A treatise on surgery : its principles and practice

Preface

TO

THIED EDITION.

The present edition does not differ in any material particular from the second. In those parts of surgery where considerable changes have been recently sanctioned by general adoption, or where changes have been proposed which seem worthy of trial, I have endeavoured to accommodate my text to the state of what I believe to be the most trustworthy surgical opinion ; trying, on the one hand, to avoid that blind eagerness after novelty which is no doubt one of the less admirable features of our profession at the present time, and on the other that equally blind opposition to all change in the practice which we were taught when young, which is so apt to distinguish men who are growing old. Whether I have been successful in this, my readers must judge. I can only say I have tried honestly, feeling deeply the responsibility which the writer of a text-book undertakes, especially towards the students, who form the bulk of his audience.

In other respects the book remains practically unchanged. The new pathological speculations, with which the name of Koch is now chiefly associated, are not in my opinion yet sufficiently proved or tested by experience to warrant their adoption as a basis of practice, interesting as they are. Before another edition of this work can be called for, we shall be able at any rate to pronounce some opinion on this point ; but at the present time I could say nothing that would not be more likely to mislead my readers than to guide them.

THE

PREFACE

TO

FIEST EDITION.

I need say little by way of preface to this volume, which, indeed, speaks for itself. It is an attempt to represent the present condition of Surgery, as it is practised in this country, by a treatise which shall be not unworthy to rank with the other excellent text-books in use in our schools. I have intended this book to be to some extent an introduction to the more elaborate System of Surgery of which I am the editor, and have freely used the treatises of that System in composing the various chapters ; and when any quotations are made the source of which is not distinctly acknowledged, it will be understood that they are taken from thence. At the same time I have not servilely followed the teaching even of those authorities ; and I hope the reader will find throughout the book sufficient evidence of that personal experience of the various exigencies of surgery which can alone justify an author in attempting the difficult task of writing on the general subject of surgical theory and practice. The task is indeed difficult. It is not only the immense number of topics, and the endless details of all of them— though necessarily some of these topics must be less familiar to any single surgeon (however wide his experience) than others are, and though it is hardly possible but that some of the details should escape the writer's attention — but, added to this, the necessary conditions of space press hardly on the writer of a surgical text-book. Though this volume extends to over 900 pages, the space allotted to each topic only permits of a brief and, I fear, far too meagre account of each, and leaves hardly any room at all to discuss varying opinions and rival viii

Preface To The First Edition

suggestions of practice. My endeavour has been to give a plain and practical account of each surgical injury and disease, and of the treatment which is most commonly advisable. For the minuter details of pathology I must refer the reader to some of the many admirable works on that subject; and for fuller disquisitions on treatment either to the essays in the System of Surgery or to the authors quoted in the text and referred to in the index of authors.

I have to acknowledge with grateful thanks the libei*ality with which the rich store of material contained in the museum and casebooks of St. George's Hospital has been put at my disposal. It is, of course, from the school of this hospital, in which I have studied and practised surgery for over a quarter of a century, that my illustrations and my teaching have been chiefly drawn ; but I have not neglected the teaching of other British schools ; nor, although I have intended this work to be an exposition especially of British surgery, have I failed to refer, as far as my information and my space allowed, to the works of American and Continental surgeons.

For the illustrations I have been indebted mainly to Dr. Westmacott, to whom my warm thanks are due for the great interest he has taken in the work and the pains he has spent upon it. Many of the minor illustrations were, however, drawn by one of my pupils, ,Mr. F. D. Drewitt, whose intelligent and able assistance it is my duty to acknowledge as it deserves; nor must I omit to thank Mr. Evans, the engraver of the woodcuts, for the great care which he has bestowed upon them, and for several of the diagrams which he has drawn under my direction.

I have thought it necessary to comprise in this treatise all the diseases which are included under the title 'surgical,' so that chapters will be found on diseases of the eye, ear, and skin. In treating the first-mentioned subject I have availed myself of the able assistance of my colleague Mr. Carter ; as it is many years since I have personally engaged in ophthalmic practice, and it is only from recent practice that a branch of surgery can be taught which has been so greatly modi tied by recent discoveries. But I hold that a knowledge of the main principles of diagnosis and treatment ought to be possessed by every surgeon ill the case of diseases of the organs of the special senses quite as much as those of the rest of the body. Among the many injuries which the

PREFACE TO THE FIRST EDITION.

ix curse of specialism has inflicted equally on the profession and the public, not the least has been the neglect of the diseases of these organs which some practitioners and many students seem almost to regard as natural. I am happy to think that in the subject of ophthalmic surgery my readers will have the benefit of so competent a guide as Mr. Carter. The chapter on Diseases of the Ear is necessarily very short, and is intended only to point out the leading facts in Aural Surgery, and those methods of treatment with which every practitioner ought to be familiar. I must express my obligation to Mr. Dalby, who has been so kind as to peruse it and correct some of its most obvious defects.

I must now submit this book to the judgment of my professional brethren, though fully conscious of its many imperfections. I fear that as we advance in life we feel more and more the difficulty of coming up to our own expectations in any enterprise of importance, and the truth of the old saying, ' Quid tarn dextro pede concipis ut te conatus non peniteat votique peracti ? '

(treat Cumberland Place : October, 1875.

Chapter I. Inflammation And The Peocess Of Union In Soft Parts

TRAUMATIC FEVER DRESSING OF WOUNDS.

PAGE I PAGE

The Process of Inflammation . . 1 Chief symptoms : Redness, Swelling, Heat, Pain, Fever ... 1 Causes of Inflammation . . 4 Pathology of Inflammation . . 5 Emigration of Leucocytes . 5 Terminations of the Inflammatory Process . . . • 7 Wounds and Contusions . . . 8 Blood-tumour: Organisation of Clot . . . ' . .8

Kinds of Wound 10

Processes of Union :

1. Primary Adhesion . . 10

2. Primary Union, or Union

by First Intention . . 11

3. Union by Suppuration, or

by Second Intention . . 12

Ulceration . . . . 13 Granulation . . .13

Processes of Union — continued.

Cicatrisation . . 14

4. Union by Secondary Adhesion, or by Third Intention ..... 14

5. Union under a Scab . . 15 Cicatrices . , . . . .15 Traumatic Fever 15

Condition of the Blood in Inflammation 17

Symptoms of Traumatic Fever . 18

Methods of Dressing Wounds . . 19

Lister's Antiseptic Method . 19

Dressing Wounds where Rapid

Union is not sought . . 22

Irrigation . . . . . 22

Pine-sawdust pads, Spongegrafting, Sutures . . .23

Strapping, Bandages . . . 24

Chapter II. The Complications Of

Abscess . . . . .25 Kinds of Pus and of Abscess ;

Progress of Abscess . . . 25

Diagnosis — Fluctuation . . 26

Treatment of Abscess . . 27

Residual Abscess . . .28

Sinus and Fistula . . . . 28

Pyaemia and Septicaemia . . .29

Symptoms of Pyaemia . . . 30

Causes of Pyaemia . . .31

Contagiousness . . . . 32

Pathology . . .- .32

Pathological Anatomy . . . 34

Diagnosis . . . . .35 Treatment . . ... 36

Chronic Pyaemia . . 36

WOUNDS AND INJURIES.

Hectic Fever 86

Visceral Disease produced by long-continued Suppuration . .38

Erysipelas and Erythema . . 38

Various Forms of Erythema . 39 Cutaneous or Simple Erysipelas 40 Phlegmonous or Cellulo-cuta-

neous Erysipelas . -. .41 Causes of Erysipelas . . . 42 Diagnosis . . . . .43 Treatment . ' . . . . 44 Local Treatment of Diffuse Inflammation . . .45

Gangrene 46

Traumatic and Spontaneous Gangrene . . . . .46 xii

CONTENTS.

Gangrene — continued.

Moist and Dry Gangrene Phenomena of" Gangrene .

Amputation in Gangrene Local and General Treatment Special Forms:

Bedsores — Frostbite .

Hospital Gangrene . ■

Phagedena

Senile Gangrene .

47 47 48 51

53 54 55

Gangrene — continued.

Cancrum Oris and Vulvae . . ' Tetanus ....

Varieties — Symptoms .

Diagnosis .

Pathology .

Treatment Delirium Tremens

Noma

Chapter III. Poisoned Wounds And Animal Poisons

Dissection-wounds . . . . 60 Acute and Chronic Form of Dissection-poison . . .67 Treatment of Dissection-wounds 08 Wounds of Venomous Animals . . 69 Intravenous Injection in Snake-bite 70

Glanders ....

Farcy

Equinia Mitis

Hydrophobia

The Disease in the Dog

Diagnosis and Treatment

72 73 73 73 77

Chapter IV. Haemorrhage And Collapse

.Spontaneous Haemorrhage . .

The Hemorrhagic Diathesis General Symptoms of Accidental

Haemorrhage Injuries of Arteries . . .

Contusion ....

Partial Laceration . . .

Complete Laceration, Subcutaneous . .

Complete Laceration in an Exposed Artery . . .

Incomplete Division Complete Division . . .

Injuries of Veins

Entrance of Air into Veins .

Diagnosis of the Sources of Hemorrhage . . .

Treatment : Method of Tying

Bleeding Arteries Treatment of Wounded Veins Cases in which Wounded Arteries should not be Tied

79 80 80 80

81 81 82 83 83

85 85

Cases in wliich the Artery

above may be Tied Ligature of Arteries . . .

Changessubsequent to Ligature Secondary Haemorrhage and its Treatment . .

Secondary Haemorrhage

in Disease .

Recurrent Haemorrhage .

Gangrene . . . .

Recurrence of Pulsation .

Ligature of Arteries with Carbolised Catgut (the ' Antiseptic Method ") . . .

Acupressure ....

Torsion .....

Other Means of Stopping Arterial Hemorrhage, Uncipression, Forcipression, &c.

Treatment of ordinary Capillary Haemorrhage ; Styptics Transfusion of Blood Collapse

86 86 87

90 91 91 91

92 94 95

98 99 101

Chapter V. Burns And Scalds

Clarification of Burns . . . 105 Symptoms and Stages of Burns . . 106 Ulceration of the Duodenum . 107

Local Treatment General „ Lightnings-stroke

. 108 . 109

. no

CONTENTS.

Chapter VI. Fractures And Dislocations General Pathology

Definition and Classification . Ill Fat-embolism . . . .112 Separation of Epiphyses . .112 Symptoms and Diagnosis . .113 Treatment . . . . . 114 Setting the Fracture . .114 Question of Amputation or

Excision . . . . 115 Treatment of Complications . 116 Union of Fractures . . .117 Usual Process in Simple Fracture (Primary Union, Intermediate Callus) . . .lis

Union — continued.

Union by Provisional Callus . 120 Union of Inflamed Simple, and of Compound Fractures by

Granulation . . .121

Defects of Union . . . . 121

Delayed Union . . .122

Ununited Fracture . . . 123

Vicious Union : Refracture . 126

Dislocation : General Pathology . 127

Reduction 128

Injuries of Cartilage . . . 120

Chapter VII. Injuries Of The Head

Classification . . . . 131

Complications ..... 131

Surgical Anatomy of the Scalp . . 131

I. Contusions of the Soft Parts . 132

Diagnosis between Extravasation and Depressed Fracture . 132

II. Scalp-woundsandtheirTreatment 133

Complications of Scalp-wound : Erysipelas .... 133 Suppuration beneath the Cranium •. . . 135

Trephining for Pus . 136

III. Traumatic Extravasation between

the Bone and Dura Mater . .137 Trephining for Wound of Middle

Meningeal Artery . . . 138 Extravasation in the Arachnoid

Cavity 130

Organisation of such Extravasation . . . . 130 Symptoms: Diagnosis from Apoplexy . . . 141

IV. Fractures of the Skull . . . 141 Fractures of the Vault . . 141

Depression of Outer Table only:

Fractures of the Frontal Sinus 142

Fractures of the Skull — continued.

Depression of Inner Table only 143 Fracture with Elevation . 143 Fracture by Contre-coup . . 143 Treatment of Simple and Compound Fracture . . . 144 Fractures of the Base of the Skull ... ... 145

In Wounds of the Orbit . 145 Of the Anterior Fossa . . 147 Of the Middle Fossa . . 147 Of the Posterior Fossa . . 147 Serous Discharge in Fracture

of the Skull . . .148 Union of Fractures of the Base .... .140

V. Lesions of the Brain . . . 150 Concussion of the Brain . . 151 Compression . . . . 153

Trephining for Fracture . 153 Cases not classifiable as Concussion or Compression. Contusion and Laceration of the

Brain 154

Traumatic Inflammation .■ . 155 Hernia Cerebri . . .156 Injuries of Cranial Nerves . . 157 The Operation of Trephining . 158

Chapter VIII

Sprains of the Back . . . 160 I Treatment : Trephining the Spine . 104 Fracture and Dislocation of the Spine 160 | Concussion and Railway Injury . 100

CONTENTS.

Chapter IX. Injuries Of The Face

I'AGF.

Bruises and Wounds . . . . 170 Salivary Fistula . . .170 Foreign Bodies in the Nostril and

Ear 171

Of Nasal Bones . . . . 172 r.iGE

Fractures — continued.

Of the Upper Jaw . . . 172 Of the Malar Bone and Zygoma 172 Of the Lower Jaw . . .173

Dislocation of the Jaw . . . 175 Subluxation of the Jaw . .178

Chapter X. Injuries Of The Neck

Cut-throat 179

Contusions of the Larynx . . 182 1 lislocation of the Hyoid Bone . . 182 Fractures of the Hyoid Bone . . 182 Of the Cartilages of the Larynx 183

Rupture of the Trachea . . . 184 Foreign Bodies in the Air-passages . 184 Burn and Scald of the Larynx . .189 Foreign bodies in the Oesophagus . 190 QSsophagotomy . . . . 192

Chapter XI. Injuries Of The Chest

Contusions and Wounds of the Pa-

rietes 194

Fractured Ribs 194

With Wound of Lung . .196 Complications : Emphysema . . . . 197 Pneumothorax . . . 198 Hemothorax, Hydrothorax, &c. . . ' . . . 198 Fracture of Costal Cartilages . 198 Fracture of the Sternum . . . 199

Dislocations of the Bibs . . . 199 Penetrating Wounds . . . 199

Hernia of the Lung . . . 200 Foreign Bodies in the Chest . . 201 Wounds of the Mediastinum, Pericardium and Heart . . . . 201

Paracentesis of Pericardium . 202

Wounds of Internal Mammary and Intercostal Arteries . 203 Rupture of Viscera without Wound 204

Thoracentesis . . . . 204

Chapter XII. Injuries Of The Abdomen

Contusions ..... 207 Contusion with Rupture of Intestine:

Rupture of the Stomach . .207 of the Intestines . . 208 of the Liver and Gallbladder . . . 209 of the Spleen . . 210 of Kidney and Ureter . 210

Wounds :

I. Superficial . . . .211 II. Penetrating :

«. Simple : Foreign bodies in

such Wounds . . . 212

Wounds — coni in ued,

b. With Wound of Viscera

which do not protrude . 212

c. With Protrusion of Unin-

jured Viscera . . 213 (1. With Protrusion of the

Wounded Viscera . . 213 Suture of the Intestine . 214 Foreign Bodies in the .Stomach or Intestines 214

Gastrotomy and Gastrostomy . 215

CONTENTS, xv

Chapter XIII. Injuries Of The Pelvis

PAGE

Injuries of the Male Organs of Generation . . . . . 225 Tying a Ligature round the Penis . 226 Injuries of the Female Organs . . 226 Wounds of the Bladder . . . 227 Wounds of the Rectum . . . 227 Foreign Bodies in the Bladder, Vagina, or Rectum . . . . 227

Contusion and Wound of the Buttock 218

Fractures of the Pelvis :

Of the Ala of the Ilium . . 219

Of the True Pelvis . . .219

Of the Acetabulum . . . 221

Of the Coccyx . . . .222

Rupture of the Bladder . . . 222

Rupture of the Urethra . . . 224

Chapter XIV. Injuries Op The

Considerations applicable to all Injuries of the Upper Extremity . . 229 Foreign bodies in the Palm . . 229 Wounds of the Palm of the Hand 229

Fractures of the Clavicle :

Of the Body of the Bone . . 230 Of the Sternal End . . . 233 Of the Acromial End . - . 233

Fractures of the Scapula . . . 234 Of the Neck of the Scapula . 235 Of the Coracoid and Acromion Processes 236

Fractures of the Humerus :

Fracture of the Anatomical Neck 237 Of the Surgical Neck . . 238 Of the Epiphysis .... 239 Of the Great Tuberosity . . 239 Of the Shaft . . . . 240 Of the Lower End . . .241

Fractures in the Forearm :

Of the Olecranon . . . . 243 Of the Coronoid Process . . 244 Of Head of Radius . . . 245 Of both Bones of the Forearm . 245 Of one Bone alone . . . 245 Colles's Fracture of the Lower End of the Radius . . 246

Fractures of the Carpus . . . 249

Fractures of the Metacarpus and Phalanges 249

UPPER EXTREMITY.

Compound Fractures in the Upper

Extremity ..... 249 Dislocation of the Sternal End of the

Clavicle 250

Dislocation of the Acromion . . 251 Dislocation of the Shoulder . . 251 Into the Axilla :

Subcoracoid and Subglenoid . 252 Subclavicular . . . . 253 Subspinous .... 254 Rarer Dislocations upwards (Su-

pracoracoid) . . . . 254 Dislocations complicated with Fracture .... 256

Reduction 256

Compound and Partial Dislocation '. " . . . . 259

Dislocation of the Elbow :

Of both Bones backwards . . 261 With Fracture of the Coronoid Process . . . . . 262

Of the Head of the Radius only 2fa'3 Rarer Dislocations . . . 264 Compound Dislocations . ' . 264 Dislocations of the Lower End of the Radius . . . ... 264

Dislocations of the Wrist ... 265 Dislocations of the Carpus . . . 265 Dislocations of the Thumb . . 265 Dislocations of the Fingers . . . 267

Chapter XV. Injuries Of The Lower Extremity'

Sprains and Wounds

Wound of Knee-joint . . .

Fracture of Cervix Femoris:

Extra- and Intra-capsular Frac-

268 269

Fr actitres — continued.

ture, Impacted and Non-impacted 269 xvi

CONTENTS.

Frac tu res — continued.

Diagnosis between Extra- and

Intra-capsular Fracture . 272 Method of Union and Treatment 274 Fractures of Trochanter and Separation of Upper Epiphysis . 275 Fracture of the Body of the Femur :

In the Upper Third . . . 270 In the Middle of the Bone . 278 Near the Knee-joint . . . 283

Fracture of the Patella :

Transverse .... 285

Y-shaped 289

Compound .... 290

Fractures of the Leg :

Of both Bones . . . . 290 Of the Tibia only . . .291 Of the Fibula only . . . 291 Compouud Fractures . . 292

Fractures of the Bones of the Foot . 21)4

PAGE

Dislocations of the II ip :

1. Upwards on the Dorsum Ilii 295

2. Backwards on the Sciatic

Notch 298

3. Downwards on the Obturator

Foramen .... 802

4. Inwards on the pubes . . 304 Anomalous Dislocations . . 305

Dislocation of the Knee . . . 306 Patella . . .306 Semilunar Cartilages 307 Head of the Fibula . 308 Dislocations of the Ankle . . . 308 Pott's Fracture .... 308 Compound Dislocations . . 310 Dislocation of the Astragalus . . 310 Subastragaloid Dislocation . . . 311 Dislocations of the Tarsus, Metatarsus, and Phalanges . . . 313

Chapter XVI. Gunshot Wounds

I. Gunshot Wounds in General :

Definition . . . . . 315 Mode of Union . . . .315 Wound of Entrance and Exit . 316 f Wind Contusions,' or Contusions from Oblique Impact . 316 Symptoms and Method of Examination . . . . . 316 Treatment .... 317

II. Gunshot Wounds in each Region of the Bodv :

Of the Head 319

Of the Spine . . . .320 Of the Face 320

II. Gunshot Wounds in each Region of the Body — continued.

Of the Neck . . . .321 Of the Chest . . . . 321 Diagnosis and Treatment of Gunshot Wounds of the Lung . . . .321 Of the Abdomen . . . . 323 Of the Hypogastrium, Peri-

nseum, and Genital Organs . 324 Of the Extremities . . . 324 Treatment of Gunshot Injury of the Upper and Lower Extremities . . . . 326

Chapter XVII. Tumours

Definition of a, ' Tumour ' Classification .

I. Innocent Tumours : Cysts : Serous .

Sanguineous Compound Cysts ceous .

Congenital Cutaneous Dermal Cysts .

Proliferous Cysts .

Cystigerous Cysts Solid Tumours :

Fatty ", Fibrous Fibrocellular Cartilaginous . . .

Bony

: Seba- Cysts .

328 329

330 331

332 333 334 334 334

334 330 336 337 338

Solid Tumours — continued.

Vascular 339

Aneurism by Anastomosis . 339

Njbvus 340

Treatment of N;evus . . 341 Degeneration of Nuevus . . 344 II. Sarcomatous or Seminialignant

Tumours .... 344 Round-celled Sarcoma . . . 345 Spindle-celled Sarcoma . . 34(> Giant-celled Sarcoma (myeloid) 346 Net-celled Sarcoma (myxoma) . 340 Alveolar Sarcoma . . . 346 Pigmentary Sarcoma (melanosis) •'! 1 7

Cylindroma 347

Diagnosis of Sarcoma from Carcinoma .... 34! »

CONTENTS.

xvii

PAGE

Sarcomatous or Semi-malignant Tumours — continued,

Carcinoma . . . . . 350

Scirrhus 351

Medullary 353

Melanotic ..... 353

Struma and Scrofula . . . . 358 Tubercle, its Kinds and Manner of Formation . . . . 358 Connection between Scrofula and Ordinary Inflammation i . 359

Definition and Pathology . . . 363 Nervous Mimicry or NerVoUs Affections . . . . 364

Gonorrhoea in the Male i . i 368 Symptoms of its Various Stages . 368 Gleet ... . .368 Complications :

Lacunar Abscess . . . 369

Balanitis 369

Phimosis ..... 369 Paraphimosis . . . . 369 Spasms and Hasmatitria . . 370 Chordee , . ; . : 370

Bubo 370

Gonorrhoeal and Capivi Rash . 370 Gonorrhceal Rheumatism . . 370 Other Complications . . i 37 1 Treatment of Gonorrhoea . . . 372 Gonorrhoea in the Female , . 373 Leucorrhcea Infantum . . . 378 Complications of Female Gonorrhoea t . . 374 Treatment . . . .374 Syphilis: Definition and Nomenclature . . . . . . . . 3?5

The Local Forms of Syphilis, or

the Non-infecting Sore . 375

1. The Common Soft Chancre 875

2. The Chancre with Suppu-

rating Bubo . . .376 Syphilitic Phimosis . . . 376

3. The Sloughing Sore . . 377

PAGE

Sarcomatous or Semi-malignant Tumours

— continued.

Osteoid 354

Epithelioma .... 354

Colloid 355

Struma and Scrofula — continued.

Kinds of Varieties of Scrofula . 360

Causes of Scrofula . . . 361

Definition and Pathology — continued.

Symptoms and Diagnosis . . 364 Treatment .... 366

Syphilis — continued.

The Constitutional Form of Syphilis — the ' Hard/ ' infecting,' or ' Hunterian ' Chancre 377"

Diagnosis between the two Forms

of Chancre . t ■. 377 Treatment : the use of Mercury . , ; . . 380

Secondary Syphilis * , 382 Skin Eruptions . « . . 383 Mucous Tubercle . . 383

Alopecia . ... 383

Sore Throat . . .384

Affections of Glands . . . 384 Inoculation of Secondary Syphilis. . . . 389

Tertiary Syphilis .... 386

Summary of the Lesions met with in

Constitutional Syphilis . . 387 Infantile or Congenital Syphilis . . 388 Syphilitic Teeth .... 390

Non-congenital Syphilis in Infants . 391 Vaccino-syphilis . . , . . 392 Irregular Forms of Syphilis . . 392 Syphilitic Inoculation and Syphilisation. ■ . • ( ■ . , i . 392'

Chapter XXI. Ulcers — Cicatrices And Their Diseases

PAGE

Classification of Ulcers . . . 395

The Healthy Ulcer . . . 395

Inflammatory Ulcer . . 396

Eczematous Ulcer . . . 396

Cold Ulcer . . .396

Senile Ulcer . . . . 396

Strumous Ulcer . . . 397

Scorbutic Ulcer . . . 397

Gouty Ulcer . . .397

Syphilitic Ulcer . . . 398

Lupous Ulcer . . . 399

Rodent Ulcer . . . 399

Cancerous Ulcer . . 400

Varicose Ulcer . . . 401

(Edematous or Weak Ulcer 401

Classification of Ulcers — continued.

Exuberant Ulcer . . 401 Haemorrhapic Ulcer . . 401 Neuralgic Ulcer . . .401 Inflamed Ulcer . . . 401 Callous or Indolent Ulcer . 402 Phagedsenic Ulcer . . 402 Cicatrices and their Diseases . . 402 Ulceration of Scars . . . 402 Neuralgia of Scars . . . 403 Excessive Formation of Scars . 403 Keloid Tumour of Scars . . 403 Warty and Epithelial Tumours 403 Contracted Cicatrix . . . 404 Skin-grafting 404

Chapter XXII. Diseases Of The Bones

Ostitis or Inflammation of the Substance of Bone .... 406

Ostitis deformans 408

Periostitis 409

Nodes 409

Diffuse Periostitis : Acute Periosteal Abscess . . .410

Osteo-Myelitis 412

Chronic Abscess . . . .414

Caries 416

Phagedaenic Ulceration of Done . 419

Necrosis 419

Acute Necrosis . . . . 422 Treatment of Necrosis . . 422 Complications: Fracture from Necrosis . . . . 424 Scrofula iu Bone .... 424

Syphilis in Bone . . . . . 426 Cancer iu Bone .... 427 Osteoid Cancer . . . . 427 Myeloid and Sarcomatous Tumours

of Bone 430

Innocent Tumours:

Enchondroma . . . . 431

Exostosis 433

Fibrous and Fibro-cellular Tumours . . . . . 43(3

Hydatids 437

Pulsatile Tumour : Osteo-Aneurism. 437

Mollities Ossiuin 438

Rickets 441

Hypertrophy of Bone . . . . 444 Atrophy of Bone .... 445 Spontaneous Fracture . . . . 446

Chapter XXIII. Diseases Of The Joints

General Pathology and Diseases of the Knee.

. Affections of the Synovial Membrane: Acute Synovitis . . . 447 ' Abscess of Joints . . . . 449 Chronic Synovitis . . . 450 Hydrops Articuli . . . 450 Pulpy Degeneration of Synovial

Membrane ... . . 450 Pendulous Growths from Synovial Membrane . . . . 452

Disease of the Articular Ends of

Bones 452

Affections of the Cartilages: ' Ulceration of Cartilage ' . . . . 455 Loose Cartilages, or Loose Bodies in

Joints 458

Chronic Rheumatic Arthritis . . 460

Ankylosis 462

Forcible Extension . . . 462 Subcutaneous Section of Bone . 4(i2 Hysterical and Neuralgic Affections . 404

CONTENTS.

xix

PAGE

Diseases op Particular Joints:

Of the Hip : ' Morbus Coxarius ' 465 Congenital Dislocation . . 468 Other Affections of the Hip . 472 Of the Sacroiliac Articulation . . 473

Of the Ankle and Tarsus . . . 473 Of the Sternoclavicular Joint . . 473 Of the Shoulder . . . .475

Of the Elbow 475

Of the Wrist and Carpus ,. • . .476

Chapter XXIV. Diseases Op The Spine

Caries of the Spine . . . . 477

Affection of the Cord . . 478

Spinal Abscess . . . . 480

Psoas Abscess . . . 480

Treatment of Diseased Spine . 481

Disease of Cervical Vertebras . 482

Lateral Curvature . . i < 485 Kyphosis, Lordosis, and other Curvatures 487

Ankylosis of the Spine . . . 487

Spina Bifida . . . 488