Manual of Surgery, Alexis Thomson [new books to read txt] 📗
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Parasitic cysts are produced by the growth within the tissues of cyst-forming parasites, the best known being the tænia echinococcus, which gives rise to the hydatid cyst. The liver is by far the most common site of hydatid cysts in the human subject.
With regard to the further life-history of hydatids, the living elements of the cyst may die and degenerate, or the cyst may increase in size until it ruptures. As a result of pyogenic infection the cyst may be converted into an abscess.
The clinical features of hydatids vary so much with their situation and size, that they are best discussed with the individual organs. In general it may be said that there is a slow formation of a globular, elastic, fluctuating, painless swelling. Fluctuation is detected when the cyst approaches the surface, and it is then also that percussion may elicit the “hydatid thrill” or fremitus. This thrill is not often obtainable, and in any case is not pathognomonic of hydatids, as it may be elicited in ascites and in other abdominal cysts. Pressure of the cyst upon adjacent structures, and the occurrence of suppuration, are attended with characteristic clinical features.
The diagnosis of hydatids will be considered with the individual organs. The disease is more common in certain parts of Australia and in Shetland and Iceland than in countries where the association of dogs in the domestic life of the inhabitants is less intimate. Pfeiler, who has worked at the serum diagnosis of hydatid disease, regards the complement deviation method as the most reliable; he believes that a positive reaction may almost be regarded as absolutely diagnostic of an echinococcal lesion.
The treatment is to excise the cyst completely, or to inject into it a 1 per cent. solution of formalin. In operating upon hydatids the utmost care must be taken to avoid leakage of the contents of the cyst, as these may readily disseminate the infection.
A blood cyst or hæmatoma results from the encapsulation of extravasated blood in the tissues, from hæmorrhage taking place into a preformed cyst, or from the saccular pouching of a varicose vein.
A lymph cyst usually results from a contusion in which the skin is forcibly displaced from the subjacent tissues, and lymph vessels are thereby torn across. The cyst is usually situated between the skin and fascia, and contains clear or blood-stained serum. At first it is lax and fluctuates readily, later it becomes larger and more tense. The treatment consists in drawing off the contents through a hollow needle and applying firm pressure. Apart from injury, lymph cysts are met with as the result of the distension of lymph spaces and vessels (lymphangiectasis); and in lymphangiomas, of which the best-known example is the cystic hygroma or hydrocele of the neck.
GanglionThis term is applied to a cyst filled with a clear colourless jelly or colloid material, met with in the vicinity of a joint or tendon sheath.
The commonest variety—the carpal ganglion—popularly known as a sprained sinew—is met with as a smooth, rounded, or oval swelling on the dorsal aspect of the carpus, usually towards its radial side (Fig. 60). It is situated over one of the intercarpal or other joints in this region, and may be connected with one or other of the extensor tendons. The skin and fascia are movable over the cyst. The cyst varies in size from a pea to a pigeon's egg, and usually attains its maximum size within a few months and then remains stationary. It becomes tense and prominent when the hand is flexed towards the palm. Its appearance is usually ascribed to some strain of the wrist—for example, in girls learning gymnastics. It may cause no symptoms or it may interfere with the use of the hand, especially in grasping movements and when the hand is dorsiflexed. In girls it may give rise to pain which shoots up the arm. Ganglia are also met with on the dorsum of the metacarpus and on the palmar aspect of the wrist.
Fig. 60.—Carpal Ganglion in a woman æt. 25.
The tarsal ganglion is situated on the dorsum of the foot over one or other of the intertarsal joints. It is usually smaller, flatter, and more tense than that met with over the wrist, so that it is sometimes mistaken for a bony tumour. It rarely causes symptoms, unless so situated as to be pressed upon by the boot.
Ganglia in the region of the knee are usually situated over the interval between the femur and tibia, most often on the lateral aspect of the joint in front of the tendon of the biceps (Fig. 61). The swelling, which may attain the size of half a walnut, is tense and hard when the knee is extended, and becomes softer and more prominent when it is flexed. They are met with in young adults who follow laborious occupations or who indulge in athletics, and they cause stiffness, discomfort, and impairment of the use of the limb. A ganglion is sometimes met with on the median aspect of the head of the metatarsal bone of the great toe and may be the cause of considerable suffering; it is indistinguishable from the thickened and enlarged bursa so commonly present in this situation in the condition known as bunion.
Fig. 61.—Ganglion on lateral aspect of Knee in a young woman.
Ganglionic cysts are met with in other situations than those mentioned, but they are so rare as not to require separate description.
Ganglia are to be diagnosed by their situation and physical characters; enlarged bursæ, synovial cysts, and new-growths are the swellings most likely to be mistaken for them. The diagnosis is sometimes only cleared up by withdrawing the clear, jelly-like contents through a hollow needle.
Pathological Anatomy.—The wall of the cyst is composed of fibrous tissue closely adherent to or fused with the surrounding tissues, so that it cannot be shelled out. There is no endothelial lining, and the fibrous tissue of the wall is in immediate contact with the colloid material in the interior, which appears to be derived by a process of degeneration from the surrounding connective tissue. In the region of the knee the ganglion is usually multilocular, and consists of a meshwork of fibrous tissue, the meshes of which are occupied by colloid material.
It is often stated that a ganglion originates from a hernial protrusion of the synovial membrane of a joint or tendon sheath. We have not been able to demonstrate any communication between the cavity of the cyst and that of an adjacent tendon sheath or joint. It is possible, however, that the cyst may originate from a minute portion of synovial membrane being protruded and strangulated so that it becomes disconnected from that to which it originally belonged; it may then degenerate and give rise to colloid material, which accumulates and forms a cyst. Ledderhose and others regard ganglia as entirely new formations in the peri-articular tissues, resulting from colloid degeneration of the fibrous tissue of the capsular ligament, occurring at first in numerous small areas which later coalesce. Ganglia are probably, therefore, of the nature of degeneration cysts arising in the capsule of joints, in tendons, and in their sheaths.
Treatment.—A ganglion can usually be got rid of by a modification of the old-fashioned seton. The skin and cyst wall are transfixed by a stout needle carrying a double thread of silkworm gut; some of the colourless jelly escapes from the punctures; the ends of the thread are tied and cut short, and a dressing is applied. A week later the threads are removed and the minute punctures are sealed with collodion. The action of the threads is to convert the cyst wall into granulation tissue, which undergoes the usual conversion into scar tissue. If the cyst re-forms, it should be removed by open dissection under local anæsthesia. Puncture with a tenotomy knife and scraping the interior, and the injection of irritants, are alternative, but less satisfactory, methods of treatment.
Ganglia in the substance of tendons are rare. The diagnosis rests on the observation that the small tumour is cystic, and that it follows the movements of the tendon. The cyst is at first multiple, but the partitions disappear, and the spaces are thrown into one. The tendon is so weakened that it readily ruptures. The best treatment is to resect the affected segment of tendon.
The so-called “compound palmar ganglion” is a tuberculous disease of the tendon sheaths, and is described with diseases of tendon sheaths.
CHAPTER XIINJURIES Contusions —Wounds: Varieties —Wounds by Firearms and Explosives: Pistol-shot wounds; Wounds by sporting guns; Wounds by rifle bullets; Wounds received in warfare; Shell wounds. Embedded foreign bodies —Burns and Scalds —Injuries produced by Electricity: X-ray and radium; Electrical burns; Lightning stroke. Contusions
A contusion or bruise is a laceration of the subcutaneous soft tissues, without solution of continuity of the skin. When the integument gives way at the same time, a contused-wound results. Bruising occurs when force is applied to a part by means of a blunt object, whether as a direct blow, a crush, or a grazing form of violence. If the force acts at right angles to the part, it tends to produce localised lesions which extend deeply; while, if it acts obliquely, it gives rise to lesions which are more diffuse, but comparatively superficial. It is well to remember that those who suffer from scurvy, or hæmophilia (bleeders), and fat and anæmic females, are liable to be bruised by comparatively trivial injuries.
Clinical Features.—The less severe forms of contusion are associated with ecchymosis, numerous minute and discrete punctate hæmorrhages being scattered through the superficial layers of the skin, which is slightly œdematous. The effused blood is soon reabsorbed.
The more severe forms are attended with extravasation, the extravasated blood being widely diffused through the cellular tissue of the part, especially where this is loose and lax, as in the region of the orbit, the scrotum and perineum, and on the chest wall. A blue or bluish-black discoloration occurs in patches, varying in size and depth with the degree of force which produced the injury, and in shape with the instrument employed. It is most intense in regions where the skin is naturally thin and pigmented. In parts where the extravasated blood is only separated from the oxygen of the air by a thin layer of epidermis or by a mucous membrane, it retains its bright arterial colour. These points are often well illustrated in cases of black eye, where the blood effused under the conjunctiva is bright red, while that in the eyelids is almost black. In severe contusions associated with great tension of the skin—for example, over the front of the tibia or around the ankle—blisters often form on the surface and constitute a possible avenue of infection. When deeply situated, the blood tends to spread along the lines of least resistance, partly under the influence of gravity, passing under fasciæ, between muscles, along the sheaths of vessels, or in connective-tissue spaces, so that it may only reach the surface after some time, and at a considerable distance from the seat of injury. This fact is sometimes of importance in diagnosis, as, for example, in certain fractures of the base of the skull, where discoloration appears under the conjunctiva or behind the mastoid process some days after the accident.
Blood extravasated deeply in the tissues gives
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