly appearance or irregularcontour in place of the well-defined outline of the articular end of thebone. In bony ankylosis the shadow of the two bones is a continuous one, the joint interval having been filled up. The minor changes are bestappreciated on comparison with the normal joint of the other limb. _Wasting of muscles_ is a constant accompaniment of tuberculous jointdisease. It is to be attributed partly to want of use, but chiefly toreflex interference with the trophic innervation of the muscles. It isspecially well seen in the extensor and adductor muscles of the thigh indisease of the knee, and in the deltoid in disease of the shoulder. Themuscles become soft and flaccid, they exhibit tremors on attemptedmovement, 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 valuablediagnostic signs, particularly in deeply seated joints such as theshoulder, hip, and spine. It is due to a protective contraction of themuscles around the joint, designed to prevent movement. This muscularfixation disappears under anæsthesia. _Abnormal attitudes of the limb_ occur earlier, and are more pronouncedin cases in which pain and other irritative symptoms of articulardisease are well marked, and are best illustrated by the attitudesassumed in disease of the hip. They are due to reflex or involuntarycontraction of the muscles acting on the joint, with the object ofplacing it in the attitude of greatest ease; they also disappear underanæsthesia. With the lapse of time they not only become exaggerated, butmay become permanent from ankylosis or from contracture of the softparts round the joint. _Startings at night_ are to be regarded as an indication that there isprogressive disease involving the articular surfaces. _The formation of extra-articular abscess_ may take place early, or itmay not occur till long after the disease has subsided. The abscess maydevelop so insidiously that it does not attract attention until it hasattained considerable size, especially when associated with disease ofthe spine, pelvis, or hip. The position of the abscess in relation todifferent joints is fairly constant and is determined by the anatomicalrelationships of the capsule and synovial membrane to the surroundingtissues. The bursæ and tendon sheaths in the vicinity may influence thedirection of spread of the abscess and the situation of resultingsinuses. When the abscess is allowed to burst, or is opened and becomesinfected with pyogenic bacteria, there is not only the risk ofaggravation of the disease and persistent suppuration, but there is agreater liability to general tuberculosis. The sinuses may be so tortuous that a probe cannot be passed to theprimary focus of disease, and their course and disposition can only bedemonstrated by injecting the sinuses with an emulsion of bismuth andtaking 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 quiescentjoint lesions by injury or by movement of the joint under anæsthesia, orby the fatigue of a railway journey. When sinuses have formed and becomeinfected with pyogenic bacteria, there may be a diurnal variation in thetemperature of the type known as hectic fever (Fig. 11). _Relative Frequency of Tuberculous Disease in DifferentJoints. _--Hospital statistics show that joints are affected in thefollowing order of frequency: Spine, knee, hip, ankle and tarsus, elbow, wrist, shoulder. The hip and spine are most often affected in childhoodand youth, the shoulder and wrist in adults; the knee, ankle, and elbowshow little age preference. _Clinical Variations of Tuberculous Joint Disease. _--The abovedescription applies to tuberculous joint disease in general; it must bemodified 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 eitherof these is the well-known _white swelling_ or _tumor albus_ (Wiseman, 1676) which is the clinical manifestation of diffuse thickening of thesynovial membrane along with mucoid degeneration of the peri-synovialcellular tissue. It is well seen in joints which are superficial--suchas the knee, ankle, elbow, and wrist. The swelling, which is the firstand most prominent clinical feature, develops gradually and painlessly, obliterating the bony prominences by filling up the natural hollows. Itappears greater to the eye than is borne out by measurement, beingthrown into relief by the wasting of the muscles above and below thejoint. In the early stage the swelling is elastic, doughy, andnon-sensitive, and corresponds to the superficial area of the synovialmembrane involved, and there is comparatively little complaint on thepart of the patient, because the articular surfaces and ligaments arestill intact. There may be a feeling of weight in the limb, and in thecase of the knee and ankle the patient tires on walking and drags theleg with more or less of a limp. Movements of the joint are permitted, but are limited in range. The disability is increased by use andexertion, but, for a time at least, it improves under rest. If the disease is not arrested, there follow the symptoms and signs ofinvolvement of the articular surfaces. _Influence of Tuberculous Joint Disease on the GeneralHealth. _--Experience shows that the early stages of tuberculous jointdisease 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 besome loss of weight. #Treatment. #--In addition to the general treatment of tuberculosis, local measures are employed. These may be described under two heads--theconservative and the operative. _Conservative treatment_ is almost always to be employed in the firstinstance, as by it a larger proportion of cures is obtained with asmaller mortality and with better functional results than by operation. _Treatment by rest_ implies the immobilisation of the diseased limbuntil pain and tenderness have disappeared. The attitude in which thelimb is immobilised should be that in which, in the event of subsequentstiffness, it will be most serviceable to the patient. Immobilisationmay 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 ofthe limb. If, when the patient first comes under observation, the limbis in a deformed attitude which does not readily yield to extension, thedeformity should be corrected under an anæsthetic. _The induction of hyperæmia_ is often helpful, the rubber bandage or thehot-air chamber being employed for an hour or so morning and evening. _Injection of Iodoform. _--This is carried out on the same lines as havebeen described for tuberculous abscess. After the fluid contents of thejoint are withdrawn, the iodoform is injected; and this may require tobe 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 considerablepain and swelling of the joint. In some cases there is sickness, andthere may be blood pigment in the urine. The severity of these phenomenadiminishes with each subsequent injection. The use of Scott's dressing and of blisters and of the actual cauteryhas largely gone out of fashion, but the cautery may still be employedwith benefit for the relief of pain in cases in which ulceration ofcartilage is a prominent feature. The application of the X-rays has proved beneficial in synovial lesionsin superficial joints such as the wrist or elbow; prolonged exposuresare made at fortnightly intervals, and on account of the cicatricialcontraction which attends upon recovery, the joint must be kept in goodposition. Conservative treatment is only abandoned if improvement does not showitself after a thorough trial, or if the disease relapses after apparentcure. _Operative Treatment. _--Other things being equal, operation is moreoften indicated in adults than in children, because after the age oftwenty there is less prospect of recovery under conservative treatment, there is more tendency for the disease to relapse and to invade theinternal organs, and there is no fear of interfering with the growth ofthe bones. The state of the general health may necessitate operation asthe most rapid method of removing the disease. The social status of thepatient must also be taken into account; the bread-winner, underexisting social conditions, may be unable to give up his work for asufficient time to give conservative measures a fair trial. The _local conditions_ which decide for or against operation aredifferently regarded by different surgeons, but it may be said ingeneral terms that operative interference is indicated in cases in whichthe disease continues to progress in spite of a fair trial ofconservative measures; in cases unsuited for conservativetreatment--that is to say, where there are severe bone lesions. Operative interference is indicated also when the functional result willbe better than that likely to be obtained by conservative measures, asis often the case in the knee and elbow. Cold abscesses should, ifpossible, be dealt with before operating on the joint. In many cases the extent of the operation can only be decided afterexploration. The aim is to remove all the disease with the leastimpairment of function and the minimum sacrifice of healthy tissue. Themore open the method of operating the better, so that all parts of thejoint may be available for inspection. The methods of Kocher, whichpermit of dislocating the joint, are specially to be recommended, asthis procedure affords the freest possible access. Diseased synovialmembrane is removed with the scissors or knife. If the cartilages aresound, and if a movable joint is aimed at, they may be left; but ifankylosis is desired, they must be removed. Localised disease of thecartilage should be removed with the spoon or gouge, and the bonebeneath investigated. If the articular surface is extensively diseased, a thin slice of bone should be removed, and if foci in the marrow arethen revealed, it is better to gouge them out than to remove furtherslices of bone, as this involves sacrifice of the cortex and periosteum. Operative treatment of deformities resulting from tuberculous jointdisease has almost entirely replaced reduction by force; the contractedsoft parts are divided, and the bone is resected. _Amputation_ for tuberculous joint disease has become one of the rareoperations of surgery, and is only justified when less radical measureshave failed and the condition of the limb is affecting the generalhealth. Amputation is more frequently called for in persons past middlelife who are the subjects of pulmonary tuberculosis. SYPHILITIC DISEASE Syphilitic affections of joints are comparatively rare. As intuberculosis, 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 eruptionsappear, one of the large joints, such as the shoulder or knee, may bethe seat of pain--_arthralgia_--which is worse at night. In thesecondary stage, a _synovitis_ with serous effusion is not uncommon, andmay affect several joints. Syphilitic _hydrops_ is met with almostexclusively in the knee; it is frequently bilateral, and is insidious inits onset and progress, the patient usually being able to go about. In the _tertiary stage_ the joint lesions are persistent anddestructive, and result from the formation of gummata, either in thedeeper layers of the synovial membrane or in the adjacent bone orperiosteum. _Peri-synovial_ and _peri-bursal gummata_ are met with in relation tothe knee-joint of middle-aged adults, especially women. They are usuallymultiple, develop slowly, and are rarely sensitive or painful. One ormore of the gummata may break down and give rise to tertiary ulcers. Theco-existence of indolent swellings, ulcers, and depressed scars in thevicinity of the knee is characteristic of tertiary syphilis. The disease spreads throughout the capsule and synovial membrane, whichbecomes diffusely thickened and infiltrated with granulation tissuewhich eats into and replaces the articular cartilage. Clinically, thecondition resembles tuberculous disease of the synovial membrane, forwhich it is probably frequently mistaken, but in the syphiliticaffection the swelling is nodular and uneven, and the subjectivesymptoms are slight, mobility is little impaired, and yet the deformityis considerable. _Syphilitic osteo-arthritis_ results from a gumma in the periosteum ormarrow of one of the adjacent bones. There is gradual enlargement of oneof the bones, the patient complains of pains, which are worst at night. The disease may extend to the synovial membrane and be attended witheffusion into the joint, or it may erupt on the periosteal surface andinvade the skin, forming one or more sinuses. The further progress iscomplicated by the occurrence of pyogenic infection leading to necrosisof bone, in the knee-joint, for example, the patella or one of thecondyles of the femur or tibia, may furnish a sequestrum. In such cases, anti-syphilitic treatment must be supplemented by operation for theremoval of the diseased tissues. In the knee, excision is rarelynecessary; but in the elbow it may be called for to obtain a movablejoint. In #inherited syphilis# the earliest joint affections are those in whichthere is an effusion into the joint, especially the knee or elbow; andin exceptional cases pyogenic infection may be superadded, and pus formin the joint. In older children, a gummatous synovitis is met with of which the moststriking features are: its insidious development, its chronic course, symmetrical distribution, freedom from pain, the free mobility of thejoint, its tendency to relapse, and its association with othersyphilitic stigmata, especially in the eyes. The knees are the jointsmost frequently affected, and the condition usually yields readily toanti-syphilitic treatment without impairment of function. JOINT DISEASES ACCOMPANYING CERTAIN CONSTITUTIONAL CONDITIONS #Gout. #--_Arthritis Urica. _--One of the manifestations of gout is thatcertain joints are liable to attacks of inflammation associated with thedeposit of a chalk-like material composed of sodium biurate, chiefly inthe matrix of the articular cartilage, it may be in streaks or patchestowards the central area of the joint, or throughout the entire extentof the cartilage, which appears as if it had been painted over withplaster of Paris. As a result of this uratic infiltration, the cartilageloses its vitality and crumbles away, leading to the formation of whatare known as gouty ulcers, and these may extend through the cartilageand invade the bone. The deposit of urates in the synovial membrane isattended with effusion into the joint and the formation of adhesions, while in the ligaments and peri-articular structures it leads to theformation of scar tissue. The metatarso-phalangeal joint of the greattoe, on one or on both sides, is that most frequently affected. Thedisease is met with in men after middle life, and while common enough inEngland and Ireland, is almost unknown in hospital practice in Scotland. The _clinical features_ are characteristic. There is a sudden onset ofexcruciating pain, usually during the early hours of the morning, thejoint becomes swollen, red, and glistening, with engorgement of theveins and some fever and disturbance of health and temper. In the courseof a week or ten days there is a gradual return to the normal. Suchattacks may recur only once a year or they may be more frequent; thesuccessive attacks tend to become less acute but last longer, and thelocal phenomena persist, the joint remaining permanently swollen andstiff. Masses of chalk form in and around the joint, and those in thesubcutaneous tissue may break through the skin, forming indolent ulcerswith exposure of the chalky masses (_tophi_). The hands may becomeseriously crippled, especially when the tendon sheaths and bursæ alsoare affected; the crippling resembles that resulting from arthritisdeformans but it differs in not being symmetrical. The local _treatment_ consists in employing soothing applications and aBier's bandage for two or three hours twice daily while the symptoms areacute; later, hot-air baths, massage, and exercises are indicated. It isremarkable how completely even the most deformed joints may recovertheir function. Dietetic and medicinal treatment must also be employed. #Chronic Rheumatism. #--This term is applied to a condition whichsometimes follows upon acute articular rheumatism in persons presentinga family tendency to acute rheumatism or to inflammations of serousmembranes, and manifesting other evidence of the rheumatic taint, suchas chorea or rheumatic nodules. The changes in the joints involve almost exclusively the synovialmembrane and the ligaments; they consist in cellular infiltration andexudation, resulting in the formation of new connective tissue whichencroaches on the cavity of the joint and gives rise to adhesions, andby contracting causes stiffness and deformity. The articular cartilagesmay subsequently be transformed into connective tissue, with consequentfibrous ankylosis and obliteration of the joint. The bones are affectedonly in so far as they undergo fatty atrophy from disuse of the limb, oralteration in their configuration as a result of partial dislocation. Osseous ankylosis may occur, especially in the small joints of the handand foot. The disease is generally poly-articular and may be met with in childhoodand youth as well as in adult life. In some cases pain is so severe thatthe patient resists the least attempt at movement. In others, thejoints, although stiff, can be moved but exhibit pronounced crackings. When there is much connective tissue formed in relation to the synovialmembrane, the joint is swollen, and as the muscles waste above andbelow, the swelling is spindle-shaped. Subacute exacerbations occur fromtime to time, with fever and aggravation of the local symptoms andimplication of other joints. After repeated recurrences, there isankylosis with deformity, the patient becoming a helpless cripple. Onaccount of the tendency to visceral complications, the tenure of life isuncertain. From the nature of the disease, _treatment_ is for the most partpalliative. Salicylates are only of service during the exacerbationsattended with pyrexia. The application of soda fomentations, turpentinecloths, or electric or hot-air baths may be useful. Improvement mayresult from the general and local therapeutics available at such placesas Bath, Buxton, Harrogate, Strathpeffer, Wiesbaden, or Aix. In selectedcases, a certain measure of success has followed operative interference, which consists in a modified excision. The deformities resulting fromchronic rheumatism are but little amenable to surgical treatment, andforcible attempts to remedy stiffness or deformity are to be avoided. #Arthritis Deformans# (_Osteo-arthritis, Rheumatoid Arthritis, RheumaticGout, Malum Senile, Traumatic or Mechanical Arthritis_). --Under the termarthritis deformans, which was first employed by Virchow, it isconvenient to include a number of joint affections which have manyanatomical and clinical features in common. The disease is widely distributed in the animal kingdom, both indomestic species and in wild animals in the natural state such as thelarger carnivora and the gorilla; evidence of it has also been found inthe bones of animals buried with prehistoric man. The morbid changes in the joints present a remarkable combination ofatrophy 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 ofauto-intoxication, the toxins being absorbed from the gastro-intestinaltract, and those who suffer are supposed to possess what has been calledan "arthritic diathesis. " The localisation of the disease in a particular joint may be determinedby several factors, of which trauma appears to be the most important. The condition is frequently observed to follow, either directly or afteran interval, upon a lesion which involves gross injury of the joint orof one of the neighbouring bones. It occurs with greater frequency afterrepeated minor injuries affecting the joint and its vicinity, such assprains and contusions, and particularly those sustained in laboriousoccupations. This connection between trauma and arthritis deformans ledArbuthnot Lane to apply to it the term _traumatic_ or _trade arthritis_. The traumatic or strain factor in the production of the disease may bemanifested in a less obvious fashion. In the lower extremity, forexample, _any condition which disturbs the static equilibrium of thelimb as a whole_ would appear to predispose to the disease in one orother of the joints. The static equilibrium may be disturbed by suchdeformities as flat-foot or knock-knee, and badly united fractures ofthe lower extremity. In hallux valgus, the metatarso-phalangeal joint ofthe great toe undergoes changes characteristic of arthritis deformans. A number of cases have been recorded in which arthritis deformans hasfollowed upon antecedent disease of the joint, such as pyogenic orgonorrhœal synovitis, upon repeated hæmorrhages into the knee-joint inbleeders, and in unreduced dislocations in which a new joint has beenestablished. [Illustration: FIG.  157. --Arthritis Deformans of Elbow, showingdestruction of articular surfaces and masses of new bone around thearticular margins. (Anatomical Museum, University of Edinburgh. )] Lastly, Poncet and other members of the Lyons school regard arthritisdeformans as due to an attenuated form of tuberculous infection, anddraw attention to the fact that a tuberculous family history is oftenmet with in the subjects of the disease. [Illustration: FIG.  158. --Arthritis Deformans of Knee, showingeburnation and grooving of articular surfaces. (Anatomical Museum, University of Edinburgh. )] _Morbid Anatomy. _--The commonest type is that in which the articularsurfaces undergo degenerative changes. The primary change involves thearticular cartilage, which becomes softened and fibrillated and is wornaway until the subjacent bone is exposed. If the bone is rarefied, theenlarged cancellous spaces are opened into and an eroded and worm-eatenappearance is brought about; with further use of the joint, the bone isworn away, so that in a ball-and-socket joint like the hip, the head ofthe femur and the acetabulum are markedly altered in size and shape. More commonly, the bone exposed as a result of disappearance of thecartilage is denser than normal, and under the influence of themovements of the joint, becomes smooth and polished--a change describedas _eburnation_ of the articular surfaces (Fig. 158). In hinge-jointssuch as the knee and elbow, the influence of movement is shown by aseries of parallel grooves corresponding to the lines of friction(Fig. 158). [Illustration: FIG.  159. --Hypertrophied Fringes of Synovial Membrane inArthritis Deformans of Knee. (Museum of Royal College of Surgeons, Edinburgh. )] While these degenerative changes are gradually causing destruction ofthe articular surfaces, reparative and hypertrophic changes are takingplace at the periphery. Along the line of the junction between thecartilage and synovial membrane, the proliferation of tissue leads tothe formation of nodules or masses of cartilage--_ecchondroses_--whichare subsequently converted into bone (Fig. 157). Gross alterations inthe ends of the bone are thus brought about which can be recognisedclinically and in skiagrams, and which tend to restrict the normal rangeof movement. The extension of the ossification into the synovialreflection and capsular ligament adds a collar or "lip" of new bone, known as "lipping" of the articular margins, and also into otherligaments, insertions of tendons and intermuscular septa giving rise tobony outgrowths or osteophytes not unlike those met with in theneuro-arthropathies. Proliferative changes in the synovial membrane are attended withincreased vascularity and thickening of the membrane and an enlargementof its villi and fringes. When the fatty fringes are developed to anexaggerated degree, the condition is described as an _arborescentlipoma_ (Fig. 159). Individual fringes may attain the size of a hazelnut, and the fibro-fatty tissue of which they are composed may beconverted into cartilage and bone; such a body may remain attached by anarrow pedicle or stalk, or this may be torn across and the body becomesloose and, unless confined in a recess of the joint, it wanders aboutand may become impacted between the articular surfaces. These changes inthe synovial membrane are often associated with an abundant exudate orhydrops. These degenerative and hypertrophic changes, while usuallyattended 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 rarerthan those described above, and is chiefly met with in the joints of thefingers and toes and in those of the vertebral column. The synovialmembrane proliferates, grows over the cartilage, and replaces it, andwhen two such articular surfaces are in contact they tend to adhere, thus obliterating the joint, cavity, and resulting in fibrous or bonyankylosis. The changes progress slowly and, before they result inankylosis, various sub-luxations and dislocations may occur withdistortion and deformity which, in the case of the fingers, is extremelydisabling and unsightly (Fig. 160). _Clinical Features. _--It is usually observed that in patients who arestill young the tendency is for the disease to advance with considerablerapidity, so that in the course of months it may cause crippling ofseveral joints. The course of the disease as met with in persons pastmiddle life is more chronic; it begins insidiously, and many years maypass before there is pronounced disability. The earliest symptom isstiffness, especially in the morning after rest, which passes offtemporarily with use of the limb. As time goes on, the range of movementbecomes restricted, and crackings occur. This stage of the disease maybe prolonged indefinitely; if it progresses, stiffness becomes morepronounced, certain movements are lost, others develop in abnormaldirections, and deformed attitudes add to the disablement. The diseaseis compatible with long life, but not with any active occupation, hencethose of the hospital class who suffer from it tend to accumulate inworkhouse infirmaries. _Hydrops_ is most marked in the knee, and may affect also the adjacentbursæ. As the joint becomes distended with fluid, the ligaments arestretched, the limb becomes weak and unstable, and the patient complainsof a feeling of weight, of insecurity, and of tiredness. Pain isoccasional and evanescent, and is usually the result of some extraexertion, or exposure to cold and wet. This form of the disease isextremely chronic, and may last for an indefinite number of years. It isto be diagnosed from the other forms of hydrops already considered--thepurely traumatic, the pyogenic, gonorrhœal, tuberculous, andsyphilitic--and from that associated with Charcot's disease. _Hypertrophied fringes and pedunculated or loose bodies_ often co-existwith hydrops, and give rise to characteristic clinical features, particularly in the knee. The fringes, especially when they assume thetype of the arborescent lipoma, project into the cavity of the joint, filling up its recesses and distending its capsule so that the joint isswollen and slightly flexed. Pain is not a prominent feature, and thepatient may walk fairly well. On grasping the joint while it is beingactively flexed and extended, the fringes may be felt moving under thefingers. Symptoms from impaction of a loose body are exceptional. [Illustration: FIG.  160. --Arthritis Deformans of Hands, showingsymmetry of lesions, ulnar deviation of fingers, and nodular thickeningat inter-phalangeal joints. ] _The dry form of arthritis deformans_, although specially common in theknee, is met with in other joints, either as a mon-articular orpoly-articular disease; and it is also met with in the joints of thespine and of the fingers as well as in the temporo-mandibular joint. Inthe joints of the fingers the disease is remarkably symmetrical, andtends to assume a nodular type (Heberden's nodes) (Fig. 160); in youngersubjects it assumes a more painful and progressive fusiform type(Fig. 161). In the larger joints the subjective symptoms usually precedeany palpable evidence of disease, the patient complaining of stiffness, crackings, and aching, aggravated by changes in the weather. Theroughness due to fibrillation of the articular cartilages causes coarsefriction on moving the joint, or, in the knee, on moving the patella onthe condyles of the femur. It may be months or even years before thelipping and other hypertrophic changes in the ends of the bones arerecognisable, and before the joint assumes the deformed features whichthe name of the disease suggests. The capsular ligament, except in hydrops, is the seat ofconnective-tissue overgrowth, and tends to become contracted and rigid. Intra-articular ligaments, such as the ligamentum teres in the hip, areusually worn away and disappear. The surrounding muscles undergoatrophy, tendons become adherent to their sheaths and may be ossified, and the sheaths of nerves may be involved by the cicatricial changes inthe surrounding tissues. _The X-ray appearances of arthritis deformans_ necessarily vary with thetype of the disease and the joint affected; in the joints of the fingersthere is a narrowing of the spaces between the articular ends of thebones as a result of absorption of the articular cartilage, andrarefaction of the cancellous tissue in the vicinity of the joints; inthe larger joints there is "lipping" of the articular margins, osteophytes, and other evidence of abnormal ossification in and aroundthe joint. Eburnation of the articular surfaces is shown by increase inthe density of the shadow of the bone in the areas affected. [Illustration: FIG.  161. --Arthritis Deformans affecting severalJoints, in a boy æt.  10. (Dr. Dickson's case. )] _Treatment. _--Treatment is for the most part limited to the relief ofsymptoms. On no account should the affected joints be kept at rest bymeans of splints or other apparatus. Active movements and exercises ofall kinds are to be persevered with. When pain is a prominent feature, it may be relieved either by douches of iodine and hot water (tinctureof iodine 1 oz. To the quart), or by the application of lint saturatedwith a lotion made up of chloral hydrate, gr. V, glycerin Ʒj, water ℥j, and covered with oil-silk. Strain and over-use of the joint and suddenchanges of temperature are to be avoided. The induction of hyperæmia bymeans of massage, the elastic bandage, and hot-air baths is often ofservice. Operative interference is indicated when the disease is of asevere type, when it is mon-articular, and when the general condition ofthe patient is otherwise favourable. Excision has been practised withsuccess in the hip, knee, elbow, and temporo-mandibular joints. Limitation of movement and locking at the hip-joint when due to new boneround the edge of the acetabulum may be greatly relieved by removal ofthe bone--a procedure known as _cheilotomy_. Loose bodies andhypertrophied fringes if causing symptoms may also be removed byoperation. When stiffness and grating on movement are prominent features we havefound the injection of from half to one ounce of sterilised whitevaseline afford decided relief. The patient should be nourished well, and there need be no restrictionin the diet such as is required in gouty patients, so long as thedigestion is not impaired. Benefit is also derived from theadministration of cod-liver oil, and of tonics, such as strychnin, arsenic, and iron, and in some cases of iodide of potassium. Luffrecommends 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--isoften beneficial. In some cases benefit has followed the prolonged internal administrationof liquid paraffin. On the assumption that the condition is the result of anauto-intoxication from the intestinal tract, saline purges andirrigation of the colon are indicated, and Arbuthnot Lane claims to havebrought about improvement by short-circuiting or by resecting the colon. Residence in a warm and dry climate, with an open-air life, has beenknown to arrest the disease when other measures have failed to giverelief. The application of radium and the ingestion of radio-active waters havealso been recommended. #Hæmophilic# or #Bleeder's Joint#. --This is a rare but characteristicaffection met with chiefly in the knee-joint of boys who are thesubjects of hæmophilia. After some trivial injury, or even withoutapparent cause, a hæmorrhage takes place into the joint. The joint istensely swollen, cannot be completely extended, and is so painful thatthe patient is obliged to lie up. The temperature is often raised (101°to 102° F. ), especially if there are also hæmorrhages elsewhere. Theblood in the joint is slowly re-absorbed, and by the end of a fortnightor so, the symptoms completely disappear. As a rule these attacks arerepeated; the pain attending them diminishes, but the joint becomes theseat of permanent changes: the synovial membrane is thickened, abnormally vascular, and coloured brown from the deposit of bloodpigment; on its surface, and in parts of the articular cartilage, thereis a deposit of rust-coloured fibrin; there may be extensive adhesions, and in some cases changes occur like those observed in arthritisdeformans with erosion and ulceration of the cartilage and a form of drycaries 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 resemblestuberculous disease of the synovial membrane. From errors in diagnosissuch joints have been operated upon, with disastrous results due tohæmorrhage. The treatment of a recent hæmorrhage consists in securing absolute restand applying elastic compression. The introduction of blood-serum (10–15c. C. ) into a vein may assist in arresting the hæmorrhage;anti-diphtheritic serum is that most readily obtainable. After an interval, measures should be adopted to promote the absorptionof 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 thefoot, when one or other of the main nerve-trunks has been divided orcompressed, the joints may become swollen and painful and afterwardsbecome stiff and deformed. Bony ankylosis has been observed. _In Affections of the Spinal Medulla. _--In myelitis, progressivemuscular atrophy, poliomyelitis, insular sclerosis, and in traumaticlesions, 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'sdisease" applied to them. Although they usually develop in the ataxicstage, one or more years after the initial spinal symptoms, they mayappear before there is any evidence of tabes. The onset is frequentlydetermined by some injury. The joints of the lower extremity are mostcommonly affected, and the disease is bilateral in a considerableproportion of cases--both knees or both hips, for instance, beingimplicated. Among the theories suggested in explanation of these arthropathies themost recent is that by Babinski and Barré, which traces the condition tovascular 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-articularswelling, unlike ordinary œdema, scarcely pits even on firm pressure. [Illustration: FIG.  162. --Bones of Knee-joint in advanced stage ofCharcot's Disease. The medial part of the head of the tibia hasdisappeared. (Anatomical Museum, University of Edinburgh). ] In mild cases this condition of affairs may persist for months; insevere cases destructive changes ensue with remarkable rapidity. Thejoint becomes enormously swollen, loses its normal contour, and the endsof the bones become irregularly deformed (Fig. 162). Sometimes, andespecially in the knee, the clinical features are those of an enormoushydrops with fibrinous and other loose bodies and hypertrophiedfringes--and great œdema of the peri-articular tissues (Fig. 163). Thejoint is wobbly or flail-like from stretching and destruction of thecontrolling ligaments, and is devoid of sensation. In other cases, wearing down and total disappearance of the ends of the bones is theprominent feature, attended with flail-like movements and with coarsegrating. Dislocation is observed chiefly at the hip, and is rather agross displacement with unnatural mobility than a typical dislocation, and it is usually possible to move the bones freely upon one another andto reduce the displacement. A striking feature is the extensiveformation of new bone in the capsular ligament and surrounding muscles. The enormous swelling and its rapid development may suggest the growthof a malignant tumour. The most useful factor in diagnosis is the entireabsence of pain, of tenderness, and of common sensibility. The freedomwith which a tabetic patient will allow his disorganised joint to behandled requires to be seen to be appreciated. [Illustration: FIG.  163. --Charcot's Disease of Left Knee. The joint isdistended with fluid and the whole limb is œdematous. ] The rapidity of the destructive changes in certain cases of tabes, andthe entire absence of joint lesions in others, would favour the viewthat special parts of the spinal medulla must be implicated in theformer group. In _syringomyelia_, joint affections (gliomatous arthropathies) are morefrequent than in tabes, and they usually involve the upper extremity incorrespondence with the seat of the spinal lesion, which usually affectsthe lower cervical and upper thoracic segments. Except that the jointdisease is seldom symmetrical, it closely resembles the arthropathy oftabes. The completeness of the analgesia of the articular structuresand of the overlying soft parts is illustrated by the fact that in onecase the patient himself was in the habit of letting out the fluid fromhis elbow with the aid of a pair of scissors, and that in another thejoint was painlessly excised without an anæsthetic. [Illustration: FIG.  164. --Charcot's Disease of both Ankles: front view. Man, æt.  32. ] The disease may become arrested or may go on to completedisorganisation; suppuration may ensue from infection through a breachof the surface, and in rare cases the joint has become the seat oftuberculosis. [Illustration: FIG.  165. --Charcot's Disease of both Ankles: back view. Man, æt.  32. ] _Treatment_, in addition to that of the nerve lesion underlying thearthropathy, consists in supporting and protecting the joint by means ofbandages, splints, and other apparatus. In the lower extremity, the useof crutches is helpful in taking the strain off the affected limb. Whenthere is much distension of the joint, considerable relief follows uponwithdrawal of fluid. The best possible result being rigid ankylosis in agood position, it may be advisable to bring this about artificially byarthrodesis or resection. Operation is indicated when only one joint isaffected and when the cord lesion is such as will permit of the patientusing the limb. The wounds heal well, but the victims of tabes areunfavourable subjects for operative interference, on account of theirliability 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, areoccasionally met with. The secondary changes in joints which are theseat of paralytic contracture are considered with the surgery of theExtremities. In cases of _hysteria_ and other _functional affections of thenervous system_, an intermittent neuropathic hydrops has beenobserved--especially in the knee. Without apparent cause, the jointfills with fluid and its movements become restricted, and after from twoto eight days the swelling subsides and the joint returns to normal. Aremarkable feature of the condition is that the effusion into the jointrecurs at regular intervals, it may be over a period of years. Psychicconditions have been known to induce attacks, and sometimes to abortthem or even to cause their disappearance. Hence it has been recommendedthat treatment by suggestion should be employed along with tonic dosesof quinine and arsenic. HYSTERICAL OR MIMETIC JOINT AFFECTIONS Under this heading, Sir Benjamin Brodie, in 1822, described an affectionof joints, characterised by the prominence of subjective symptoms andthe absence of pathological changes. Although most frequently met within young women with an impressionable nervous system, and especiallyamong those in good social circumstances, it occurs occasionally in men. The onset may be referred to injury or exposure to cold, or may beassociated with some disturbance of the emotions or of the generativeorgans; or the condition may be an involuntary imitation of the symptomsof organic joint disease presented by a relative or friend. It is characteristic that the symptoms develop abruptly withoutsatisfactory cause, that they are exaggerated and wanting in harmonywith one another, and that they do not correspond with the features ofany of the known forms of organic disease. In some cases the onlycomplaint is of severe pain; more often this is associated withexcessive tenderness and with impairment of the functions of the joint. On examination the joint presents a normal appearance, but the skinover it is remarkably sensitive. A light touch is more likely to excitepain than deep and firm pressure. Stiffness is a variable feature--insome cases amounting to absolute rigidity, so that no ordinary forcewill elicit movement. It is characteristic of this, as of otherneuroses, that the symptoms come and go without sufficient cause. Whenthe patient's attention is diverted, the pain and stiffness maydisappear. There is no actual swelling of the joint, although there maybe an appearance of this from wasting of the muscles above and below. Ifthe joint is kept rigid for long periods, secondary contracture mayoccur--in the knee with flexion, in the hip with flexion and adduction. The _diagnosis_ is often a matter of considerable difficulty, and thecondition is liable to be mistaken for such organic lesions as atuberculous or pyogenic focus in the bone close to the joint. The greatest difficulty is met with in the knee and hip, where thecondition may closely simulate tuberculous disease. The use of theRöntgen rays, or examination of the joint under anæsthesia, is helpful. The _local treatment_ consists chiefly in improving the nutrition of theaffected limb by means of massage, exercises, baths, and electricity. Splints are to be avoided. In refractory cases, benefit may follow theapplication of blisters or of Corrigan's button. The general conditionof 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 anurse. Complete recovery is the rule, but when the muscles are weak andwasted from prolonged disuse, a considerable time may elapse before thelimb returns to normal. TUMOURS AND CYSTS New growths taking origin in the synovial membrane are rare, and are notusually diagnosed before operation. They are attended with exudationinto the joint, and in the case of _sarcoma_ the fluid is usuallyblood-stained. If the tumour projects in a polypoidal manner into thejoint, it may cause symptoms of loose body. One or two cases have beenrecorded in which a _cartilaginous tumour_ growing from the synovialmembrane has erupted through the joint capsule and infiltrated theadjoining muscles. _Multiple cartilaginous tumours_ forming loose bodiesare described on p. 544. _Cysts of joints_ constitute an ill-defined group which includes gangliaformed in relation to the capsular ligament. Cystic distension of bursæwhich communicate with the joint is most often met with in the region ofthe knee in cases of long-standing hydrops. It was suggested by MorrantBaker that cystic swellings may result from the hernial protrusion ofthe synovial membrane between the stretched fibres of the capsularligament, and the name "Baker's cysts" has been applied to these. In the majority of cases, cysts in relation to joints give rise tolittle 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 twoheads: those composed of fibrin, and those composed of organisedconnective tissue. #Fibrinous Loose Bodies# (Corpora oryzoidea). --These are homogeneous orconcentrically laminated masses of fibrin, sometimes resembling ricegrains, melon seeds, or adhesive wafers, sometimes quite irregular inshape. Usually they are present in large numbers, but sometimes there isonly one, and it may attain considerable dimensions. They are notpeculiar to joints, for they are met with in tendon sheaths and bursæ, and their origin from synovial membrane may be accepted as proved. Theyoccur in tuberculosis, arthritis deformans, and in Charcot's disease, and their presence is almost invariably associated with an effusion offluid into the joint. While they may result from the coagulation offibrin-forming elements in the exudate, their occurrence in tuberculoushydrops would appear to be the result of coagulation necrosis, or offibrinous degeneration of the surface layer of the diseased synovialmembrane. However formed, their shape is the result of mechanicalinfluences, and especially of the movement of the joint. _Clinically_, loose bodies composed of fibrin constitute an unimportantaddition to the features of the disease with which they are associated. They never give rise to the classical symptoms associated with impactionof a loose body between the articular surfaces. Their presence may berecognised, especially in the knee, by the crepitating sensationimparted to the fingers of the hand grasping the joint while it isflexed 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 openincision. [Illustration: FIG.  166. --Radiogram of Multiple Loose Bodies inKnee-joint and Semi-membranosus Bursa in a man æt.  38. (Mr. J.  W.  Dowden's case. )] #Bodies composed of Organised Connective Tissue. #--These arecomparatively common in joints that are already the seat of some chronicdisease, such as arthritis deformans, Charcot's arthropathy, or synovialtuberculosis. They take origin almost exclusively from an erraticovergrowth of the fringes of the synovial membrane, and may consistentirely of fat, the arborescent lipoma (Fig. 159) being the mostpronounced example of this variety. Fibrous tissue or cartilage mayform in one or more of the fatty fringes and give rise to hard nodularmasses, which may attain a considerable size, and in course of time mayundergo ossification. Like other hypertrophies on a free surface, they tend to becomepedunculated, and so acquire a limited range of movement. The pediclemay give way and the body become free. In this condition it may wanderabout the joint, or lie snugly in one of its recesses until disturbed bysome sudden movement. A loose body free in a joint is capable of growth, deriving the necessary nutriment from the surrounding fluid. The sizeand number of the bodies vary widely. Single specimens have been knownto attain the size of the patella. The smaller varieties may numberconsiderably over a hundred. [Illustration: FIG.  167. --Loose Body from Knee-joint of man æt.  25. Natural size. a = Convex surface. B = Concave surface. ] In arthritis deformans a rarer type of loose body is met with, a portionof the lipping of one of the articular margins being detached by injury. In Charcot's disease, bodies composed of bone are formed in relation tothe capsular and other ligaments, and may be made to grate upon oneanother. The _clinical features_ in this group are mainly those of the diseasewhich has given rise to the loose bodies, and it is exceptional to meetwith symptoms from impaction of the body between the articular surfaces. Treatment is to be directed towards the primary disease in the joint, aswell as to the removal of the loose bodies. [Illustration: FIG.  168. --Multiple partially ossified Chondromas ofSynovial Membrane, from Shoulder-joint, the seat of arthritis deformans, from a man æt.  35. ] _Loose Bodies in Joints which are otherwise healthy. _--It is in jointsotherwise healthy that loose bodies causing the classical symptoms andcalling for operative treatment are most frequently met with. They occurchiefly in the knee and elbow of healthy males under the age of thirty. The complaint may be of vague pains, of occasional cracking on movingthe joint, or of impairment of function--usually an inability to extendor flex the joint completely. In many cases a clear account is given ofthe symptoms which arise when the body is impacted between the articularsurfaces, namely, sudden onset of intense sickening pain, loss of powerin the limb and locking of the joint, followed by effusion and otheraccompaniments of a severe sprain. On some particular movement, thebody is disengaged, the locking disappears, and recovery takes place. Attacks of this kind may recur at irregular intervals, during a periodof many years. On examining the joint, it is usually found to containfluid, and there may be points of special tenderness corresponding tothe ligaments that have been overstretched. In cases in which there hasbeen recurrent attacks of locking, the ligaments become slack, the jointis wobbly, and the quadriceps is wasted. The patient himself, or thesurgeon, may discover the loose body and feel it roll beneath hisfingers, especially if it is lodged in the supra-patellar pouch in theknee, or on one or other side of the olecranon in the elbow. In mostinstances the patient has carefully observed his own symptoms, and isaware not only of the existence of the loose body, but of its erraticappearance at different parts of the joint. This feature serves todifferentiate the lesions from a torn medial meniscus in which the painand tenderness are always in the same spot. As the body usually containsbone, it is recognisable in a skiagram. [Illustration: FIG.  169. --Multiple Cartilaginous Loose Bodies fromKnee-joint. ] There are two methods of _removing the body_; the first and simplermethod is applicable when the body can be palpated, usually in thesupra-patellar pouch; it is preferably transfixed by a needle and canthen be removed through a small incision; otherwise, the joint must befreely opened and explored, firstly to find the body and further toremove it. The characters of this type of loose body are remarkably constant. It isusually solitary, about the size of a bean or almond, concavo-convex inshape, the convex aspect being smooth like an articular surface, theconcave aspect uneven and nodulated and showing reparative changes, healing over of the raw surface, and the new formation of fibroustissue, hyaline cartilage and bone, the necessary nutriment beingderived from the synovial fluid (Fig. 167). The body is sometimes foundto be lodged in a defect or excavation in one of the articular surfaces, usually the medial condyle of the femur, from which it is readilyshelled out by means of an elevator. It presents on section a layer ofarticular cartilage on the convex aspect and a variable thickness ofspongy bone beneath this. The origin of these bodies is one of the most debated questions insurgical pathology; they obviously consist of a portion of the articularsurface of one of the bones, but how this is detached still remains amystery; some maintain that it is purely traumatic; König regards themas portions of the articular surface which have been detached by amorbid process which he calls "osteochondritis dessicans. " _Multiple Chondromas and Osteomas of the Synovial Membrane. _--In thisrare type of loose body, the surface of the synovial membrane is studdedwith small sessile or pedunculated tumours composed of pure hyalinecartilage, or of bone, or of transition stages between cartilage andbone. They are pearly white in colour, pitted and nodular on thesurface, rarely larger than a pea, although when compressed they maycake into masses of considerable size. With the movements of the jointmany of the tumours become detached and lie in the serous exudateexcited by their presence. They are found also in the diverticula of thesynovial membrane, in the shoulder in the downward prolongation alongthe tendon of the biceps, in the hip in the bursal extension beneath thepsoas. The patient complains of increasing disability of the limb, movements ofthe joint becoming more and more restricted and painful. There isswelling corresponding to the distended capsule of the joint, and onpalpation the bodies moving under the fingers yield a sensation as ofgrains of rice shifting in a bag. If the bodies are so numerous as to betightly packed together, the impression is that of a plastic mass havingthe shape of the synovial sac. The stiffness and the cracking onmovement may suggest arthritis deformans, but the X-ray appearances makethe diagnosis an easy one. We have observed two cases of this affectionin the knee-joint of adult women, one in the shoulder-joint of an adultmale (Fig. 168), and Caird has observed one in the hip. The treatmentconsists in opening the joint by free incision and removing the bodies. _Displacement of the menisci_ of the knee is referred to with injuriesof 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 pyæmic, 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 hyperæmia, 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 Aërobes, 19 Air embolism, 265 hunger, 276 Albumosuria, 195, 474, 492 Aleppo boil, 129 Alexins, 22 Ambrine, 13, 238 Amputation neuroma, 344 Anaërobes, 19 Anæsthesia, 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 œdema, 348 sarcoma, 199 Angler's elbow, 406 Ankle, cellulitis of, 58 Ankylosis of joints, 503. _See also_ Individual Joints Anoci-association, 253 Anthracæmia, 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 hyperæmia, 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 aërogenes capsulatus, 99 anthracis, 119 coli communis, 27 diphtheriæ 109 drum-stick, 112 of Ducrey, 154 of glanders, 123 Klebs-Löffler, 109 of malignant œdema, 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 hyperæmia, 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 hæmatoma 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 Bursæ. _See also_ Individual Bursæ adventitious, 426 affections of, 426 individual, 428 diseases of, 426, 428 hæmatoma 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 hæmorrhage, 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 Chylorrhœa, 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 Cloacæ in bone, 443 Cocci, 18 Cœliac 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 hæmorrhagic, 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 hæmorrhage, 271 Forearm, aneurysm of, 318 cellulitis of, 58 Foreign bodies, embedded, 6, 231 Fracture, pathological, 444 Fraenkel's pneumococcus, 28 Fragilitas ossium, 479 Friedländer'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 œdema, 101 moist, 87 noma, 102 phagedæna, 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 hæmophilia, 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 Gonorrhœal 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 Hæmatemesis, 259 post-operative, 275 Hæmatoma, 220 bursal, 426 pulsating, of bone, 498 Hæmaturia, 259 Hæmophilia, 277 Hæmophilic joint, 531 Hæmoptysis, 259 Hæmorrhage, 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 Hæmorrhagic diathesis, 277 Hæmostatics, 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 Hyperæmia, 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 nævus, 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 Ischæmic 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 hæmophilic, 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 pyæmic 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-Löffler 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 Leucocythæmia, 340 Leucocytosis, 22, 29 absence of, 30 digestion, 30 after hæmorrhage, 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 bursæ, 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 œdema, 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 œdema, 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 œdema, 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 Melæna, 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 nævus, 295 venereal infection, 156 Moist gangrene, 87 Moles, 390 nævoid, 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 gonorrhœa 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 Nævoid mole, 295 Nævus, 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 Œdema, 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 fasciæ, 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 sequelæ 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 Ozœna, 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-anæsthetic, 360 pseudo, of syphilis, 174, 466 Parasitic bacteria, 20 cysts, 213 Paronychia. _See_ Onychia Parotid abscess in pyæmia, 66 lymph glands, 321 tumours, 195 Parotitis, 66 Parrot's nodes, 175, 465 Passive hyperæmia, 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 Phagedæna, 153 Phagedænic 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, Friedländer's bacteria, 28 Pneumococcal arthritis, 509 Pneumococcus, 28 Polypi, 195 Popliteal aneurysm, 320 artery, embolus of, 93 bursæ, 432 lymph glands, 323 nerves. _See_ Common Peroneal Nerve and Tibial Nerve Port-wine stain, 294 Post-anæsthetic 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-leucæmia, 337 Pseudo-paralysis of syphilis, 174, 466 Psoas bursa, 430 Pulmonary osteo-arthropathy, 480 Pulsating aorta, 305, 314 exophthalmos, 317 hæmatoma of bone, 498 Punctured wounds, 222 Purpura, 280 Purulent blister, 55 Pus, 45 varieties of, 46 Pyæmia, 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 nævus, 297 ulceration from, 239 Ranula, 329 Rarefying ostitis, 437 Ray fungus, 126 Raynaud's disease, 97 Reaction of degeneration, 347 Reactionary hæmorrhage, 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, fœtal, 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 gonorrhœal, 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 Röntgen 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 hæmorrhage, 276 Salvarsan in syphilis, 162 Sapræmia, 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 hæmorrhage, 273 syphilis, 151, 147 Selenium in malignant tumours, 201, 208 Semilunar ganglion, 375 Semi-membranosus bursa, 432 Sepsis, 18 Septicæmia, 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 hæmophilia, 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 hæmorrhage, 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 Spirochæte 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 bursæ, 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 phagedæna, 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 spirochæte 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 Tænia 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 Toxæmia, 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 bursæ, 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 hyperæmia 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 phagedænic, 80, 85 pressure, 70 from radium, 70 rodent, 395 from Röntgen 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 ischæmic 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