Elements of Surgery

by Robert Liston

and are found lying in the cavity of the abscess, as seen in this specimen, taken from a young subject. When the bodies of the vertebræ are attacked by ulcerative absorption, and sometimes the disease is very extensive, involving perhaps four, five, or six of the bones, there is more or less curvature of the spine outwardly—excurvation. If the disease affects one or two bones, and their bodies are almost destroyed, then the projection is sharp and angular. When the disease is more extensive the curve is greater, and more gradual ulceration sometimes exists to a considerable extent in one articulation, without change of form externally in the spinal column, and sometimes without any great collection of pus. When curvature commences there is very generally more or less weakness of the limbs, though curvature, whether from ulceration or interstitial absorption, is by no means of necessity attended by any degree of paralysis. The power of motion of parts supplied by nerves in the neighbourhood of disease is diminished earlier in general than the sensation, in consequence, possibly, of the mischief commencing in the anterior part of the bodies of the vertebræ. It is wonderful to what extent disease may extend in the vertebral column, without much impairment of the functions of the spinal chord, and how perfectly the functions are restored in cases where it has suffered. The lumbar vertebræ are those most frequently affected, but the ulceration may also be either in the dorsal region or in the pelvis. Disease of the last lumbar vertebra at its connection with the sacrum, or disease of the sacrum itself, is attended with abscess around, which descends into the pelvis, displacing the bowel, and appearing by the side of the buttock.

Such abscesses may have been allowed to come to the surface, and to discharge their contents spontaneously; or they may have been at a late period opened either at one point or at several. In these circumstances, the discharge is generally profuse, long-continued, and attended with exhaustion and hectic, gradually but surely destroying the patient. But, by good management, a perfect and permanent recovery may in many cases be obtained. When the vertebræ are affected, absolute rest must be enjoined and enforced; and a drain is to be established by the sides of the spinous processes, either by moxa, potass, or seton—it is immaterial which. The discharge is kept up by occasionally dressing the issue for a few hours with an acrid ointment, so as to reproduce a slough. When the abscess begins to present, it should be opened as early as possible, and a free exit allowed to the matter; the discharge should be at no time confined. The opening of the cavity, and again shutting it up, however carefully conducted, is in almost every instance followed by alarming and hazardous results. Rapid accumulation of putrid and bloody matter takes place, and air is extricated within the cavity; the vessels of the cyst, being unsupported, part with their contents; irritative fever is lighted up, with rapid pulse, anxious countenance, and delirium. These symptoms are relieved only by immediate evacuation of the fluid. Some slight constitutional disturbance follows the making of a free opening, but quickly subsides; then the discharge improves in quality, becomes more pure and unmixed, diminishes in quantity, and gradually ceases. During the discharge the strength requires support; and the attention to the original mischief must not be neglected or intermitted.

Spina Bifida is a congenital fluctuating tumour, with deficiency of the subjacent vertebræ. It is usually situated in the lumbar region, sometimes in the dorsal, and often over the sacrum. The size of the swelling varies according to the age of the child, and the extent of deficiency in the parietes of the spinal canal. The spinous processes are either imperfect or altogether wanting, and over the space so formed the tumour is situated. Its contents are usually of a serous character, thin and colourless; sometimes they are turbid and flaky. The parietes seem to be a continuation, or protrusion, of the membranes of the spinal chord, thickened and somewhat altered in structure, and usually in close contact with and adherent to the integuments. By pressure the size of the tumour is diminished; but, if firm or long continued, unpleasant effects are apt to result. There is often debility of the lower limbs, and the disease is not unfrequently coexistent with hydrocephalus. Children with this affection seldom live more than a few years.

The application of gentle, uniform, and continued pressure affords support to the parts, and prevents increase of the tumour; and, under this palliative treatment, life may be both rendered more comfortable and prolonged. It has been proposed to combine continued pressure with occasional puncturing of the cyst by means of a fine needle, with the view of diminishing the tumour and ultimately obtaining entire obliteration of the cyst. The practice has been made trial of, and the result may warrant repetition; caution, however, is necessary, for the too free opening of the tumour is often followed by a rapidly fatal issue. A case occurred to me not long since, in which the tumour, of large size, was situated over the sacrum. The fluid was evacuated by a small trocar and canula, the parietes shrank, and a very satisfactory cure resulted.

AFFECTIONS OF THE RECTUM AND NEIGHBOURING PARTS.

Of Hemorrhoids or Piles.—Piles are blind, furnishing no discharge, except a mucous or puriform fluid; or open, pouring out a greater or less quantity of blood from time to time. They are usually of small size, invested by the mucous membrane, thickened, congested, and consequently of a dark colour; and either within the sphincter or projecting externally. Internally, they may sometimes consist of blood, coagulated or not, effused between the mucous and muscular coats of the intestine; but in general their inner structure is venous, at least in the first instance. Branches of the hemorrhoidal veins, ramifying near the inner surface of the gut, become varicose, probably from their superior trunks being compressed by hardened feculent matter or other obstructions. The varix protrudes the superimposed mucous membrane; and at first the excrescence is composed of the dilated venous trunks containing fluid blood, and invested by the membrane, which inflames, thickens, loses its villous character, and discharges a vitiated secretion. In this stage the tumour is easily compressible, and by pressure may be made to disappear almost entirely, the communications between the varicose vessels and the trunks above being still unobstructed. But inflammatory action is soon kindled in the incommoded venous branches, as frequently happens in varix of the lower extremities; their coats become changed, are thickened, effuse lymph externally and internally, adhere to one another, and are ultimately matted into one confused and solid mass; the contained blood coagulates, becomes fibrinous, the whole tumour feels hard and firm, and often is exceedingly painful. At length all traces of venous structure disappear; the tumour seems to consist chiefly of effused lymph, condensed cellular tissue, and coagula.

In not a few instances, however, the contents of the veins remain partially fluid, and a communication exists between the vessels of the tumour and those of the surrounding parts.

That such is the usual structure of piles I am convinced, from repeated and careful dissection of the tumours.[48]