The Principles and Practice Of Modern Surgery

CONTENTS.

GENERAL SURGERY. — INTRODUCTION.

An ultimate analysis of the primary causes of disease, excluding traumatisms, will permit their reduction to one or the other of the following categories: nutritional (functional) and parasitic. These may co-exist, in which case each tends to modify the other more or less, usually unpleasantly, or either may precede and perhaps pave the way for the other. In general, it may be said that parasitism perverts nutrition, locally or generally, and, per contra, that perverted nutrition often prepares the way for parasitic infection, so that even between these primary causes there may occur all possible combinations.

With traumatisms surgery alone is mainly concerned, but its conceded scope is now widened to include an ever-increasing number of morbid conditions, which, in time past, were treated medicinally—or not at all. Thus it has come to pass that it is no longer possible to make an abrupt distinction between medicine and surgery, nor even briefly to define the words “surgery” and “surgeon,” nor yet to ascribe to either the physician or the surgeon his exact functions as such. In centuries past physicians were exceedingly jealous of their vested rights, and with propriety, when the only surgeons were uneducated barbers. But about one hundred years ago conditions were materially altered for the better, and surgery, liberated from its medieval environment, and from the restrictions imposed by the clergy, rapidly developed into both a science and an art, while the surgeon came to take that position in society to which his increasing attainments entitled him. During the past thirty years surgery, thanks to earnest workers in the surgical laboratories of the world, has made progress scarcely equalled by the science of electricity, and the impossibilities of yesterday have become the routine of today.

Thus has come about the earlier separation, and now, in some respects at least, the closer appreciation of the respective scope and functions of the physician and the surgeon. Between them lies yet what has been felicitously called the “borderland,” where they meet on common ground, too often as rivals and not often enough as co-workers. Nowhere do comprehensive knowledge, wide experience, and trained judgment appear to better advantage, nor lead to better results, than when exhibited where co-operation in these respects is most hearty. Someone has most happily said that “the surgeon is a physician who knows how to use his hands,” yet to regard a course in surgery as one in manual training would be a most lamentable conception of its purposes. Rather is it to be regarded as a superstructure, to be built upon a thorough familiarity with anatomy, physiology, pathology, and therapeutics. In fact, the better general practitioner a man is, the better surgeon may he thereby become, providing he possess the other necessary attributes. John Hunter took this view, but too many since his day have forgotten or never realized it.

In the pages which follow it has been impossible to do more than epitomize our present-day knowledge of surgery, an early disavowal which is intended to save too frequent repetition of the advice to consult, as needed, other larger and more specialized works. The attempt here has been rather to build up a framework upon which the student and the investigator may build with such other material as they may later select from the quarries which are accessible to them. Hence it has been impossible to describe or even mention all the operations which have been devised to meet various indications. Preference has therefore been given to those which have best served the author in his personal experience.

Because of the numerous interrelations between surgery and internal medicine, so called, I have not hesitated to insert paragraphs and even whole chapters on subjects hitherto omitted from the later works on surgery. To teach a student how to recognize nasopharyngeal adenoids, to appreciate the widespread harm they may cause and how to cope with them, and at the same time to leave him quite unfamiliar with their too frequent relation to the status lymphaticus and its dangers, and to omit in such a work all reference to the latter, is to put knowledge and instruments into his possession without teaching him how rightly to employ them. A case of exophthalmic goitre affords another equally apt illustration, as being one in which the physician and the surgeon should heartily co-operate.

The surgeon and the physician have drifted too far apart. It is time that they met again in the presence of the pathologist. Such a group, when properly constituted, forms an almost invincible triumvirate.

It has been said that “the resources of surgery are rarely successful when practised on the dying.” Throughout these pages the attempt has been made to impress the fact that delay, in many of the borderland cases, is dangerous, and, often fatal, and that it is not just to charge to surgery the blame for such a result due to the physician’s dilatoriness.

It may lead to a better understanding of the teaching contained in the following pages if it is here made clear just what is understood by the suffix “itis” in medical terminology. The old tendency was to regard all morbid conditions as expressions of inflammation in some of its protean manifestations. The attempt has been made in this work to distinguish as clearly as possible between inflammation, as an expression of infection, and the vascular, nutritional, and other changes which may be brought about by perverted nutrition without necessary participation of parasites. To describe “ostitis,” for example, as “inflammation of bone,” is to revert to an obsolete definition. Let us, then, always translate the termination “itis” as implying an affection, not necessarily an inflammation, of the structure named in the word to which it is affixed. With this conception of the word or the term there can be no contradiction in its use under various conditions, and one does not necessarily commit himself, by using it, to any definite view concerning the pathology of the affection which is thereby implied.

With regard to one other feature there has been also a departure from previous nomenclature. The term “lymph glands” or “lymphatic glands” has always seemed objectionable, because, although they belong to the lymphatic system, they are in no sense glands, having no ducts, and no distinct secretion to be discharged through passageways. Whether in any sense they are to be regarded as furnishing an “internal secretion” is not the question here, their most obvious function being to act as filters. Throughout the work, then, the term “lymph gland” has been carefully excluded and the more accurate and far preferable term “lymph node” has been substituted. This seems to be a suitable place to explain the substitution and the reason therefor.

PART I. SURGICAL PATHOLOGY. — CHAPTER I. HYPEREMIA: ITS CONSEQUENCES AND TREATMENT. — Active Hyperemia. — Passive Hyperemia. — RESULTS OF HYPEREMIA AND CONGESTION. — TRANSUDATES AND EXUDATES. — TREATMENT OF CONGESTION AND HYPEREMIA. — ATROPHY AND HYPERTROPHY, AND THE CONSEQUENCES OF ALTERED, DIMINISHED, AND PERVERTED NUTRITION. — ATROPHY.

The reactionary results of injury to various tissues and the first local appearances due to the surgical infectious diseases are indicated by certain appearances, which, for a few hours at least, are in large measure common to both. Their beginnings being pathologically similar, their results depend not alone on the violence or intensity of the process, but also, and in predominating measure, upon the primary influences at work. The consequences of mere mechanical injury—such as strain, laceration, etc.—are in healthy individuals promptly repaired by processes which will be taken into consideration in the ensuing chapters. They are throughout conservative and reparative, and are directed toward restoring, as far as possible, the original condition. The consequences, on the other hand, of the surgical infections are more or less disastrous from the outset, although the extent of the disaster may be localized within a very small area, as after a trifling furuncle, or they may be so widespread as to disable a limb or an organ, or they may even be fatal. It is of the greatest importance, not alone for scientific reasons, but also because treatment must in large measure depend upon the underlying conditions, to differentiate between these two general classes of disturbance, which we speak of as—

A. Those produced by external or extrinsic disturbances, i. e., traumatisms, sprains, lacerations, etc.; and

B. Those produced by internal and intrinsic causes, which, for the main part, are the now well-known microörganisms, such as cause the various surgical diseases.

These latter disturbances may be imitated or simulated in the presence of certain irritants within the tissues, such as the poisons of various insects and plants; the irritation produced by foreign bodies, minute or large; and possibly the presence within the system of certain poisons whose nature is not yet known, such as that of syphilis, or certain others whose chemistry is fairly well understood, but whose presence cannot be easily explained, as uric acid, etc.

Clinically, all these disturbances are manifested by certain phenomena common to each, which may present themselves at one time more prominently, at another less so. These significant appearances have been recognized from time immemorial as the calor, rubor, dolor, tumor, et functio lesa of our ancestors, or as the heat, redness, pain, swelling, and loss of function of our common experience. When one or more of these are present, the surgeon cannot afford to disregard the fact, while he should, moreover, be able to account for each on general principles which should to him be well known.

To their more exact study we must, however, make some preface in the way of general remarks concerning a phenomenon everywhere easily recognized, but as yet incompletely understood. This phenomenon has reference to an undue supply of blood to a part, and is commonly known under two terms which are practically synonymous, namely, congestion and hyperemia. To begin with these, then, we must note, first of all, that congestion and hyperemia may be—

• A. Active; and
• B. Passive.

They may also be spoken of as—

• 1. Acute; and
• 2. Chronic.

Considering first the two latter distinctions, it will be found that the acute hyperemias are met with most often in consequence of sharp mechanical disturbances. The chronic hyperemias, on the contrary, are conditions which in many individuals are more or less permanent. Note accurately here the proper significance of certain terms. Hyperemia means, in effect, an oversupply of blood to the given part; the term should have only a local significance. When the entire body seems to be too well supplied with blood, the condition is known as plethora, the counterpart of which term is usually anemia. The direct counterpart of the term hyperemia should perhaps be ischemia, meaning a perverted blood supply in reduced amount. With plethora and anemia as terms implying general conditions, with hyperemia and ischemia implying local conditions, there should be little room for confusion in phraseology.

The active form of hyperemia used to be called “fluxion,” a term now rarely used. Active hyperemia means an increased supply of arterial blood. In passive hyperemia the oversupply is rather of venous blood. In the former case the condition seems due to overactivity of the heart, with such local tissue changes as permit it to occur. In passive hyperemia the blood current is slower—there is a tendency toward, and sometimes an actual, stagnation; all of which is usually due to obstruction of the return of blood to the heart. The conditions permitting these two results may be widely variant.

—Active hyperemia may be produced by purely nervous influences, even those of emotional origin. The flushing of the face which is known as “blushing” is, perhaps, the most common illustration of this fact. It is well known also that this is, in some degree at least, the result of division of certain nerves which have to do with the regulation of the blood supply. The cervical sympathetic is the best known and most often studied of these, and the consequences of division of this nerve in the neck are stated in all the text-books on physiology. So also by electrical stimulation of certain nerves the parts supplied by them can be made to show a very active hyperemia, which will subside shortly after discontinuance of stimulation, providing this has not been kept up too long. In active hyperemia there is absolute increase of intra-arterial tension, and under these circumstances pulsation may be noted in those small vessels in which commonly it is not seen nor felt. This is the explanation of the throbbing pain complained of under many actively hyperemic conditions. This hyperemia affords the explanation of the clinical signs to which attention has already been called. The increased heat of the part is the result of greater access of blood, which prevents cooling by radiation and evaporation; the peculiar redness is due to the greater filling of the capillaries with the blood, which gives the peculiar hue to the skin and visible textures; while to the increased pressure upon sensory nerves is also due the pain. The minuter changes occurring within the congested part call for more accurate description. Whether or not there is actual dilatation of capillaries under these circumstances is a matter still under dispute, but of the dilatation of the larger vessels there can be no possible question.

As hyperemia is to such a great extent brought about by action of the nervous system, it is well to divide it more accurately into the hyperemia of paralysis, or neuroparalytic congestion, which is the result of a paralysis of the constrictor fibers of the vasomotor system, and into the hyperemia of irritation, or neurotonic congestion, which is due to the irritation of the dilators (Recklinghausen). Physiologists are fairly well agreed that as between the dilating and the constricting apparatus of the vasomotor system there is ordinarily preserved a certain degree of equilibrium; to which fact is probably due that normal condition of affairs inaugurated after temporary disturbance, since overaction in one direction succeeds reaction in the other. As Warren has illustrated this, our common treatment of frostbite by cold applications is a concession to this fact, since by the cold applications we endeavor to limit the reaction which would otherwise follow after thawing out the frozen part.

The best examples of the hyperemia of paralysis are perhaps to be met with after certain injuries to nerves, as, for instance, flushing of the face and hypersecretion of nasal mucus, tears, etc., after injury to the cervical sympathetic. Such, too, in its essentials is that form of shock known as brain concussion, which is often followed by nutritive disturbances among the brain cells, with consequent perversion of brain function.

Waller’s experiment of placing a freezing mixture over the ulnar nerve at the back of the elbow is also significant, the result being congestion and elevation of surface temperature of the fingers supplied by this nerve. Congestion and swelling have also been observed after fracture of the internal condyle of the humerus, by which this nerve was pressed upon; and similar phenomena may be noted in fingers or toes as the result of injuries of other nerves.

Hyperemia due to paralysis of the perivascular ganglia is observed sometimes in transplanted flaps, in the suffusion of a limb after removal of the Esmarch bandage, in the congestion of certain sac walls after tapping, in the hyperemia of, perhaps even hemorrhage from, the bladder wall after too quickly relieving its overdistention, and in the swelling of the extremities when they begin to be first used after having been put at rest because of injury.

The hyperemias of dilatation are more acute in course and manifestation. Along with them go sharp pain, hypersecretion of glands, edema, and sometimes desquamation of superficial parts. The facial blush due to effusion; the temporary flushing due to indulgence in alcohol; the suffusion of the conjunctiva, perhaps the face, with hyperlacrymation, accompanying facial neuralgia or hemicrania; and the hyperemia consequent upon herpes zoster, urticaria, etc., are illustrative examples of this form. The erythema due to nerve irritation or injury, the swelling of the joints which appears after similar lesions, and that condition described by Mitchell as erythromelalgia, probably also belong here. In fact, almost all the reflex hyperemias are hyperemias of dilatation.

The forms of hyperemia considered above belong mainly to the designation of active.

—Passive hyperemia is most often a mechanical consequence of obstruction of the return of blood, which can be imitated at will, and which is not infrequently the result of carelessness, as when an injured limb is bandaged too tightly. Experiment shows that when such mechanical obstruction has taken place there is temporary increase of intravenous pressure, which soon returns to the normal standard, such readjustment meaning that blood has found its way back by collateral circulation. Only when such rearrangement is possible do we have anything like permanent passive hyperemia. In organs with a single vein, such as the kidneys, the question of obstruction may assume a very important aspect. Under these circumstances the appearance of the involved part, when visible, is spoken of as cyanotic, while its surface, instead of being abnormally warm, is the reverse, due to impeded access of warm blood and more rapid surface cooling. The blood under such conditions is often darker than natural, because, remaining longer in the part, it absorbs more carbonic dioxide, or at least gives up more of its oxygen. As long as actual gangrene is not threatened, the blood column has a communicated pulsation, at least in the large veins. Escape of corpuscular elements may occur after the phenomena above noted have been present for some time; but the corpuscles rarely, if ever, escape until there has been more or less copious transudation of the fluid portion of the blood—i. e., the serum. When anatomical changes can be grossly, yet carefully, observed, as in the fundus of the eye, it is seen that under these circumstances the arteries become smaller, although whether this is a primary or secondary change is not to be determined. Discoloration of the integument is the frequent result of leakage of blood corpuscles and their pigmentary substance into the tissues, and is consequently a frequent accompaniment of chronic passive edema. It is seen often in connection with varicose veins of the legs.

Another form of passive congestion or hyperemia is that due to enfeeblement of the heart’s action by serious injury or wasting disease. When under these circumstances the lung has become more or less infiltrated with fluid, with hemorrhagic extravasation, the condition is known as hypostatic pneumonia—a misnomer, nevertheless indicating a condition which is only too frequent in the aged and feeble.

These may be—

• 1. Speedy subsidence of all hyperemic phenomena—resolution.
• 2. Acute swelling.
• 3. Chronic swelling.
• 4. Gangrene.
• 5. Nutritional changes—atrophy and hypertrophy.

1. Resolution.

—The speedy subsidence of hyperemic phenomena is known as resolution—a term which has also been applied to the retrograde phenomena after a genuine inflammation. For present purposes it implies, first, the subsidence into inactivity of the exciting cause or its complete removal. This may include the passing of an emotion, the removal of an irritant, the loosening of a bandage, the resort to certain applications or to constringing or astringing measures by which the effect is counteracted. A particle of dust in the conjunctiva may within a few moments produce an active congestion of the conjunctival vessels, which, ordinarily scarcely visible, becomes prominent and easily noted. The removal of the offending substance permits a return to their original size in perhaps a half-hour. This is an example of the speedy subsidence of the hyperemia of dilatation after removal of the cause. Should the hyperemia not subside promptly, it is well to use cold applications, or in this instance an astringent collyrium, or some agent whose physiological effect it is to produce vascular contraction, as cocaine, adrenal extract, etc.

2. Acute Swelling.

—When the effusion above referred to takes place into loose connective tissues the condition is spoken of technically as edema, while when it occurs into a previously existing cavity, such as that of a joint, it is known as an effusion. The amount of blood thus effused will be influenced by the anatomical and mechanical conditions existing about the part. It may be presumed, as a general rule, that when the extra vascular pressure equals the intravascular pressure little or no more fluid may escape. As a matter of fact, it is seldom that the former rises to the degree of the latter. Conversely, one method of treating such edemas and effusions is by some device which shall make the extravascular pressure exceed the intravascular, when the fluid is, as it were, forced back into the vessels, and is made to resume its proper place within the same. This is often done by taking advantage of elastic compression, as when a rubber bandage is applied about the part. In certain parts of the body it may be done by pressure brought about by some other device. Pressure may be used for two purposes:

A. To so increase extravascular pressure as to limit the possible amount of an effusion, as when it is put on early after an injury; or,

B. When it is used as a later resort for the purpose of reducing swelling which has already occurred.

3. Chronic Swelling.

—This is something more than the swelling alluded to under Acute Swelling. Chronic swelling implies either a continuous passive hyperemia, or, what is more common, a positive increase in tissue elements as the result of an oversupply of nutrition brought by the blood, which itself was furnished to the part in a degree far in excess of its needs. The result is a more rapid reproduction of cell elements, with result in the shape of tissue thickenings or tissue enlargements, known as hypertrophy, or, more properly speaking, hyperplasia, of a part, and to the laity as “overgrowth.” This chronic swelling or chronic enlargement is in some degree also connected with the phenomena of escape of white corpuscles from the bloodvessels and mitotic division of certain tissue cells, which have up to this time been usually regarded as a feature of the true inflammatory process.

4. Gangrene.

—This may be the result of hyperemia—for the most part the passive forms—though most instances of gangrene due to intrinsic causes are inseparable from the presence of infectious microörganisms. The gangrene which is spoken of here includes that due to the pressure of tumors, tight dressings, or any natural or intrinsic agency, and that due to pressure from without when not so pronounced as to produce immediate and total loss of circulation in a part. It includes the formation of many bed-sores and so-called pressure-sores, which may be due to an enfeebled heart, to an obstructed pulmonary circulation, or to external pressure in conjunction with cardiac debility. While insisting, then, that gangrene should be recognized as a possible result of hyperemia, it may be added that it is in effect a tissue death, and that dead tissue is always and everywhere practically the same thing, no matter by what causes brought about. Consequently, the subject of gangrene will be considered under a separate heading.

5. Nutritional Changes

will be considered later.

The consequence of persistent hyperemia is transudation—i. e., escape of blood plasm from the vessels into body cavities and tissue interspaces. This leads to consideration under a distinct heading of—

Exudation may occur in vascular and non-vascular, in firm and soft tissues, in, under, and upon membranes. With respect to location, exudates are described as free, when found upon free surfaces or within natural cavities; interstitial, when found between the tissues or parts of tissues; and parenchymatous, when they are situated within the tissues themselves, particularly in epithelial and glandular cells of any kind.

Exudates are serous, mucous, fibrinous, or mixed, the mixed forms including the so-called seropurulent, the mucopurulent, the croupous, and the diphtheritic.

When any exudate contains red globules in sufficient quantity to stain it, it is called hemorrhagic.

Serous transudates from free surfaces are sometimes spoken of as serous catarrhs; when into cavities, as dropsies; when into tissues, as edema; when occurring beneath the epidermis they form serous vesicles or blebs or bullæ.

Fibrinous exudation refers to the fluid which coagulates soon after its exit from the vessels within those spaces into which it has oozed. When flocculi of coagula float in serous fluid it is known as a serofibrinous exudate. Pure fibrinous exudate occurs rarely, save in and upon mucous membranes. The extent to which exposure to the air is responsible for the firm coagulation of the fibrin previously held in solution is uncertain. The most potent factors in producing such coagulation are bacteria, but it is not yet disproved that coagulation may occur without their aid. When such coagulation occurs upon the surface of a mucous membrane it has been spoken of as croupous. When the epithelial covering as well as the basement membrane, and often the submucous tissues, are involved, so that the membrane cannot be stripped off without tearing across minute bloodvessels, the exudate has been known as diphtheritic. These terms may possibly be still retained in an adjective sense as implying the exact location of a surface exudate, but are scarcely to be used in any other significance.

The following table illustrates significant differences whose full importance cannot be impressed before a study of inflammation has been carefully entered upon:

These disturbances are to be combated, first of all, by insisting upon physiological rest. This, perhaps, is the most important measure of all. The profession is indebted to Hilton for the decided advance which he made in the treatment of congestive and inflammatory affections by insisting upon this principle in his celebrated work on Rest and Pain, which every young practitioner should read. Aside from this first and underlying principle, the treatment must, in some measure at least, be based upon the time at which we are called upon to treat the case. If seen at once, before exudation has been excessive or the other disturbances marked, we may carry out a certain line of treatment for the purpose of limiting all these unpleasant features. On the other hand, if seen late, when exudation has been copious and when pain and other disturbances are due to its presence, a distinctly different course will be adopted.

Toward the end first mentioned—namely, the limitation of hyperemia—we may adopt local and general measures. Local measures include graduated pressure, providing this is not intolerable to the patient, so equalized that outside of the vessels it shall equal that inside. This may be done by careful bandaging, extreme care being taken that the pressure be applied from the very extremity of the limb; otherwise, passive exudation might be augmented and gangrene be precipitated. Elevation of a limb will often accomplish the same purpose. Cold, which is in effect an astringent and which tends to contract bloodvessels, is another measure in the same direction, and if applied early will do much to limit the degree of the attack. This may be applied as dry or moist cold, and should be gradually mitigated as the congestion subsides. It acts through the vasomotor system, and is a measure to be resorted to with caution. An efficient way of applying dry cold can be extemporized by a few yards of rubber tubing, held in place by wire or sewed in place to a piece of cloth, through which a stream of cold water is permitted to pass.

Heat is another efficient means, acting, however, in a rather different way. Heat is a measure to be employed to hasten the disappearance of exudation—in other words to quicken resorption, which it does by equalizing blood pressure, dilating the capillaries, stimulating the lymphatic current, and in every way helping to clear the tissues of that which has left the bloodvessels.

It is necessary also, at least in extreme cases, to employ some detergent or derivative measures, including bloodletting, to which we do not resort sufficiently often. When used for this purpose, depletion should be applied at the area involved, if possible. This may be done either as venesection, by leeching, either with the natural or the artificial leech, or by a series of minute punctures or incisions, which give relief to tension, permit the rapid escape of fluid exudate, and often save tissues from the disastrous effects of strangulation. In some cases of deep-seated congestions these measures are inapplicable, and venesection at the point of election—say the cephalic vein in the arm—may be followed by great benefit. Another method of depletion is by administration of cathartics, such intestinal activity being stimulated as shall lead to copious watery evacuations. The salines rank high as measures directed to this end, but in emergency much stronger and more drastic drugs may be administered, such as jalap, calomel, elaterium, etc. Diaphoretics and diuretics help to reduce temperature and in some degree to deplete, but their action is usually slow. When exudation is considerable in amount and confined to some one of the body cavities, it is often best combated, if at all obstinate, by the method of aspiration. This includes any suitable suction apparatus by which the fluid may be withdrawn through a small needle or cannula, the operation being trifling in difficulty, but one to be performed under strictest aseptic precautions, lest infection of an exudate already at hand be permitted.

Certain individuals, especially the neurotic, will need more or less anodyne, particularly when local applications fail to give relief. Sometimes a small dose of morphine administered hypodermically will act magically in making efficient those measures which would otherwise be inefficient. In little children some anodyne or hypnotic will be of great service. Under all circumstances it is well to keep the lower bowel empty, and certain elderly individuals with weak and enfeebled hearts will need the stimulation to be afforded by digitalis, quinine, and alcohol, or preferably strychnine administered subcutaneously.

In cases of chronic hyperemia and its consequent hyperplasias (induration, thickening, etc.) there is no one measure so generally applicable and effective as the continued use of cold-water dressings. These are generally spoken of as “cold wet packs,” and may be continued—constantly or intermittently—for many days.

Massage is also an invaluable agent in the reduction of swelling and tissue overproduction. It promotes absorption, even of acute effusions, by equalizing the blood and hastening the lymph circulation, and under its scientific application it is surprising how firm exudates and old adhesions seem to disappear.

As a consequence of increase of nutrition we have a condition known commonly as hypertrophy, more accurately as hyperplasia. Hypertrophy literally means overgrowth, whereas hyperplasia more accurately describes that which constitutes hypertrophy—namely, numerical increase of constituent cells. Common usage has made the more inaccurate name “hypertrophy” cover nearly all these conditions. Hypertrophy, or hyperplasia, means enlargement of a part or of an organ beyond its usual limits, and as the result of increased function or increased nutrition. It is to be distinguished from gigantism, which means inordinate enlargement as the result of a congenital tendency or condition. Hypertrophy is—

Fig. 1

Congenital hypertrophy: gigantism of both lower extremities. (Case of Dr. Graefe [Sandusky].)

A. Physiological Hypertrophy.

—1. This includes many of the compensatory enlargements of an organ or a part when extra work is put upon it, owing to deficiency of some other organ or part. This is spoken of as compensatory enlargement. Illustrative examples may be seen in the heart, which becomes larger and stronger when the bloodvessel walls are diseased and their lumen narrowed, or when other obstructions to circulation are brought about; again, in enlargement of one kidney after extirpation of the other, or of the wall of the stomach when the pylorus is constricted or obstructed; again, of the fibula after weakening or more or less destruction of the tibia, or of the shaft of any bone when it has been weakened at some point by not too acute disease; or, again, of the walls of bursæ after constant friction.

2. The best examples of physiological hypertrophy owing to deficient use are perhaps seen in some of the lower animals; as, for instance, in the teeth of such rodents as beavers when kept in captivity and prevented from natural use.

B. Pathological Hypertrophy.

—3, 4. Instances of this are everywhere and every day are met in the results of so-called chronic inflammation, a term which is a complete misnomer and should be expunged from text-book use. So-called chronic inflammation simply means increase of nutrition owing to a certain degree of hyperemia, which may have been produced in the first place as the result of traumatism, which may have come from chemical irritants circulating in the fluids of the part—as, for example, uric acid, etc.—or which is brought about as the result of perverted trophic-nerve influence. Instances of local pathological hypertrophy may be seen in the thickened periosteum after injury, in the enlargement of a phalanx known as the “baseball finger,” and in numerous other places; or they may be general, in which case they are brought about mainly by some irritating material in the general circulation. The unknown poison of syphilis generally provokes such nutritive disturbances.

5. Senile hypertrophy is connected with nutritional disturbances characteristic of old age, as to whose remote causes we are still uncertain. Instances of senile hypertrophy, however, are common, particularly in the prostates of elderly men, which are liable to undergo extensive enlargement.

6. Of congenital hypertrophy and that of unknown origin we see, for instance, examples in certain rare cases of hypertrophy of the breast, in leontiasis, perhaps even in acromegaly, etc.; and these are to be distinguished from gigantism, because in most instances of the former type the hypertrophic tendency is not manifested until youth or adult life, whereas gigantism is a condition in which the tendency was apparent even before the birth of the individual.

Atrophy implies impaired nutrition, and means diminution in the size of an organ or part, and is the converse of hypertrophy. It is necessary to make plain that in atrophy nutrition is only impaired and not arrested, since complete arrest of nutrition means necrosis—i. e., gangrene or disappearance of parts. It may be—

A. Physiological Atrophy.

—1. This is always the result of disuse or impaired function from any cause. Its evidences are generally seen in the fatty structures and muscles—i. e., in the soft parts. It is true, however, even of the bones, or, of greater interest, even in the brain cells. We see evidences of it also in minute organs; as, for example, in the digestive glands in certain cases where diet is restricted. Again, we see it in the diminution of the size of the heart after hip amputation, less being required of that organ, and also in the entire structure of the rectum after colostomy.

2. Examples of the developmental type are best seen in the natural disappearance of the hypogastric arteries, the ductus arteriosus, the vitelline duct, the Wolffian bodies, and in the various generative ducts (Gärtner’s, etc.) shortly after the birth of the human individual. We sometimes see it also in the prostate after orchidectomy. Equally illustrative is the disappearance of the tail and gills of the tadpole, the eyes of animals living in caverns, and, in a general way, of organs which become useless owing to a different environment.

3. Senile atrophy is seen equally well in the hair follicles, the teeth, the bones, and the sexual organs of elderly people—in fact, in all their tissues, even in the brain.

B. Pathological Atrophy.

—4. Acute atrophy of surrounding tissues is the necessary accompaniment of destruction by suppurative or other disturbances; that is, parts disappear by absorption which have not been interfered with by pyogenic organisms. So complete may atrophy occur under these circumstances as to cause disablement of an organ or part. This kind of senile disappearance is merely an expression of phagocytic activity, although not now a question of bacteria.

5. The same is true of that variety spoken of above as biological or developmental, since phagocytes are the active agents in producing the disappearance of the tadpole’s tail.

6. A more slow form of pathological atrophy is seen in the gradual disappearance of tissues in the neighborhood of advancing tumors, enlarging cysts, etc. This is perhaps but another expression of atrophy from continuous pressure. But a still better illustration is the atrophy which comes from immobilization of a part without pressure. This is usually the case when splints or orthopedic apparatus have to be kept in place for some time.

7. Specific forms of pathological atrophy are largely connected with disturbances in the central nervous system. They are often referred to as trophoneurotic. Their exact mechanism is not yet understood, and cases may be confused under this head whose remote causes are widely different. Here should be included, for instance, the atrophy of a deep bone which occurs after extensive burn of the surface; also that peculiar form of atrophy of tissues in the stump which produces the so-called conical stump. These cases are of a more complicated character, for if pressure is removed from the bone end, especially in young people, the bone tends to grow faster than it should, while the soft parts disappear, partly as the result of mere disuse or loss of function. In this way conicity is produced, which sometimes calls for subsequent re-amputation. Under this head might also be included the so-called “trophic inflammation” (misnomer) of some writers, such, for example, as ulceration of the cornea after division of the trigeminus. The general subject of atrophic elongation also belongs here, referring to the fact that as a result of disuse, or sometimes of active disease, the bones, while showing atrophic changes in other respects, actually increase in length. Should such increase occur in one bone of those portions of the limbs which are supplied with two, the result would be posture deformity and displacement of the terminal portion.

CHAPTER II. SURGICAL PATHOLOGY OF THE BLOOD. — Fibrin. — The Formed Elements of the Blood. — Differential Leukocyte Count. — Glycogen in the Blood and the Iodine Reaction. — HEMOGLOBIN. — THROMBOSIS. — EMBOLISM. — PHYSICAL PROPERTIES OF THE LEUKOCYTES.

The part played by the constituent elements of the blood in inflammation, suppuration, and other still more disastrous conditions is so great and so important that, before proceeding to discussion of these lesions, it seems necessary to set forth a resume of facts illustrating the importance of accurate knowledge concerning this most important fluid.

The total amount of blood in the human body has been variously estimated at from one-eleventh to one-twenty-fifth of the body weight, the average being about one-sixteenth. The amount which the body may lose and still retain vitality is very vague and differs not only with individuals, but very greatly under various conditions. Severe loss of blood is one to be atoned for as quickly as possible, and is to be prevented as far as it can be after accidents or during operation. For this reason the so-called bloodless method of operating upon limbs, by the use of the rubber bandage, constituted a great advance in surgery. For the same reason the use of hemostatic forceps is of equal value in operating upon other parts of the body; other things being equal the quickest and most satisfactory recoveries follow the bloodless operations, and it is an advantage to conserve this vital fluid as far as possible.

It has been roughly estimated that the blood is divided about as follows, between the different parts of the body: the heart, lungs, and large vessels holding one-fourth, the skeletal muscles one-fourth, the liver one-fourth, the remaining quarter being distributed over the balance of the body.

The blood varies within wide limits in its coagulability, and this variation occurs apparently even within conditions of health. In some patients the blood may be seen to coagulate almost as rapidly as it collects upon the surface, while in others the exposed parts continue to ooze, and the checking of hemorrhage is a difficult, sometimes almost impossible, matter. There are certain diseases in which the blood is known to have reduced power in this direction; for example, in the toxemias, especially those connected with biliary obstruction and jaundice. There were not a few of these cases of slow bleeding to death in days gone by, simply because the capillary hemorrhage could not be controlled. Recently, it has been shown that calcium chloride administered internally has a marked effect in favoring coagulation, and when opportunity is afforded it should be given for several days previous to operating and as part of the necessary preparation. It may be administered in doses of from 1 to 2 Gm., and should be given three or four times, at least, in twenty-four hours.

A test of the coagulation time, normally three to five minutes, but lengthened under circumstances like those mentioned above, even to an hour, will often prove of great value.

There are certain albumoses whose effect on coagulation of the blood is very suggestive and very mysterious. A very minute dose of cobra poison, for instance, will make the blood of an experimental animal remain fluid for days, unless this animal has been previously immunized against it, in which case coagulation takes place even more rapidly than normally. A trace of serum from an immunized rabbit is enough to prevent the fluidifying effect of the cobra poison, but quite insufficient to neutralize its toxic effects. The surgeon practically never desires to reduce coagulability of the blood, but frequently to increase it. When it is increased by natural conditions or those not easily controlled, then it may lead to thrombosis and produce trouble in that way.

—Increase of fibrin, hyperinosis, accompanies the leukocytosis of inflammation and suppuration. It may be approximately estimated on the cover-glass by noting the closeness of the network resulting after fifteen minutes’ exposure. The inflammatory indication of leukocytosis may, therefore, be inferred from its determination, while the leukocytosis of malignant disease will not be so accompanied. Hyperinosis is most marked in pyogenic processes, pneumonia and rheumatism. Its opposite, hypinosis, is met with in pernicious anemia. There is no change in the percentage of fibrin in the ordinary anemias or chlorosis. In hemophilia and purpura hemorrhagica the coagulation time is greatly increased.

—The specialized elements of the blood which are of particular interest to the surgeon are the red and the white corpuscles. These may both vary in relative size within certain physiological limits. The red cells especially are not of uniform size and vary from 6 to 9 microns in diameter. There are also present in normal blood a small number of red cells having a diameter of only 6 microns, which are known as microcytes. In infancy there are present also so-called giant corpuscles, or megalocytes, with a diameter of 10 microns or more. Considerable variation occurs in disease, especially in the severe anemias. Red corpuscles ordinarily stain with acid dyes, which facilitate their examination and a computation of the number present. When present in unusually large number the condition is spoken of as a polycythemia; when in reduced number as oligocythemia. In several of the anemias variations in size, shape, and color occur, and in certain of them many of the red corpuscles are found to be nucleated. Red cells which are nucleated are known as erythroblasts, and according to their size are spoken of as microblasts, normoblasts, and megaloblasts. Again, under certain diseased conditions the ordinary discoid form of the cells becomes irregular and crenated, and to those which are thus altered is given the name of poikilocytes.

There is another form of degeneration which consists in death or necrobiosis of the cell, whereby it loses its capacity for staining, or, at all events, stains irregularly and abnormally. This is seen also in cases of severe anemia and in conditions where the blood has been altered by the addition of toxic material, such as chloroform, etc. Occasionally also the red cells show a tendency to a granular change, which is probably entirely degenerative.

The red corpuscles have a certain degree of elasticity which helps them to pass through capillaries which are smaller even than their own diameter; after escaping from these the corpuscles regain their original form. In the presence of carbon dioxide they lose this elasticity and become distorted or crenate. The influence of high altitudes in increasing the number of corpuscles is known, but unexplained. For instance, a residence of less than a month in the mountains will cause an increase of from 2,000,000 to 3,000,000 corpuscles per cubic millimeter. It has been surmised that under the influence of oxygen red corpuscle formation is stimulated to greater activity; in other words, that the red marrow becomes more active in the production of the hematoblasts.

In general terms it may be said that the blood of a normal adult male contains 5,000,000 red corpuscles per cubic millimeter, and that of an adult female 4,500,000. These figures are, of course, approximate and variable. When the number is reduced to 3,000,000 by common consent the case will be regarded as oligocythemia, and when increased to 6,000,000 as one of polycythemia.

The latter condition is most evident in cases of newly born infants. The excess rapidly diminishes during the first week of extrauterine life. It is to be explained by the loss of fluid suffered by the infant upon the establishment of respiration. The proportion of red cells also varies according to the nutrition of the individual, the season of the year, the altitude (as above), and climate, and varies during menstruation, pregnancy, lactation, and at the climacteric. With the loss of red cells the number is reduced in proportion to the hemoglobin, although the change in one respect is not exactly proportionate to that in the other.

That the colorless corpuscles, or leukocytes, are not all of one kind has been recognized for nearly sixty years, and long ago they were divided into granular and nucleated cells. A vast impetus to the study of hemocytology was given by Ehrlich, in 1878, when he introduced the use of aniline dyes. The reader must be reminded that some of these, like eosin, are acid in reaction, and others, like methyl blue, are basic; while a third group has been supposed to be neutral in reaction, like a mixture of methyl blue and acid fuchsin; but it has been found that the so-called neutral dyes have really a slightly acid reaction. We may, therefore, divide the cells according to the reaction of the dyes with which they usually are distinguished into the acid and basic, or, more technically, into oxyphile, which includes neutrophile, and basophile.

This is not the place in which to go into any minute discussion of this subject nor further than should be of practical interest to the surgeon; nevertheless an examination of the blood by some common and routine procedure is so necessary in many surgical conditions that it is impossible to entirely avoid the subject in a work like this. I have accordingly condensed it and put the salient facts about leukocytes into the following table:

Classification of Leukocytes.

In normal blood by far the greater part of the leukocytes consists of A and D. Lymphocytosis means a relatively high percentage of C and D. Eosinophilia means an increase in the proportion of B. Basophile cells are not absolutely pathological, for they may be present in very small numbers in normal blood.

The number of leukocytes in normal blood will average about 7000 to 10,000 per cubic millimeter, the percentage of each variety being given in the above table. Leukocytes are sometimes diminished in number; under diseased conditions they are often increased, and these are then included under the term leukocytosis. Variations occur daily and almost hourly under normal conditions. Increase naturally occurs after digestion, when the number of leukocytes may be almost doubled, the same being due principally to lymphocytes which are washed into the blood system from the lymph nodes by the flow of lymph or chyle. In starvation, however, the number may be remarkably reduced and in the case of the fasting man, Succi, the leukocytes were reduced at the end of the first week to 860 per cubic millimeter. The rather unusual condition of reduction of the number of corpuscles is called leukopenia.

Leukocytosis is usually the rule in carcinoma, with increase in A and F; the more rapid the growth, the greater this increase. In sarcoma this is even more pronounced; when occurring without hyperinosis the probability of malignancy is greater. Non-malignant tumors produce no such changes.

The blood platelets or plaques first described by Bizzozero, in 1882, have no small interest for physiologists and pathologists, but little for the practising surgeon. They number perhaps 5,000,000 per cubic millimeter and sustain a fairly constant ratio to the red cells. Their surgical interest is limited to the role which they may play in the formation of thrombus.

The term phagocytosis has to do in a general way with those leukocytes which act as scavengers by removing from the blood its noxious elements, presumably by a process of ingestion and digestion (see Chapter III).

Examination and estimation of the various formed elements of the blood are very valuable to the surgeon in the study of the anemias, of acute inflammation when the presence of pus is suspected, in the presence of suspected cancer, and in the presence of such conditions as Hodgkin’s disease, the various disorders of the spleen, etc. The so-called primary anemias include only the pernicious anemias and chlorosis; all others are designated as secondary. This distinction is not for convenience only, but serves a useful purpose.

Pernicious anemias produce a reduction both of the red corpuscles and the hemoglobin, the former usually in a greater degree than the latter, so that the color index (see below) is usually plus. Many of the cells become nucleated and, in general, their size is increased. In chlorosis the reduction of the hemoglobin is relatively large and the color index is extremely low. In the secondary anemias the red cells and hemoglobin are reduced disproportionately, so that the color index is minus. There may or may not be a relative increase of leukocytes and of the nucleated red cells, but these latter are not so likely to be as large as those seen in primary anemias. The color index is obtained by dividing the percentage of the hemoglobin present by the percentage of the red cells.

Leukocytosis becomes pathological in conditions of acute inflammation where the neutrophiles (A) show the greatest relative increase. The degree of leukocytosis depends on two different factors: the intensity or the virulence of the infection, and the vitality or resisting power of the individual. These vary within such wide limits that it is hard to predicate anything definite in a given case. In general the increase is supposed to be proportionate to the severity of the infection, though the greater the reactionary ability of the patient the larger the number of white cells. Where vitality is very low leukocytosis is less pronounced. It is possible to have toxemia to such a degree that the activity of the leukocytes seems to be destroyed. The following summary from Cabot puts things in very distinct form.

Infection mild, vital reaction good—small leukocytosis.

Infection less mild, vital reaction less good—moderate leukocytosis.

Infection severe, vital reaction good—very marked leukocytosis.

Infection severe, vital reaction poor—no leukocytosis.

From this it will appear that the absence of leukocytosis in cases where it naturally would be expected is a serious indication and justifies an unfavorable prognosis; or else it may be interpreted in evidently favorable cases as indicating infection of very mild grade.

There are but few diseases in which leukocytosis by itself (or for that matter any other indication which the ordinary examination or blood count may give) is wholly sufficient for diagnostic purposes. But a blood count and estimate of the amount of hemoglobin present will often be of such advantage to the surgeon that he may well afford to wait in order to secure them. This is rarely necessary in acute cases, but in chronic cases, and especially the anemias, he may gain great benefit by such investigation. In trichinosis, for example, eosinophilia is most pronounced, B forming even as high as 70 per cent. of the leukocytes present.

The anemias which are of particular interest to the surgeon may be classified as follows:

• 1. Anemias without marked leukocytosis.
• A. Characterized by oligocythemia.
• B. Characterized by diminution of hemoglobin.
• 2. Anemias with marked leukocytosis.
• A. Leukemia (leukocythemia).
• B. Pseudoleukemia (Hodgkin’s disease).

1. A. Anemias due to hemorrhage may assume one of two forms, that resulting from sudden and extensive loss of blood or that resulting from constant oozing. Example of the former is seen in hemorrhages of the stomach or intestines after perforating ulcer, etc. Examples of the latter are met with in hemophilia and in uterine hemorrhages, or in excessive menstruation where the loss of blood extends over a considerable length of time. It is known, moreover, that certain entozoa in the intestines will produce a chronic anemia. Thus the red corpuscles may be reduced to even less than 1,000,000 per cubic millimeter. Immediately after acute hemorrhage the hemoglobin percentage is still normal, but after a short time it becomes reduced. If such cases do not speedily end fatally, nucleated red corpuscles appear in the blood and the observer will recognize both normoblasts and megaloblasts. At the same time the bone-marrow, which is normally yellow, becomes red, vascular, and richly cellular, and seems to furnish these cells just mentioned. Certain drugs, like potassium chlorate and glycerin, affect also the number of red corpuscles, but such poisons as these cause not only disintegration of the red cells, but produce also jaundice and hemoglobinuria. Pernicious anemia sometimes interferes with or fatally complicates surgical treatment. It is characterized by the extreme changes already mentioned, with which it marches steadily to a fatal termination. Quincke has reported an instance in which their number was reduced to 43,000 per cubic millimeter, while the hemoglobin was reduced to 20 or 25 per cent. of the normal amount.

1. B. The best example of anemia which depends upon diminution of the hemoglobin content of the red cells is that known as chlorosis. In this there are few recognizable signs of destruction of corpuscles, even under chemical microscopic examination; consequently the blood picture is very simple. The color index is very low, yet similar conditions may also be seen in syphilis, tuberculosis, and cancer. The underlying feature of all of these cases is malnutrition.

Within a few years a peculiar form of intense anemia has been described by Banti and others, and is often spoken of as splenic anemia or Banti’s disease. It is characterized by three stages: first, of splenic enlargement and anemia; second, a transitional stage; third, a stage of ascites which increases up to death. It is quite closely allied to Hanot’s hypertrophic cirrhosis of the liver. It is quite generally regarded as an example of an infection by some as yet unknown organism. It is of interest to the surgeon because if the spleen is removed early there are fair prospects of recovery.

2. A. Anemias with marked leukocytosis include especially those first spoken of by Virchow as leukemia. Originally he applied the term to a particular alteration of the blood, but it is now made to cover a group of diseases, all of which are characterized by peculiar and more or less similar increase of white corpuscles. Sometimes these are increased to such an extent as to make the blood grossly resemble a mixture of blood and pus. This resemblance led some of the earlier observers to speak of the condition as “suppuration of the blood.” The number of leukocytes is sometimes enormously increased; 1 to 10 of the red cells is quite common and 1 to 5 not exceedingly rare. Cases have been known in which the white cells outnumbered the red. In well-marked cases of leukemia, the red cells will be somewhat diminished, while the white will number from 100,000 to 500,000 per cubic millimeter. Accompanying this change in the blood there are alterations in the spleen, the lymph nodes, and the bone-marrow, sometimes one predominating, sometimes another. It has been customary in fact to speak of splenic, lymphatic, and medullary leukemia, but these forms are not sharply differentiated and a pure type of either form is rare. In this country we speak mainly of lymphatic and splenomedullary forms, the latter being much more common. The latter is accompanied by enlargement of the spleen, while in the lymphatic form the lymph nodes are involved and may become as large as walnuts. In the lymphatic form over 90 per cent. belong to C and D; in the splenomedullary or splenomyelogenous form the increase of F and G is most marked, while A will be reduced to 50 per cent. and D to about 10 per cent. The red corpuscles are decreased in number, but not necessarily in an inverse ratio; their number may be reduced even to 2,000,000 in extreme cases.

In these cases, besides the change in number and form of the leukocytes already described, there are frequently found in the blood very minute crystals first described by Charcot. These are small, often adherent to the leukocytes, and most frequently found when eosinophile cells predominate; their exact significance is not known. The pathology of leukemia is too remote from the purpose of this work to receive consideration here. Without asserting its germ character one may say that it is under suspicion, and that various observers have described appearances supposed to indicate a specific cause, probably a protozoön.

2. B. Pseudoleukemia.—This has, in time past, gone under many different names, of which the most common is Hodgkin’s disease (q. v.). Many speak of it as malignant lymphoma. This is doubtless a disease with a specific cause, as yet unrecognized, which produces very significant changes in the blood, especially in the white corpuscles. The spleen and lymph nodes are both involved, mainly the latter. The general blood changes are quite variable and one may find many types. As a rule, these comprise not so much an increase in the number of leukocytes as a decrease in the number of red cells by which an apparent leukocytosis is brought about; hence the expression pseudoleukemia. Many cases, however, will present a certain degree of actual leukocytosis, the proportion of the whites to the reds being about 40 to 50.

What interpretation in general is to be given to leukocytosis? A condition deserving this name is, first of all, essentially temporary. In acute infectious diseases it shows itself during the febrile stage and the principal increase is in the finely granular oxyphile cells. In such diseases as erysipelas, as well as pneumonia, it lasts but a short time after the crisis has been reached and the temperature has fallen. In diseases like acute appendicitis and acute peritonitis from any cause a marked leukocytosis may be regarded as indicating the presence of pus; it should be emphasized, however, that pus may be present without this indication, and it has been previously stated that such a fact is to be interpreted either as an example of a mild degree of infection or an exceedingly reduced vitality.

—It seems to be now quite clearly demonstrated that the mere establishment of a certain degree of leukocytosis does not furnish the surgeon a reliable guide for determining the presence of pus, it being an index of reaction rather than of actual severity of any particular kind of infection. A much more reliable guide is found in the proportion of polynuclear cells to the total number of leukocytes counted, i. e., by what may be called a differential count. In order to make this reliable, the normal ratio should first be determined. This is put at a point between 68 and 80 per cent. by various writers. As Gibson (Annals of Surgery, April, 1906) says, 75 per cent. may be considered the best working average. This average should be maintained as the total number of leukocytes increases, or else there is a disproportion which becomes significant. With a moderate leukocytosis there is a notable increase in polynuclear cells, and it may be estimated that there is either a severe form of lesion or less resistance to absorption, or both.

PLATE I

Fig. I.

Fig. II.

Fig. III.

Fig. IV.

Fig. V.

Fig. VI.

Fig. VII.

Fig. VIII.

DRAWN BY J. N. Z. CHASE

PLATE I.

BLOOD.
(Ehrlich triple stain.)
(Prepared by Dr. I. P. Lyon.)

Fig. I. TYPES OF LEUCOCYTES.

a. Polymorphonuclear Neutrophile. b. Polymorphonuclear Eosinophile. c. Myelocyte (Neutrophilic). d. Eosinophilic Myelocyte. e. Large Lymphocyte (large Mononuclear). f. Small Lymphocyte (small Mononuclear).

Fig. II. NORMAL BLOOD.

Field contains one neutrophile. Reds are normal.

Fig. III. ANÆMIA, POST-OPERATIVE (secondary).

The reds are fewer than normal, and are deficient in hæmoglobin and somewhat irregular in form. One normoblast is seen in the field, and two neutrophiles and one small lymphocyte, showing a marked post-hæmorrhagic anæmia, with leucocytosis.

Fig. IV. LEUCOCYTOSIS, INFLAMMATORY.

The reds are normal. A marked leucocytosis is shown, with five neutrophiles and one small lymphocyte. This illustration may also serve the purpose of showing the leucocytosis of malignant tumor.

Fig. V. TRICHINOSIS.

A marked leucocytosis is shown, consisting of an eosinophilia.

Fig. VI. LYMPHATIC LEUKÆMIA.

Slight anæmia. A large relative and absolute increase of the lymphocytes (chiefly the small lymphocytes) is shown.

Fig. VII. SPLENO-MYELOGENOUS LEUKÆMIA.

The reds show a secondary anæmia. Two normoblasts are shown. The leucocytosis is massive. Twenty leucocytes are shown, consisting of nine neutrophiles, seven myelocytes, two small lymphocytes, one eosinophile (polymorphonuclear) and one eosinophilic myelocyte. Note the polymorphous condition of the leucocytes, i. e., their variations from the typical in size and form.

Fig. VIII. VARIETIES OF RED CORPUSCLES.

a. Normal Red Corpuscle (normocyte). b, c. Anæmic Red Corpuscles. d-g. Poikilocytes. h. Microcyte. i. Megalocyte. j-n. Nucleated Red Corpuscles. j, k. Normoblasts. l. Microblast. m, n. Megaloblasts.

Gibson has suggested the formation of a chart where the number 10,000 of leukocytes shall appear upon the same line with 75 per cent. as the average normal proportion of polynuclears. Then drawing a parallel line, which shall indicate on one side each 1000 in increase of the former and each advance of one in the percentage, it will be seen that 15,000 leukocytes will correspond to 80 per cent. of polynuclears, 20,000 to 85 per cent., etc. When upon this chart there is drawn a line between that dot which represents the total leukocytosis on one side and that on the other which indicates the percentage of polynuclears, then the more horizontal this line the less the disproportion, while the more marked the angle it makes with the base line the greater the disproportion appears. It furnishes an admirable graphic record which the eye appreciates at once.

It would appear, then, that a differential blood count made in this way, and thus recorded, affords the most valuable diagnostic and prognostic aid in acute surgical diseases, indicating especially the presence of suppuration or of gangrene.

—Glycogen occurs in the blood especially in three classes of cases: those where there is marked respiratory disturbance in certain of the anemias, and, what is of especial interest to the surgeon, toxemias, either of chemical or bacterial origin. It is usually present in the secondary and pernicious anemias as well as in acute and late leukemias. It is considered by some that in these cases it really indicates the occurrence of some bacterial infection. Especially is glycogen present in cases of suppuration and surgical sepsis, i. e., in those cases where leukocytosis is usually, but not invariably, present; indeed, it would seem to be a most significant indication. While the iodine test is more easily carried out than is a blood count, the latter affords more information. The reaction is reliable and its relative intensity gives an idea of the intensity of the inflammatory process. In many cases with obscure symptoms and without leukocytosis its presence will afford much aid in diagnosis. It is of great assistance also in distinguishing between a deep-seated pneumonia and serous pleurisy, since in the latter there is no reaction, or in distinguishing between pleurisy with effusion and empyema; again, in distinguishing gonorrheal arthritis from true rheumatism. In a case of strangulated hernia the presence of the iodine reaction would indicate that pressure had produced gangrene, whereas its absence would indicate a relatively lesser degree of destruction. It has been aptly said that the presence of iodine reaction indicates that the patient is seriously sick.

It is easily obtained by staining a cover-glass with a blood smear in a gummy solution of iodine and potassium iodide. When the blood is normal all the cells take on a uniform, bright-yellow color, while the white cells stain more lightly than does their protoplasm. When the glycogen reaction is present, brown granules are seen in the protoplasm of the polynuclear leukocytes, which may often take on a different brown tint. Frequently brown particles are to be seen outside of the corpuscles, while occasionally the other forms of leukocytes show also the reaction.

The value of a careful blood examination is well illustrated by Plate I, prepared by Dr. Irving P. Lyon, in which are displayed the alterations of greatest interest to the surgeon.

The principal interest of the red blood corpuscles for the surgeon, aside from their relative number and shape, inheres in their relation to hemoglobin, and hemoglobin is of particular interest here because much can be learned by estimating the proportion in which it is present. Hemoglobin has, furthermore, an interest which reaches beyond the mere blood appearance, since it is considered to be the apparent source from which both the urinary and biliary pigments are produced. That the amount contained in the blood varies within wide limits under different conditions has long been known. When notably reduced in amount the condition is referred to as oligochromemia. The ideal normal standard is present in but a small proportion of cases, even in strong young men in the third decade of life. The average is considerably lower and can scarcely be placed above 90 per cent. Females show a smaller amount than males—3 or 4 per cent. less. In anemia its reduction is not usually proportionate to that in the number of red cells. After hemoglobin loss, as after surgical operations, much can be gained in the matter of prognosis by estimating the speed of its regeneration. With regard to how much actual hemoglobin loss a patient can bear, it seems to be more important to determine how much still remains in the body. The minimum is apparently 20 per cent. In three cases dying of collapse after operation, Mikulicz found only 15 per cent. remaining. The rapidity of regeneration is a fairly accurate indication of improvement in every other respect. Regeneration is interfered with by constitutional syphilis, and, on the other hand, is often apparently favored in cases of tuberculosis. In malignant tumors the average of hemoglobin is reduced to about 60 per cent., and in these cases also complete regeneration is materially retarded. Incomplete removal or recurrence of cancer prevents typical regeneration or restoration, while, after successful or radical removal, complete restoration to the previous standard, often with positive gain, is obtained. Thus, a woman who had gained thirty pounds after resection of a cancerous pylorus, showed, after three months, hemoglobin repair to the amount of 65 per cent. A prognostic significance often attaches to the accurate estimation of hemoglobin at intervals after removal of malignant tumors.

A very convenient method for the ready estimation of hemoglobin is afforded by the Tallquist color scale. It can be practised at the bedside and is sufficiently accurate for the surgeon’s general purposes.

Thrombosis is a term applied to the formation of a thrombus—i. e., a clot within the cavity of the heart or one of the bloodvessels—the term being limited to coagulation of blood within these natural cavities, and without specifying the exciting cause of the same. A clot so formed is called a thrombus. To be accurate, a distinction should be made between a thrombus, which is caused always before death—or, rather, during life—and the clot, which is essentially a postmortem affair. Our application, then, of the terms “thrombosis” and “thrombus” refers solely to that which takes place during life. In order to appreciate the conditions which lead to thrombosis it is necessary to fully appreciate the reciprocal conditions which must normally be maintained between the circulating blood and the walls of the vessels in which it flows. Fluidity of blood depends always upon integrity of the vessel wall. As long as its lining membrane is absolutely undisturbed and normal, moving blood will never coagulate within it, and the only thrombi that may be met within it are those which are propagated from a distance. Coagulation of blood is, for the main part, associated with the peculiar properties of fibrin.

Fibrin is produced from fibrinogen, a globulin which is held in solution under ordinary circumstances, which has certain peculiarities of its own. When the change occurs it is entirely consumed and none remains in the blood serum. Fibrinogen is split up by a peculiar ferment called thrombin into what we ordinarily speak of as fibrin and a small amount of a soluble globulin, which remains in solution in the serum. Thrombin is not a normal constituent of the blood, but is formed when it escapes, as the result of the reaction between certain calcium salts and a nucleoproteid, which has been called prothrombin. The latter arises from the disintegration of the leukocytes, especially the polynuclear, and the blood plaques, after the blood leaves the bloodvessels. Calcium salts seem absolutely necessary for coagulation; hence the value of the administration of calcium chloride in certain cases previous to operation. Another essential feature seems to be the absolute integrity of the endothelial lining of the bloodvessels, although for this fact there is no satisfactory explanation. If a portion of a vein is removed from the body after double ligation its contained blood will not coagulate for a long time. Blood which is kept circulating through the lungs and heart alone soon loses its coagulability; hence the liver seems to be concerned in some way in maintaining it. Certain other substances also seem to retard coagulation, such as the albumoses of snake venom, and certain synthetic, colloid, proteid-like substances, which can be introduced very gradually. If, however, they are introduced rapidly, or in large quantities, thrombosis occurs promptly. We have much to learn about the coagulation of the blood, but the above facts are at least suggestive to the surgeon.

PLATE II

FIG. 1

Small Vein showing Diapedesis of Leukocytes. (Engelmann.)

a, leukocyte escaping between endothelial cells; b, c, leukocytes escaped; f, leukocytes migrating toward centre of attraction.

FIG. 2

Septic Thrombosis of Pulmonary Capillaries after Puerperal Septicemia, showing Rapidly Increasing Colonies of Streptococci. (Klebs.)

Causes.

—The underlying cause of all thrombi is, then, alteration of the endothelium. In consequence, when it is desirable to produce coagulation artificially, advantage may be taken of this fact, and mechanical injury to the vessel walls may be quickly followed by the desired results. Advantage is also taken of this fact in surgery, especially in certain methods of treating aneurysm, by rude handling, by needling, by the introduction of horsehairs, fine wire, etc. A venous thrombosis is certainly favored by the thinness of the venous walls, by which poorer protection is afforded to their lining endothelium, and infection more easily occurs. Arterial thrombosis is favored when cardiac vigor is impaired and vessel walls are thickened so as to obstruct the blood current. This occurs particularly in syphilitic endarteritis, where the intima suffers most, and final occlusion is due to the thrombus thus formed. Arteriosclerosis does not, by itself, often produce this trouble; it comes rather with atheromatous and calcareous degenerations. The local ischemia which is occasioned by ergotism, by pellagra (due to use of certain kinds of maize), by the vasomotor spasm of Raynaud’s disease (see under Gangrene), by too long-continued constriction, or by frostbite, causes results comparable to those produced experimentally in parts supplied by a terminal artery, e. g., in the kidney after temporary occlusion of its artery. All the tissues involved undergo profound alterations, in which thrombosis figures very largely and may lead to gangrene.

While such endothelial lesions are essential, there are, nevertheless, numerous other accessory causes which should be mentioned. These comprise:

A. The presence of foreign bodies, as, for example, needles, hooklets of echinococci, parasites, particles of tumors, fragments from the heart valves, and, most of all, that which is essentially a foreign body, a clot which has come from some other point. Around such foreign particles will quickly group themselves a relatively large number of leukocytes, thus affording another example of phagocytosis, soon to be described. Mere slowing of blood stream without some such mechanical irritation is not sufficient to produce coagulation. If, for instance, a section of vein is isolated between two ligatures, the ligation being aseptically done and the surroundings of the vein wall disturbed as little as possible, the blood thus shut up within the vein remains fluid indefinitely. If, however, the vessel wall is separated from its surroundings, so that its nourishment is compromised, the contained fluid quickly coagulates.

B. Necrosis, gangrene, etc., lead to quick involvement of the endothelium of the vessels contained within the involved part, and consequently to quick coagulation of the blood which they contain.

C. Temperature has also an influence in the same direction, and extremes in either direction, or drying of vessels which may happen to be exposed to the air for some time, lead to the same results.

D. Inflammatory and degenerative processes occurring in and about the vessel walls tend always to produce coagulation. This is well seen in the influence exerted by the so-called atheromatous ulcers—i. e., the degeneration of certain areas in the walls of large vessels.

E. Microörganisms and their products are perhaps the most frequently effective of all the accessory causes of thrombosis. In other words, in all the surgical infectious diseases we may expect to find more or less, sometimes extensive, thrombosis in the vessels of the affected part. This may so far shut off circulation as to produce temporary or permanent edema, or it may lead to gangrene, which may be local or may terminate the life of the patient.

Thrombi are classified as:

• 1. Primary; and
• 2. Propagated.

The primary thrombus is one which has originated at the spot where it has been first produced, and is usually co-extensive with its cause. The propagated thrombus may be one which has been carried to a considerable distance, and is met with at a point widely different from that where it originated, or one which has extended along the vascular channel in which it was first formed, but far beyond the limits of its prime cause. When a thrombus attaches itself to a part of the vessel wall it is called parietal or valvular, because it does not completely occlude the vessel; when it involves the entire circumference of the vessel, but does not completely occlude it, it is spoken of as annular. The obstructive thrombus is that which completely fills a given vessel and shuts off all circulation through it.

The propagated thrombus extends usually in both directions, and always much farther in veins than in arteries. Thus, thrombi may be met with extending from the ankles even into the inferior vena cava. The venous valves may on one hand excite coagulation, or on the other tend to fix the coagula more firmly in their place. In arteries thrombi usually extend only to the first collateral channel on the cardiac side, but occasionally they spread farther. The cause of a primary thrombus is to be sought at the site of its lodgement; the cause of propagated thrombi is often observed at a wide distance from the effect.

Thrombosis is, again, to be spoken of as—

• a. Marasmic;
• b. Mechanical or traumatic;
• c. Infective.

a. The marasmic forms are due to essential alterations in the constituents of the blood, which are due mainly to starvation or wasting disease. Marasmic thrombi seldom give rise to serious disturbance during life until the condition is so complex and grave that the patient is at death’s door. Postmortem evidences of marasmic thrombi, however, are often found, and yet have but little surgical significance. They are seen perhaps as often in the cranial sinuses as anywhere.

b. Thrombi of mechanical or traumatic origin are those, for instance, which are due to the presence of foreign bodies, to stagnation of blood as the result of ischemia or local anemia, to compression by tumors, etc.

c. Infective thrombi are those distinctly due to the injurious effects of micro-organisms, and are those mainly concerned in the various manifestations of sepsis which are of interest to surgeons.

While the ordinary evidences of thrombosis are most often looked for in the veins of the extremities, in the lungs, and in the cranial sinuses, it must not be forgotten that thrombosis may occur equally easily in the portal system of vessels; in which case we find the most marked expressions in this system and in the liver. In cases also of pyemia proceeding from lesions in the rectum or in the bowels there are evidences of infection, abscess, etc., in the liver, but not in the lungs, to which point infective thrombi from other sources are promptly carried.

The ultimate fate of a thrombus depends entirely upon the presence or absence of bacteria. If septic, it invariably breaks down. If aseptic, it may undergo one or more of the following metamorphoses:

A. Decolorization.—This is noted particularly in the red thrombi, and is due to disintegration of the red corpuscles, their coloring matter being diffused and resorbed or transformed into hematoidin. It would be a mistake, however, to suppose that all light-colored thrombi are those which, originally red, have been decolorized. The possibility of white thrombi must always be remembered.

B. Organization.—This is the result of time, and means a metamorphosis into solid vascular connective tissue. Newly formed, minute, vascular loops project from the vasa vasorum into the thrombus, and it becomes thus vascularized, while the completion of the organization is due, in the main, to spindle-cell connective tissue, which is formed by wandering cells that penetrate into the thrombus from without. This gives the organized thrombus a certain resemblance to a sponge, and makes the original vein resemble a cranial sinus, since its interior is spanned by bands of connective tissue. Typical illustrations of this kind are seen, for instance, where the iliac veins join to form the inferior cava, by which a certain amount of obstruction to venous return is produced without its being total. The length of time required for these changes is indefinite. They begin, however, within a short time after ligature of a vein, and proceed with a rapidity varying according to circumstances.

C. Calcification.—Calcium salts are occasionally deposited in thrombi, usually not until they have undergone considerable contraction and alteration; as the result of which we have formation of small masses, essentially minute calculi, to which the name of phleboliths has been given. These phleboliths are not infrequently found in more or less occluded and much distended varicose veins of the extremities, and they prohibit the occurrence of softening.

D. Softening.—This is the most serious termination of the thrombotic accident, and is usually due to the agency of infecting organisms. A non-infectious form is, however, recognized, by which there is a metamorphosis of original clot into an oily or pulpy fluid, usually dark colored, but in the white thrombi often yellowish white, reminding one crudely of pus. The discovery of such material under these circumstances has led in time past to the supposition that pus, as such, was found floating in the blood—a condition that does not exist except under extraordinary circumstances. It is with infection of thrombi and consequent softening, however, that surgeons have most to deal, and the paramount importance to them of such disturbances is emphasized in the article under Pyemia.

A closely allied topic to that above considered is the subject of thrombophlebitis. This means, in effect, inflammation of one or more veins, which is directly due to the presence therein of thrombi. Such a condition is, in its strict sense, an inflammation, since it is always an infectious process. If in the veins of a non-infected region simple thrombi form, they may be occluded by organization of the included masses, but such a process never extends beyond the immediate area involved. On the other hand, if the process is essentially an infectious one, either from without or from within, then both vessel and its contained thrombi succumb completely to the infectious process, which is also essentially a spreading one; and this is limited only by mechanical barriers, by conservative suppuration, or often only by the life of the individual. Excellent examples of thrombophlebitis are seen in the involved uterine sinuses in cases of puerperal septicemia, and in the cranial sinuses after infected compound fractures, or particularly after disease originating in the middle ear has extended to them.

Thrombosis is, at times, a distinctly surgical condition, and often a surgical complication of febrile and other diseases, especially typhoid, in which it constitutes a serious complication and prolongs convalescence for a period of several months. If foreseen it can scarcely be prevented, and when present calls for treatment varying with the location of the lesion and the exciting causes. In the earlier stage anything like rude manipulation or massage is very unfortunate, since soft clots might thus be broken up and distributed to other parts of the body. Absolute physiological rest combined with the application of silver ointment, of ichthyol-mercurial ointment, which should be covered with some non-absorbent material, will probably give the best results. If the lower limbs are affected it may be well to elevate the feet so as to favor return of blood through vessels not yet obstructed. After a certain length of time the thrombi may be regarded as at least adherent if not organized, and massage will prove an important remedy, since by it the lymphatics will be better enabled to take up the fluids which have leaked from the bloodvessels and produced the edema which always characterizes these cases. Sluggishness of circulation is nearly always followed by more or less laxness of tissue, or actual hypertrophy, and a limb thus involved may never regain its original size or flexibility. Veins once compromised, if not occluded, frequently become varicose, or varicosities develop in adjoining veins and still further complicate the case. For such difficulty the measures discussed in the chapter on the Veins may be later required.

In every fresh case of thrombosis or thrombophlebitis great care should be taken in order that by no means shall the clots be disengaged and float away. The dangers correspond to those existing in variocele and nevi, often treated by the older methods of injection of coagulating material. In one instance reported, a child died within half an hour after the injection of an iron salt into a small nevus of the face. Coagulation was excited to a point far beyond the limits intended.

Thrombophlebitis is essentially a surgical condition, occasionally terminating favorably by suppuration and spontaneous evacuation, but calling for surgical intervention whenever it can be recognized and the parts are accessible. The principles of treatment of these conditions are positive and unmistakable. They comprise evacuation of the infective material and disinfection of the involved cavities and tissues. Thus, in sinus phlebitis—i. e., thrombophlebitis of the lateral sinus—it has been made practicable not only to open the sinus in the mastoid region, but to expose the jugular vein in the neck, to ligate it, and to wash through from one opening to the other, effectually getting rid in this way of a long mass of infected thrombi. Only by such bold and radical measures in many of these instances may life be saved.

Embolism means the transportation of any material by which a bloodvessel can be occluded or plugged from one part of the vascular system to some other. The underlying idea is that of transportation or carriage. An embolus is anything so transported, without implying its exact character. The name is even applied to so unsubstantial an affair as a minute bubble of air, which, however, in a tube containing a circulating fluid is a possible source of considerable disturbance. A single bubble thus carried would, by itself, be a trifling affair, but when numerous bubbles are thus transported the result is such local disturbance as may lead to loss of function. Thus, air embolism, so called, may provoke profound, even fatal, disturbances, as, when, with the returning blood stream through the cranial sinuses or one of the large veins in the neck, when opened by accident or operation, air is sucked in, it is carried to the right side of the heart, whose action is perhaps completely perverted because of the new and strange substance which thus enters it, so different from that for which its lining membrane is prepared and to which it reacts. The entrance of air into veins, which constitutes in effect air embolism, has been in time past a bugbear to surgeons, but nevertheless is a source of probable danger when large venous trunks in proximity to the heart are thus exposed. Air embolism is certainly a rarity. On the other hand, those substances which figure most often as emboli are vegetations from the valves of the heart; drops of fat; fragments of tumors; pieces of softened and disintegrated thrombi; foreign bodies, as hooklets of echinococcus cysts; and, perhaps most often of all, the microorganisms clinging to some minute fragment of thrombus which has been dislodged. Embolism is also produced experimentally by the artificial introduction into the circulating blood of cinnabar or small particles of pith or other material. Emboli differ in number and size from the smallest appreciable up to the largest, which may be met with in the larger venous trunks. They are dislodged from their primary site sometimes by accident, as by rude manipulation, injury, etc.; sometimes by undue cardiac activity, as when detached from a valve wall; sometimes by the process of softening of thrombus and a subsequent introduction into the blood stream as a result of some trifling motion; or even by spontaneous processes. Emboli also differ in numbers according to the nature of the primary lesion. In cases of so-called fat embolism fluidified fat is taken into the returning blood stream, carried to the heart, churned up with the contained blood, and distributed to the lungs in such a way that myriads of minute fat masses are distributed throughout the capillaries of the lungs, and free circulation of blood through them is thereby impeded.

It will thus be seen that the relations between thrombosis and embolism are most intimate, but that either one may occur without the occurrence of the other.

Among the viscera, with the exception possibly of the brain, the disastrous consequences of such processes as those just described are more apparent and indicative than in thrombosis and embolism of the mesenteric bloodvessels—a condition not so rare as journal articles would imply, yet, nevertheless, one seldom recognized either during life or after death. Its principal symptoms consist of intense abdominal pain, bloody diarrhea, subnormal temperature, sometimes with vomiting, perhaps in the latter stages vomiting of blood. Shock is usually also extremely marked. The consequence of this condition is almost inevitably gangrene of the intestine supplied by that particular portion of the mesenteric vessels. The pain comes on within a short time after the occurrence, and under the peculiar circumstances gangrene may be practically determined within a few hours. Some two hundred and fifty cases of this kind are now on record, and the condition is one well worth the prompt attention of the surgeon, because only by surgical intervention—i. e., by resection of the necrotic mass of intestine—can life possibly be saved. That when a limited portion of the intestine is involved the gangrenous part may be successfully removed has been proved by several operators. (See Chapter LII.)

It will thus be seen that embolism constitutes often a distinctly surgical condition for which unfortunately only radical measures are suitable. Many cases of gangrene of the toes and feet, extending to the legs, are produced by embolism of the femoral and popliteal arteries, similar conditions being noted less often in the upper extremities. Amputation offers the only resource in such instances, at the same time affording no guarantee against any similar embolic disturbance elsewhere. In only most exceptional instances is it possible, by resorting to moist heat, position, etc., to encourage circulation to such an extent as to obviate the necessity of amputation. (See Chapter V.)

Fat Embolism.

—Fat embolism as a distinct, sometimes fatal, surgical condition has received of late so much study as to be entitled to consideration by itself. By this term is meant a plugging of small arteries by minute drops of fat, which, having been set free somewhere about the periphery, are carried into the venous circulation and thence distributed to various parts of the system. Inasmuch as the capillaries of the lungs are often their first lodging place, fat embolism here is most often met with, and consequently recognized and studied. But it may occur in the brain, the choroid, the kidneys, or other parts, provided only that there has been sufficient ris a tergo on the part of the heart to force the fat globules through the pulmonary capillaries and into the systemic circulation.

Fig. 2

Fat embolism of lungs. Large branching pulmonary artery filled with spherical, oval, cylindrical, and branching masses of fat. Fresh mashed preparation in potassium hydrate. (Kaiserling.)

Fat embolism occurs frequently, and to a slight extent in nearly every case of fracture and laceration. So common is it, and so closely allied are some of its most prominent symptoms to those of shock, that as a matter of fact many cases heretofore considered shock are to be regarded as instances of this condition. Indeed, even in a miscellaneous series of 260 dead bodies fat embolism was found in 10 per cent. The injuries most likely to be followed by it are simple, and particularly compound fractures of bones; laceration of soft parts, especially of adipose tissues; certain surgical operations; acute infections of bone and periosteum; rupture of fatty liver; and certain pathological conditions where the phenomena are not so easily explained, e. g., icterus gravis, diabetes, etc.

Drops of fat may be seen floating on fluid or semifluid blood after many operations and compound injuries, and the possibility of escape of fat—or, more accurately, its suction into the vessels from which this blood has escaped—is easily appreciable. But it has also been shown that absorption of fat is possible even from serous surfaces, and that fat embolism may occur when fluid fat has been passed into the heart through the thoracic duct, although more slowly. Oil drops are also found in the interior of the tissues, while in a piece of lung spread out in water in the visible vessels highly refracting fatty material may be noted. Fatty infarction, particularly in the lower lobes, is sometimes plainly visible to the naked eye. Under a low objective, especially with osmic-acid staining, the presence of fat is easily demonstrated.

The essential danger in case of fat embolism is of so clogging the pulmonary capillaries that oxygenation shall become so imperfect as to lead to absolute asphyxiation from carbonic dioxide poisoning. When this fact is understood, the cyanosis, the rapid breathing, the overaction of the heart, etc., are easily and correctly interpreted.

Fat embolism by itself cannot cause inflammation nor infection, nor sepsis in any sense. It may, however, lead to ecchymoses in conjunction with fatty infarcts in the organs most affected. The minute hemorrhages are easily explained by the bursting of the capillaries in the attempt to force blood through them. Fatty emboli, however, take the same course as do septic—are carried first to the right side of the heart and distributed over the lungs; are, if the patient lives, forced through the lungs into the systemic circulation, and are then carried to the brain, kidneys, etc. The first symptoms are referable to the plugging of the pulmonary capillaries; the secondary symptoms to the systemic disturbance.

Symptoms.

—Pallor of countenance with facial expression of anxiety and distress, followed by cyanosis and contracted pupils, are seen. Patients are usually first excited, sometimes more or less disturbed, then become somnolent, and, finally, comatose in the fatal cases. The respiration rate increases from normal up to 50 or 60, and breathing is sometimes stertorous. Dyspnea, increasing in intensity until it becomes agonizing, sometimes marks these cases. Occasionally foam, possibly blood, proceeds from the mouth, as in edema of the lungs. Sometimes hemoptysis occurs. The pulse becomes weak, frequent, and irregular, while toward the close it is fluttering. Temperature is not notably disturbed, at least not typically.

These symptoms set in usually within thirty-six to seventy-two hours after the lesion which has caused them. I have, however, known death to occur in one or more cases within eighteen hours after reception of injury.

After fat has been forced through the lungs and carried to the kidneys it will be eliminated with the urine, and may be found floating upon it in the shape of oil-like drops. Discovery of this condition is positive evidence of fat embolism. It is to be distinguished from shock in that by the time the symptoms of embolic disturbance are at their height, all or nearly all symptoms of pure shock have subsided. Furthermore, cyanosis and embarrassment of respiration are not indicative of shock; and, finally, the discovery of fat in the urine will be corroborative.

A mild degree of fat embolism may be noted, if looked for, after almost all serious fractures. It will give rise to slight embarrassment of respiration and cyanosis and to the elimination of fat by the kidneys.

Prognosis.

—Prognosis varies according to the extent of the injury and the proximity of the lesion to the heart and lungs; also to the possibility of continuous entrance of fat, i. e., from its continual absorption. Prognosis really depends upon whether the heart can be given sufficient vigor and endurance to continue pumping blood with its burden of fat through the pulmonary circulation. A secondary danger may come from the circulation of this fat-ladened blood through the capillaries of the brain. Should the source of motive power thus become paralyzed with resulting general enfeeblement, death may ensue. When well-marked evidences of fat embolism are present, but are followed by recovery, the worst of the trouble is usually over within forty-eight hours after it begins.

Treatment.

—Obviously treatment is mainly directed toward the heart, so that we may stimulate it to carry its load of fat through from the venous into the arterial system. If it can do this, the fat is disposed of by oxidation or is saponified by the alkalies in the blood. Physiological rest of the injured part is the first indication, however, and if this occurs in a patient, say with delirium tremens, powerful mechanical restraint may be necessary. The most effective cardiac stimulants are called for—alcohol, adrenalin, strychnine. In other respects treatment is largely symptomatic. Next to giving the heart vigor in this way, inhalations of oxygen give the most promise, because of the crying need of the system during this ordeal for this life-giving gas.[1]

Phagocytosis.

—All leukocytes have the power of shifting their location. The lymphocytes, so called, being the youngest of the white corpuscles, show it less than the older forms. The eosinophile cells are less able to manifest the peculiar activities of the other forms. It is particularly the mononuclear and polynuclear corpuscles which are endowed with most pronounced activity. These have the power, like the ameba among the lowest forms of life, to not only spread themselves around inert bodies, like granules of carmine or other particles used for experiment, or the particles of coal-dust found in certain conditions in the human body, but they also have the power to englobe many living organisms, for the main part vegetable (bacteria). Under the microscope it is possible to see living bacilli, performing active movements, although enclosed in the nutritive vacuoles of the leukocytes, in some of the lower animals. This ameboid power possessed by these cells of thus attacking and disposing of foreign bodies or irritants has been demonstrated and proved, especially by Metchnikoff, and has been called by him phagocytosis. His views were for a long time disputed, and are perhaps not yet absolutely and generally accepted. Nevertheless, they fulfil every demand made upon them for explanation, and are susceptible of such demonstration under the microscope that we now have practically a new and apparently a correct theory of the inflammatory process. (See Chapter III.) Any cell which has this property is known as a phagocyte. It is shared by some of the leukocytes with certain other cells to be spoken of later (wandering tissue cells). Cells which possess this power do not attract all microbes indiscriminately, and it is often the case that the leukocytes of an animal peculiarly susceptible to a certain kind of bacteria do not attract them at all, even though they are directly in contact. It is plausible that an explanation of the peculiar susceptibility of certain animals to certain diseases is furnished by this fact (Fig. 3).

Fig. 3

Phagocytosis in anthrax pustule. (Gaylord.)

On the other hand, leukocytes may and do englobe virulent microbes. In man the mononuclear forms do not take up either the streptococcus of erysipelas or the gonococcus; whereas these two organisms are readily attracted by the polynuclear neutrophile cells. The bacillus of leprosy, on the other hand, is never attacked by the polynuclear forms, but is speedily devoured by the mononuclear cells. This shows that the various leukocytes may exercise a marked selective ability. This inclusion of minute bodies within ameboid cells seems to be an evidence of a peculiar tactile sensibility upon the part of the latter. In fact, this is clearly established, and seems to be inseparable from the peculiar attraction between leukocyte and bacterium, to which the name chemotaxis has been given, and which is described in an ensuing chapter. If the included organism is, as is usually the case, killed, it is disposed of by a true process of intracellular digestion in a neutral or alkaline protoplasmic medium, and its inert portions are again extruded. On the other hand, if the leukocyte is poisoned or die in this phagocytic attempt, it presents usually as a so-called pus cell or corpuscle, and the solid part of pus is made up in large measure of cells which have perished in this way. (See Inflammation and Suppuration.)

To regard phagocytosis as an affair mostly of certain tissue cells and invading bacteria would be altogether too narrow a view to take of it. It is really a process of the greatest importance and of constant performance in our systems. By virtue of it disintegrated muscle fibers and other tissue cells are disposed of, sloughs are separated, certain absorbable foreign bodies (catgut, etc.) taken away—i. e., absorbed—cellular tissue reduced in numerical strength (progressive atrophy), and a great variety of changes, either normal, as those pertaining to health and advancing years, or abnormal, like those incident to many diseases, are actually the product of this kind of phagocytic activity. The protective power, then, which the phagocytes exert as against bacteria is only one part of their normal functions, by virtue of which they become, in effect, perhaps the most important cells within our bodies. Their powers are limited, however, as will be seen when describing pus, for the so-called pus corpuscle is nothing but a phagocyte which has perished in its self-assumed task. It is known also that in certain instances phagocytes, which are incapable of defence as against the mature bacterial organism, are nevertheless capable of englobing its spores and preventing their development. This is true, for instance, in case of anthrax in animals ordinarily immune, as, for instance, the frog and fowl. If, however, in these very animals the vitality of the phagocytes be affected—as by cooling in fowls or heating in frogs—phagocytosis is so far interfered with that the spores germinate within the enfeebled leukocytes and the entire organism is infected.

CHAPTER III. INFLAMMATION. — CHEMOTAXIS AND OPSONINS. — SPECIFIC IRRITANTS. — CIRCUMSTANCES WHICH FAVOR INFECTION. — SOURCES OF INFECTION. — CLASSIFICATION OF INFECTIONS. — BACTERIA OF PUS FORMATION. — YEASTS. — FUNGI. — PROTOZOA. — CLINICAL CHARACTERISTICS OF PUS FROM DIFFERENT AGENCIES. — BACTERIAL DETERMINATION AS AN INDICATION IN TREATMENT. — SUPPURATION. — SINUS AND FISTULA.

Inflammation is an expression of the effort made by a given organism to rid itself of or render inert noxious irritants, arising from within or introduced from without (Sutton, modified).

After having duly considered hyperemia as a phenomenon having an identity and termination of its own, we are prepared to study the more complex processes included under the term inflammation, the first of which is the hyperemia already considered. The characteristic of the truly inflammatory process is that it does not stop with mere congestion nor with any of its previously mentioned terminations, but goes on to something more complex. It must be understood, therefore, in this consideration that hyperemia is the first act of the vessels, resulting from peculiar stimuli which will shortly be considered. Even the hyperemia seems to be now more distinct than under other circumstances, and, along with the dilatation of vessels and the stagnation of blood current, the capillary vessels seem crowded with blood corpuscles to an abnormal degree, the rapidity of their motion is checked, and there occurs accumulation of blood cells along the walls of the small veins, to which they seem to adhere as if by some new cohesive property. The result is that before long the vessel wall appears to have received a new coating of white corpuscles, this being more marked in the veins than in the arterioles, while in the latter the red are more numerously mingled with the white than in the veins, in which the distinction between the two classes of cells is better maintained.

Next comes the phenomenon whose clear recognition and description is inseparably connected with Cohnheim’s name. This is known under different names as migration or diapedesis of the leukocytes. The program is about as follows: A little protrusion of the vascular wall, a marked alteration in the shape of a leukocyte, which yet adheres to this point of its lumen, and then the curious fact so often seen under the microscope—the gradual passage of this cell through the vascular wall, from its inner to its outer side, by what is generally known as its ameboid movement. This migration of the leukocyte is not confined to its mere escape from the restriction of the vessel lumen, but goes on to an indeterminate extent after it has detached itself from the outer surface of the vessel. This seems to occur by virtue of the same ameboid characteristic which it exhibited in passing through between the cells of the vessel itself. If this occurs at one point, it occurs at innumerable points, in consequence of which a large number of leukocytes escape into the tissues of the part involved. This diapedesis occurs most markedly from the smaller veins, to a less extent from the capillaries. The cells which escape from the latter are usually accompanied by red cells, the consequence being that the exudate which necessarily occurs at the same time is more or less tinged with the coloring matter of the blood, and is known as a hemorrhagic exudate.

The above phenomenon, described in so few words, is in its minutiæ a really complex one, depending on a variety of causes not easily appreciated; but it is at least positive and well known, because it can be observed at will in the mesentery or web or tongue of certain animals which can be confined upon the stage of the microscope. The phenomena of inflammation, therefore, comprise, first, hyperemia, and then escape from the bloodvessels of the corpuscular and fluid elements of the blood. The former may be due, as already seen, to various irritations of a non-specific character; while, as we shall learn, the latter practically never take place save when the irritation has been, as pathologists say, specific or infectious.

The phenomena of true inflammation comprise practically the roles played by the three elements which conspire to produce those changes—namely, the tissues, the blood, and the specific irritants which are the primary cause of the entire lesion. Each of these should be considered separately.

All observers agree that in actively inflamed tissues the number of cells is very greatly increased. A certain increase may be accounted for by that which has already been described—namely, the escape into the tissues of the wandering cells from the bloodvessels. But neither this alone nor the products of their rapid proliferation are sufficient to account for all the cells found in the truly inflammatory condition. It is now well established that in connective tissue there are two varieties of cells—the fixed and the wandering—the former concealed in the trabeculæ of the intercellular substance, while the latter are small, ordinarily round in shape, much resembling the white corpuscles, possessed of ameboid characteristics, and having the power of changing position. These are known as the wandering cells, which meander through the lymph spaces of the tissues or back and forth into and out of the blood-vascular system, their migration being regulated by causes not yet known. Under natural conditions their number is relatively small. Once given a true inflammatory disturbance they are reproduced with amazing rapidity; and their numbers, added to those produced by diapedesis of leukocytes, with the combined proliferative activity of both forms, serve to account for the new cells whose presence characterizes phlegmonous and other similar disturbances. That these wandering connective-tissue cells have much to do with these changes is shown by the unmistakable evidences of excessive activity known as karyokinesis (i. e., nuclear activity).

Karyokinesis is common not only in inflammatory disturbances, but in new-growths of rapid formation, especially sarcomas, which are formed from mesoblastic cells, the same which have to do with connective tissue. Endothelial cells also undergo the same changes.

The peculiar characteristics of the leukocytes have already been described at considerable length in the preceding chapter. It must suffice, then, here to say that during the inflammatory attack the leukocytes are increased in number, i. e., there is a temporary leukocytosis which is the usual accompaniment of suppuration. For instance, this is regularly present in purulent, but not in catarrhal, forms of appendicitis. The recognition of this fact may be of great value in diagnosis. For instance, leukocytosis is rarely present in tuberculous disease unless suppuration complicates the case. It is met with in suppurative osteomyelitis and in all cases of pocketing of pus. Moreover, when leukocytosis is present coagulability of the blood is increased. Of the various leukocytes, it is the mononuclear and polynuclear forms (see Chapter II) which are endowed with the most pronounced activity and which play the principal role among the blood cells or phagocytes. That phagocytosis plays a most important part in the inflammatory process is a matter to be emphasized in more than one way and in more than one place. The account of the process already given should suffice for descriptive purposes; the importance of the act, however, should be made most prominent in considering inflammation and suppuration. That the phagocytic properties of these cells are limited will be remembered when we recall that in certain instances phagocytes, which are incapable of defence as against the mature bacterial organism, are yet capable of englobing the spores and preventing their development. Nevertheless, the activities of even the most lively phagocytes are capable of being influenced and repressed by extremes of heat and cold to which patients may be exposed, either locally or generally.

Having considered briefly the cells which take prominent part in the inflammatory process, and the escape along with them of the fluid portions of the blood, whether these coagulate or not, it is necessary before referring to specific factors to discuss that which induces the above cells to act in this way. That there is a peculiar, even a mysterious, attraction which brings specific irritant and phagocyte together has been for some time recognized, but it remained for Pfeffer to study it carefully and to give it the name by which it now passes, i. e., chemotaxis, while others have widened our knowledge of it, especially by a recognition of the opsonins or material which “prepares food,” i. e., prepare microbes for ingestion by the phagocytes.

Chemotaxis is a term implying a peculiar property of attraction and repulsion between cells, both animal and vegetable. It mainly pertains to vegetable cells alone, and has been offered as the explanation of the sporulation of ferns, for example; but as it interests us most in this place it is manifested between the animal cells of the human body and the bacteria, which are vegetable cells. As a result the former, i. e., the phagocytes, having power of migration, are drawn toward the latter. To be more accurate, this mutual or peculiar attraction is known as positive chemotaxis, it being also known that exactly the reverse prevails under certain circumstances, and that mobile cells will move away as rapidly as possible from certain organisms or substances for which they seem to have a repugnance, this being known as negative chemotaxis.

These are essentially living organisms, bacteria, fungi, and the protozoa, the first named being by far the most frequent. Before a lesion can assume the type of inflammation as here understood some one or more of these organisms must have secured an entrance into the tissues, the circumstances determining such invasion being considered a little farther on. It is these living organisms which, having once invaded the tissues, determine that most active congregation and proliferation of certain cells which we have just described under the head of Phagocytosis. When once the irritants are present there begins that very active conflict which Virchow has so graphically alluded to as the battle of the cells. Now the mysterious chemotactic properties of the component substances manifest themselves, and now phagocyte is drawn toward bacterium, or the reverse, while the tiny war goes on with sometimes varying results, it being a question which can prove victor in the conquest. This is no fiction of the imagination, but is a contest which may be seen under the microscope in certain of the lower animals, while its results may be seen in the examination of pus from any human source. In another place I have also likened this conflict to that in which certain of the enemy resort to poisoned weapons, because modern biological chemistry has now shown very evidently that it is a part of the life history of many of these microörganisms to produce, probably as excretory products, albuminoid or other substances having sometimes extremely toxic properties. And so it comes about that in many of the surgical infections, while the local destruction is produced by the actual death of tissues which have been invaded by microörganisms, the general or systemic symptoms, generally referred to as the toxic symptoms, are literally due to poisons generated in the infected area, dispersed throughout the system, and often proving fatal.

The local effect of these specific irritants, when they are not promptly attacked, devoured, and removed by phagocytes, is pus, which means cellular death, or gangrene, which is death of masses of cells which have not had time to separate from each other. Pus, then, is the ordinary consequence of the contest above alluded to, and each pus cell represents the dead body of a phagocyte which has perished in the attempt to protect the parent organism from harm. That it has died valiantly can almost invariably be determined, because within its dead body may be seen one or more of the minute invaders which it has attacked. This, then, is the light in which inflammation and infection should be viewed.

In other words, we may have escape of fluid portions of the blood, which may or may not coagulate; we may even have some escape of corpuscular elements with some activity in the extravascular cells, which shall lead to temporary or even permanent enlargement of a part; all of which may be provoked by injury or by the presence of certain chemical irritants within the blood or tissues; for example, alcohol, uric acid, etc. But the factors which provoke the greatest activity on the part of intravascular and extravascular cells, and which determine the richness in albumin of fluid exudates, or their prompt coagulation as soon as blood serum has escaped from the vessels, and which particularly determine the furious rush of phagocytes and that kind of intercellular conflict which leads many of the contestants on both sides to death, are living organisms which are introduced from without, whose presence at the point of inflammation is abnormal and injurious, which are offending substances in every respect, while the whole phenomenon of inflammation is an expression of an effort to rid the system thereof. Taking this view of the subject, there is an important distinction between hyperemia and its consequences, which is absolutely a non-infectious condition, and inflammation with its consequences, which is always an infection and is always followed by more or less death of cells, the same being often extruded in a semifluid mass known as pus.

1. The Virulence of the Infecting Organisms and the Amount Introduced.

—There is the widest difference between various forms of microörganisms in the matter of virulence; and it is true that there are very great differences between the same species under different circumstances, these differences depending on conditions as yet absolutely unknown. With certain organisms it is enough to infect an animal with one alone in order to bring about a fatal result, this meaning that the organism itself is extremely virulent and the animal extremely susceptible.

In a guinea-pig, for instance, a single virulent anthrax bacillus will produce death, whereas in a more resistant animal many are required, and in still others there is absolute immunity against the disease. Man is much more susceptible to the pyogenic organisms than most of the lower animals, which is one reason why wrong deductions have been drawn from many experiments, and why veterinary surgeons, who are so careless of all antiseptic precautions, as a rule have good results in work which, done after the same fashion on the human being, would be inevitably fatal. It is one reason also why one may draw false inferences from experimental work, for instance, upon dogs, which survive many an operation which can scarcely be successfully repeated upon a human being. The influences which affect the vitality and virulence of microörganisms are most numerous and widespread. Temperature, sunlight, moisture or dryness, association with other bacteria, are but a few of the conditions known to be more or less operative. Inoculation with a small number of certain bacteria may be harmless; up to a certain number it may produce only a local disturbance, like abscess, while a still larger dosage may produce fatal results. This is not the case with all, however, but only with some organisms. Bacteria which have been repeatedly passed through the animal body become more virulent than those cultivated for many generations in test-tubes in the laboratory. This variable virulence is especially characteristic of the colon bacillus, the anthrax bacillus, and the micrococcus of erysipelas. Nor does it always follow that the most virulent organism is necessarily cultivated from the most toxic or serous manifestation of its activity.

2. Association.

—Bacteria are seldom found in pure cultures under natural conditions. By mutual association remarkable changes are produced, sometimes in the direction of enhanced virulence, sometimes in the direction of attenuation of effect. Certain organisms, extremely dangerous alone, lose their power when combined with others, while still others have their virulence increased to a rapidly fatal degree. In fact, these effects are so strange and so contradictory that no law governing them has yet been formulated, it being necessary to establish each case by experimental investigation. The virulence of the anthrax bacillus under ordinary circumstances is well known, as is also that of the streptococcus of erysipelas in man. Yet, when these two organisms are introduced simultaneously, the mixture is apparently wellnigh harmless. On the other hand, the simultaneous inoculation of certain other species greatly increases the danger from either alone. The diplococcus pneumoniæ when combined with the anthrax bacillus seems to have a greatly augmented power.

3. Hereditary Influences.

—The fact that immunity against certain infections and susceptibility to other conditions are transmitted from parent to offspring is one which admits of no dispute. The explanation, however, is almost as remote from us today as it ever was. But the recognition of the fact is of the greatest importance to all practising surgeons. That bacteria frequently enter through wounds and bruises is self-evident, but we all know that such wounds are more likely to suppurate in some than in others, and the causes of infection in some are, to a certain extent, connected with the hereditary habit of tissues. The same causes influence not merely liability to infection, but its severity and character. There are undoubtedly also local as well as general variations, and it is very certain that among these the results of bruising or contusion are by far the most prominent. There is also undoubted experimental evidence that under certain circumstances bacteria produce only local lesions, whereas under others they produce general and even fatal infection.

4. Local Predisposition.

—Local predisposition is a factor of almost equal importance. Once given a distinct infection, and hyperemia is sometimes a contributing cause of inflammation. Per contra, anemia of tissues seems to be also a favoring condition. In parts involved in chronic congestion the blood flows more slowly, while the vessels are dilated and apparently susceptibility is increased. Infection here produces a type of disease mentioned as hypostatic inflammation. Conspicuous exception as to the occasional value of an artificial passive hyperemia is seen, however, in the so-called congestion treatment (Bier’s) of tuberculous joints, where the more or less constant flooding of the tissues with venous blood seems to render them uninhabitable for living bacilli, which apparently die and disappear (by phagocytosis), thus permitting a slow return to the normal condition. General anemia, again, is a predisposing cause, while toxemias, including diabetes, etc., are still more so. The liability of diabetic patients to suppurative and even gangrenous infection is proverbial. The presence of foreign bodies has much to do also, and, infection once having occurred along with its introduction, the presence of a foreign body will nearly always excite suppuration; otherwise it will ordinarily remain inert. The withdrawal of trophic nerve influences also apparently permits infection, as is instanced by the ease with which bed-sores form in paralytic patients. Obstruction to the circulation or to escape of secretions more easily permits infection; for example, in the appendix, in the kidney, in the gall-bladder, the salivary glands, etc. Furthermore, one may formulate a quite comprehensive statement and say that all such lesions as solutions of continuity, hemorrhages, degenerations, vascular stasis produced by strangulation, etc., and all perforations, increase more or less the liability to infection.

5. Pre-existing Disease.

—Here are reckoned, first, previous and long existent toxemias, e. g., syphilis, diabetes, scurvy, etc. Other conditions, like lithemia, cholemia, acetonemia, and the various conditions represented by oxaluria, or in which acetone, peptone, and excess of uric acid are found in the urine, also come under this head. One need never be surprised to find suppuration occurring in those cases in spite of due observance of all ordinary precautions, since by their existence immunity is destroyed and vulnerability increased. (See chapter on Auto-infections.)

Recent toxemias also have important bearing in this same respect. For instance, after typhoid fever and other acute wasting diseases, including the exanthemas, surgical operations are sometimes followed by failure, and should always be postponed until complete recovery, except in cases of emergency. The condition to be hereafter described as enterosepsis, and which has previously been known under many different names, as fecal anemia, stercoremia, etc., is one which makes the performance of all operations dangerous, and which certainly predisposes to septic disturbances of all kinds. The postpuerperal state is also one in which operations are to be avoided if possible.

Certain anatomical changes peculiar to the various ages also belong in this category. Old age, with its accompanying arterial sclerosis, its cardiac debility, and other well-known tissue alterations, favors sluggishness of wound repair and leads not infrequently to sloughing or to bed-sores. Amyloid changes betoken impaired vitality. Children are much more liable to acute osteomyelitis than adults. Nursing infants are apparently exempt from many of the infectious diseases, but possess relatively small power of vital resistance to surgical operations. General anemia and impaired nutrition of the body predispose to most infections and to acute starvation.

6. Personal Habits and Environment.

—Diet has much to do with tissue resistance. Rats fed on bread are more susceptible to anthrax than those fed on meat. Hunger makes pigeons highly susceptible to the same disease, and artificial immunity induced in various animals is quickly destroyed by starvation. Prolonged thirst seems to have the same result. Excessive fatigue generally reduces immunity, as already mentioned. The various drugs which destroy red corpuscles impair immunity, and even by injection of water into the circulation the bactericidal power of the blood is reduced. White mice fed with phloridzin, which produces artificial diabetes, become highly susceptible to glanders, from which they are ordinarily exempt. In this connection may also be mentioned the various toxemias alluded to under the previous heading, which may proceed from the intestine, from the genito-urinary tract, and probably also from other sources. Climate has more or less to do, as also extremes of weather, with power to resist infection or to survive serious operations. Dark habitations, poorly ventilated, constitute surroundings which manifestly predispose to infection of all kinds. Rabbits inoculated with tuberculosis and confined within a dark cell, badly ventilated, become rapidly diseased, while others similarly inoculated, but allowed to roam at large, present but slight evidences of the affection. Certain occupations predispose to certain diseases. This is pre-eminently the case, for example, with workers in mother-of-pearl, who are exceedingly liable to a particular form of osteomyelitis; and with those who make phosphorus matches, who are prone to suffer from a peculiar necrosis of the lower jaw. Prolonged suppuration may produce such changes in the blood and tissues that vital processes of repair, cell resistance, and chemotaxis may be so far interfered with as to facilitate subsequent infection.

Finally, the influence of local injury to tissues, particularly of contusions which cause tissues to lose their vitality, is strenuously insisted upon by all, and is spoken of repeatedly in other places in this work. Many tissues will succumb to inoculation after bruising, ligature en masse, etc., which before such injury are not in the least disturbed.

7. Fetal Infection.

—It is only in a very limited class of cases that infection can be transmitted from mother to fetus, but there are instances of this kind in which the surgeon is deeply concerned. As Welch has stated, syphilis is the only infection capable of direct transmission through the ovum or spermatozoön; but intra-uterine infection may occur in many ways, and many diseases may be thus transmitted. The placenta is usually regarded as a perfect filter; nevertheless, it is occasionally passable to microörganisms. These may be caused by preëxisting lesions in the placenta or by the virulence and activity of bacteria. It is known that in animals the bacilli of chicken cholera (inoculated into the mammalia), of symptomatic anthrax, and the pyogenic cocci, frequently traverse this barrier. In mankind infection in utero has been observed in smallpox, measles, scarlatina, relapsing fever, syphilis, tuberculosis, croupous pneumonia, typhoid fever, anthrax, and surgical sepsis.

That the effects of bacterial invasion may be anticipated and guarded against most effectually it is necessary that the practitioner should be thoroughly familiar with the sources from which they come, and the localities in and about the body which they most commonly inhabit or where they are met with in largest numbers.

Skin and Mucous Membranes.

—Of all possible sources of infection, the skin itself is probably the most fertile. It is exposed to contamination by air and by everything which may come in contact with the body, and there is perhaps no organism met with in disease which may not be found upon its surface or within its recesses. In fact, these recesses, such as the crevices beneath the nails, the spaces between the toes, and the various pockets like the tonsils, the axillæ, etc., are those most commonly inhabited by microörganisms.

Bacteria may penetrate the skin by means of three different routes, namely, the sweat glands, the hair follicles, and the sebaceous glands, by means of their regular openings. The hairy appendages of the skin are even greater sources of danger than the skin itself, since a direct path of infection into the depths of the skin is afforded by their follicles. Experimentally it has been shown that when bacteria are rubbed into the skin where there are no follicles, there is freedom from infection, whereas the reverse is equally true, and it is clinically generally recognized that furuncles and carbuncles form almost exclusively in those parts provided with hair and sebaceous glands.

The mucous membranes are in constant contact with microörganisms and furnish conditions in many respects favorable for their rapid development. Nevertheless, the latter is interfered with and often inhibited by certain mechanical and chemical influences which afford protection. The conjunctiva is an extremely exposed membrane, which harbors, however, but a relatively small number of bacteria under ordinary circumstances. The tears before escaping from the conjunctival sac are sterile, and are probably saline enough to act as an antiseptic bath for the cornea. Moreover, by free escape of secretion through the nasal duct the conjunctival sac is kept constantly irrigated, to which is mainly due its ordinary healthy condition, as it is well known how commonly lesions follow obstruction to the lacrymal duct. The horrible results of Egyptian ophthalmia, i. e., the pyogenic form of conjunctivitis, are familiar to travellers in Egypt. Howe and others have shown that this disturbance is due to flies, which are carriers of infection, and are attracted toward the eyes of infants, while the superstitious notions of the parents restrain their children from instinctive protection of the eyes when thus irritated. There is probably no greater common carrier of pyogenic infection than the common house-fly, and nowhere is this agency more demonstrated than in the hot climates of the Orient.

PLATE III

FIG. 1

Artificial Dental Caries in Cross-section. Tubules Filled with Bacteria. (Miller.)

FIG. 2

Putrid Tooth Pulp. Infection of Dental Tissue. × 1000. (Miller.)

FIG. 3

Dental Caries. Disappearance of Dental Tissues as Result of Presence of Bacteria. (Miller.)

FIG. 4

Dental Caries. Tubule Filled with Cocci. (Miller.)

FIG. 5

Dental Caries. × 500. (Miller.)

FIG. 6

Dental Caries. Tubules Plugged with Cocci. × 500. (Miller.)

 

Upper Respiratory Tract.

—The oral cavity and pharynx are seldom free from bacteria. Miller has studied over one hundred species that he has found under various circumstances in the human mouth. Some of these are pathogenic; others are apparently absolutely innocent. Many of the forms which grow in saliva will not grow in ordinary media. (See Plate III, illustrating infection of the teeth.) Miller has also shown that many forms of dental caries are but expressions of bacterial invasion even of those apparently most solid structures, the teeth; and of late we have been taught more fully that such invasion may extend far beyond the confines of the teeth alone, and may spread to various, even to distant parts, and produce possibly fatal mischief. Abscesses in the brain and extensive septic infections have been traced to invasion along the line of the dental tubules. One of the most virulent of all the common inhabitants of the mouth is the pneumococcus of Fränkel, known also as the micrococcus lanceolatus of Stebernrg. In virulence it is a variable organism, but it is present in a virulent state in only 12 or 15 per cent. of cases of infection due to it. This is the organism which is the cause of lobar pneumonia, and frequently of bronchopneumonia, as well as of numerous phlegmons and other inflammations of the throat, and which, getting into the general circulation through the tonsils or other possible ports of entry about the mouth, causes serious septic and inflammatory disturbances in widely distant regions. Aside from dental caries, a widely opened port of entry is often afforded by those ulcerations around the margins of the gums which are produced by accumulations of tartar. Disease in the antrum of Highmore, for instance, and many other local destructions, are frequently caused in this way.

The next most common port of entry is the tonsils, faucial, lingual, and pharyngeal, which contain a variety of crypts which are often filled with secretions or retentions loaded with bacteria. One of the most common sources of an involvement of the cervical lymph nodes in tuberculous disease is an infection springing first from the tonsils or the teeth.

In spite of the fact that myriads of bacteria are swept into the nasal cavities with the air we breathe, few are seen in the nose. A peculiar capsule bacillus, closely allied to that described by Friedländer, has been found in a number of cases of ozena, while the pneumococcus of Fränkel is also often found there, and is known to produce abscesses of the brain. One specific organism—namely, that of rhinoscleroma—concerns the nose almost solely, its first ravages being met with in this location.

Alimentary Canal.

—Probably more microörganisms enter the alimentary canal than gain access in any other way, these coming both from food and drink as well as air. Once within its confines, few of them are capable of prolonged existence. Welch states that the meconium of newborn infants is sterile, but that within twenty-four hours it usually contains abundant bacteria. That bacterial infection through this passage-way is a fertile source of non-surgical lesions is well known. The possibility of surgical infections being produced in the same way is both more remote and less demonstrable. Naturally, anaërobic organisms find here more favorable conditions, and even extremely acid or extremely alkaline conditions do not serve to destroy all such life. Pyogenic cocci are often present and are frequently found in peritoneal exudates. In the intestines of herbivorous animals the tetanus bacilli and those of malignant edema are regularly found. The fungus of actinomycosis also finds its way into the bowel along with ingested food. Under ordinary conditions the bile in its natural reservoirs is free from bacteria, but the colon bacilli and pyogenic cocci often invade these precincts.

Genito-urinary Tract.

—Even the healthy urethra may contain bacteria. While these may wander upward to an indefinite extent, it is believed that the urine contained within the bladder in a condition of perfect health is free from bacteria, and that if such gain entrance they do not long remain. The same is true of the female bladder and urethra. The vagina contains organisms of many species, some of which do not grow on ordinary culture media, but are to be recognized by the microscope. While it is generally acknowledged that the vaginal secretion is, as a rule, possessed of bactericidal properties, there is as yet no satisfactory nor comprehensive explanation of this fact, its normal acidity not being sufficient to account for the fact.

The Milk in the Lacteal Ducts.

—In a condition of perfect health milk secreted from the ideal mammary gland is sterile, but may easily become contaminated upon its exit from the nipple. Conversely, under many favoring conditions organisms may travel into the lacteal ducts from the skin without, and thus contaminate the milk. In all probability the breast corresponds in behavior to other glands whose ducts open upon the surface, and, while such openings invite entrance of bacteria, their migrations do not extend far from the surface unless some of the other conditions already mentioned predispose to further infection or extension.

In summarizing the general topic of possible sources and paths of infection bacteria may enter and exert deleterious action:

• A. From within the system; and
• B. From without.

A. From within they may enter the tissues either through the inspired air, through food and drink, i. e., ingesta, or by means of more direct inoculation, e. g., by foreign bodies or by venereal contact. The danger through infection by inspired air is very small, and concerns probably a limited number of organisms, of which the tubercle bacillus is the most important. Foul air and air which emanates from sewers, cesspools, etc., while most unpleasant to breathe and deleterious in many other ways, do not necessarily contain any microörganisms which can be injurious. This fact, in opposition to general belief, is, nevertheless, proved by recent investigations. The ingesta furnish the most fertile source of contagion from within, but the diseases thereby produced fall for the most part into the domain of medicine rather than that of surgery.

B. Infection from without the body may come by actual contact with previous skin or mucous lesions, and particularly from noxious insects and certain parasites. Among surgeons the principal sources of contact infection to be enumerated and guarded against are:

• 1. Skin and hair;
• 2. Instruments;
• 3. Sponges or their substitutes;
• 4. Suture materials;
• 5. The hands of the surgeon and his assistants;
• 6. Drainage materials;
• 7. Dressing materials;
• 8. From miscellaneous sources, e. g., drops of perspiration, unclean irrigator nozzle, a contaminated nail-brush, the clothing of the operator, etc.

While insisting here upon the recognition of these sources of danger, the precautions to be taken against them are to be considered under another heading, to which the reader is referred.

One of the greatest sources of possible infection has of late been shown to be the presence of flies and other noxious insects, which act as carriers of infection. The Egyptian ophthalmia, which ruins the sight of 30 per cent. of the inhabitants of Egypt, has been shown by Howe and others to be due to infection by this mechanism; and a simple bacteriological experiment will suffice to show that the foot-tracks of a single fly across a wound furnish abundant opportunities for infection with organisms which are presumably virulent. In fact, the danger of carriage of infection by this means is greater than from almost all other sources, except the use of improper materials during surgical operations.

We speak of infections as primary, secondary, and mixed; and it is necessary, for purposes of accuracy at least, to make a reasonably clear distinction between them.

Primary Infection.

—By primary infection is meant infection with a single form of organism whose effects are prompt and speedy. Of this, erysipelas or syphilis may serve as illustrations. Most of the acute infections belong to the primary type.

Secondary Infection.

—Secondary infection means that after certain disturbances due to a primary infection, i. e., one of a given type, there occurs at some later period and from a distinct source another infection whose results may be more or less disastrous, and cause the case, at least for the time being, to assume a different aspect. We have an illustration of this in the case, for example, of primary tuberculosis with distinct infection of a number of lymph nodes, which, acting as filters, have caught in their tissue net a large number of tubercle bacilli that, lodging there, have produced the usual well-known results and have practically converted the infected nodes into granulomata. In these infected masses well-known changes, such as those which follow tuberculous infection—atrophy, caseation, calcification, etc.—may be occurring, when suddenly there comes infection of a pyogenic type from another source, and suppuration of the granuloma is the result. It is possible even to have a tertiary infection, of which the following may be a hypothetical instance: Primary infection with scarlatina or measles, by which vital susceptibility is in some instances lowered; as the result of this, secondary tuberculous infection in an individual previously resistant; and, third, a suppurative infection, as above described.

In contradistinction to these distinct events, separated by an appreciable, sometimes a considerable, length of time, we recognize a mixed infection, where two or more organisms are implanted at or about the same time. An illustration of this is seen in most cases of gonorrhea in which there is a synchronous attack made by the gonococcus, which is a specific microörganism, accompanied by staphylococci or streptococci, whose effect will complicate the case and make it assume a less particulate type of infection. Mixed infections may often occur in other ways, as syphilis and chancroid, chancroid and gonorrhea, etc. Most cases of mixed infection belong rather to surgery than to general medicine, and constitute an apparent violation of the rule to which physicians often point—that two distinct infectious diseases are seldom communicated or acquired at the same time. Nevertheless, the facts remain as above.

Terminal Infections.

—Terminal infections constitute an apparent paradox, perhaps oftener in medical than in surgical cases. Few people, as Osler has shown, die of the diseases from which they suffer. The final exitus is due to a more or less rapid infection which terminates life. These terminal infections are mainly due to a few well-known microbes, such as the streptococcus, staphylococcus aureus, pneumococcus, bacillus proteus, gonococcus, bacillus pyocyaneus, and the gas bacillus. In surgery such infections are, perhaps, most often seen in malignant lymphoma, diabetes, tuberculosis, syphilis, cancer, and in the so-called surgical kidney.

Bacteria which act as agents in the formation of pus are collectively known as pyogenic organisms. These are divided into two groups:

• A. The Obligate; and
• B. The Facultative.

Obligate pyogenic organisms are those whose activity is manifested in the direction of pus formation, which seem to produce it if they produce any unpleasant action whatever. On the other hand, the facultative organisms are those which are known occasionally to be active in this direction, and yet which are not always nor necessarily so. The members of group A are fairly well known and catalogued, and are not numerous. On the other hand, there is reason to believe that many organisms may have the occasional effect of producing pus, as it were, by accident or at least in a way not absolutely natural or peculiar to themselves, but still are frequently found when there is no pus present. A suitable list of the facultative organisms, therefore, can hardly be made, and will not be here attempted, the effort being only to mention the more common organisms which play this facultative role. It may be mentioned also that even the adjectives “obligate” and “facultative” are to be accepted with some mental reservation, since staphylococci, for instance, may be met with even in the absence of pus, although nearly all that we know about these organisms implies that pus would be the result of their presence. Furthermore, there are certain other organisms, not, strictly speaking, bacteria, which also have the power of producing either pus or pyoid material. These also will be mentioned in their place. Some of them belong not only to the vegetable, but also to the animal kingdom.

Obligate Pyogenic Organisms.

A. The Staphylococcus Pyogenes Aureus, Albus, Citreus, the Staphylococcus Epidermidis, etc.

—One of the characteristics of the staphylococci as a group is the powerful peptonizing action which they exert. Moreover, the chemical products of their life changes seem to be more potent in a local than a general way, leading to greater destruction of tissue in their immediate vicinity, with greater inhibition of the chemotactic powers of the leukocytes; that is, with more interference with phagocytosis, by which their progress would be interfered with. Their presence is recognized by a peculiar odor, as of sour paste, which should lead to a prompt change of dressings and disinfection of the wound (by irrigation, spraying with hydrogen dioxide, etc.).

B. Streptococcus Pyogenes and Streptococcus Erysipelatis.

—These two organisms do not differ in morphology nor characteristics, and, while for some time considered as distinct from each other, are now by most observers regarded as identical. The streptococci grow in chains of variable length, and individual cocci vary in size. They grow with and without oxygen, in all media, at ordinary temperatures, do not liquefy gelatin, stain readily, sometimes but not invariably coagulate milk, and vary in longevity. They differ extraordinarily in virulence according to their sources.

Fig. 4

Staphylococci in pus. × 1000. (Fränkel and Pfeiffer.)

Fig. 5

Streptococci in pus. × 1000. (Fränkel and Pfeiffer.)

 

There are many streptococci not included under the above head which are indistinguishable morphologically and in other respects, and yet which are partly or entirely free from pathogenic activity in man. A biological study reveals remarkable and unexplainable transformation between the different members of this species, a part of which may be referable to conditions pertaining to the organisms infected, but part of which apparently pertains to the bacteria. It is held by some that scarlatina is an invasion by certain organisms of this class; this, however, is not yet definitely established. When found in the stools of children with summer diarrheas they are regarded as indicating ulceration of the intestinal mucosa.

In contradistinction to the staphylococci, the streptococci manifest a predilection for lymph vessels and lymph spaces, along which they extend with great rapidity. They have less peptonizing power than the staphylococci (except in the absence of oxygen); hence streptococcus infection assumes usually the type of widespread infiltration rather than of circumscribed and distinct edema. One sees remarkable instances of this in cases of phlegmonous erysipelas. It is suggested also that the peculiar manner of growth of the streptococci, in long chains which may coil up and entangle blood corpuscles, has much to do with the formation of fat emboli and with pyemic disturbances.

Both these bacterial forms have the power of producing lactic fermentation in milk; and lactic-acid formation sometimes takes place with suppuration in the human tissues, causing acidity of discharge, sour odor, and watery pus. It appears also that these two pyogenic forms have less power of ptomain or toxin formation than many others, and, consequently, that the pyrexia attending suppuration or purulent infiltration is not always to be ascribed to this cause alone, for fever may in some measure be due to tissue metabolism attending their growth, the metabolic products being pyretic. This is in a measure substantiated by the fever attending trichinosis, where the question of ptomain poisoning has not yet been raised.

C. Micrococcus Lanceolatus.

—Micrococcus lanceolatus is also known as the diplococcus pneumoniæ or the pneumococcus of Fränkel and Weichselbaum, and as the micrococcus of sputum septicemia of Pasteur and of Sternberg. It is of interest to surgeons because it causes many localized inflammations and is a frequent factor in causing septicemia; it is often present in the mouths of healthy individuals. It may produce the various forms of exudates as the result of congestion set up by its presence; also otitis media, meningitis, osteomyelitis, and suppurative disturbance in the periosteum, the salivary glands, the thyroid, the kidney, the endocardium, etc.

Fig. 6

Diplococcus pneumoniæ of Fränkel. (Karg and Schmorl.)

D. The Micrococcus Tetragenus.

—Suppurations produced by these organisms are prolonged, mild in character, not painful, but accompanied by much brawny induration of tissues.

E. The Micrococcus GonorrhϾ.

—The micrococcus gonorrhœæ, or gonococcus, is found constantly in the pus of true gonorrhea, in many cases the pus being a pure culture of this organism. These cocci are generally seen in pairs (biscuit-shaped), while their inclusion within the leukocytes or their attachment in or to epithelial cells is characteristic. Unlike other pyogenic cocci, they do not stain by Gram’s method, being decolorized by iodine, by which fact they may be distinguished. They are cultivated with difficulty, and are known rather by their clinical effects than by their laboratory characteristics; are human parasites, other animals, so far as known, being practically immune. The gonococcus may also produce abscesses, and may be carried to distant parts of the body, where its effects are commonly noted as pyarthrosis, although endocarditis, pericarditis, pleurisy, etc., are known to be due to it, and fatal pyemia has been produced in consequence. In some way it is probably the explanation of the post gonorrheal arthritis, wrongly spoken of as gonorrheal rheumatism.

F. The Bacillus Coli Communis or Colon Bacillus.

—This is an inhabitant of the intestinal canal; varies extremely in virulence and somewhat in morphological appearances; coagulates milk; is often associated with other organisms; migrates easily both along the alimentary canal and from it into the surrounding tissues or channels. It is a disturbing element in the production of kidney and hepatic disease, also in the production of appendicitis and peritonitis. Ordinarily its pyogenic properties are not virulent; occasionally, however, it becomes extremely virulent.

G. The Bacillus Pyocyaneus.

—The bacillus pyocyaneus, a widely distributed organism, often observed in the skin and outside of the body; a motile, liquefying bacillus, growing at ordinary temperatures, seldom seen alone, but occasionally producing pus without association with other organisms; it stains the discharges and dressings a bluish-green and imparts sometimes an offensive odor. Suppuration caused by this bacillus is usually prolonged, but characterized by little constitutional disturbance.

Facultative Pyogenic Organisms

—i. e., those which have the power of provoking suppuration, but which have other and more distinct pathogenic activities as well.

A. Bacillus Typhi Abdominalis.

—This is found in many pus foci, developing during or after typhoid fever. It is occasionally met with alone, though most of these abscesses are really mixed infections. It is generally found in the bone or beneath the periosteum. Such abscesses are frequently seen in the ribs, and may not be noticed until months after convalescence from the fever. The pus contained within them is not always typical in appearance, but may be unduly thin or unduly thick.

B. Bacillus Proteus.

—Under this name are included three distinct forms, which were originally described by Hauser as distinct species, but which are now regarded as pleomorphic forms of the same organism. It is a motile bacillus, met with in decomposing animal and vegetable material, and occasionally found in the alimentary canal. It has been known to produce pus, especially in the peritoneal cavity and about the appendix. It may even cause general infection and peritonitis.

C. Bacillus Diphtheriæ.

—A non-motile bacillus, varying considerably in size and shape, changing the reaction in sweet bouillon from acid to alkaline; produces a dangerous infective inflammation of exposed surfaces, with tenacious exudate amounting to a distinct membrane. As a part of its life history it also produces a toxalbumin, which is one of the most powerful cell poisons known, the disintegration of the cell constituents due to its action being rapid and pronounced. This accounts for the heart failures which are often reported in connection with the disease.

D. Bacillus Tetani.

—More will be said about this organism when considering tetanus, and to that subject the reader is referred. The tetanus bacillus is occasionally found in pus which comes from the area through which the original infection was produced. But these bacilli do not travel to any distance in the human body, and are seldom found away from the area involved. Under most circumstances the pus is the product of a mixed infection.

E. Bacillus Œdematis Maligni.

—This organism will be more fully considered under a different heading. (See Malignant Edema.) It is a long, anaërobic bacillus, widely distributed in the soil and the feces of animals. It is believed that this, like the tetanus bacillus, may occasionally lead to formation of pus.

F. Bacillus Tuberculosis.

—This organism likewise will receive fuller description in an ensuing chapter. (See Tuberculosis.) The pus of old cold abscesses in which the more obligate pyogenic organisms have long since died usually contains this organism in mildly virulent form. On the other hand, fresh suppurations occurring in connection with tuberculous disease are mixed infections. There is reason to believe, however, that this organism is capable of producing pus even when none of these are present; for example, in that form of acute miliary tuberculosis which is occasionally met with as bone abscess it may be found.

G. Bacillus Anthracis.

—This is one of the most malignant and resistant organisms known, being in the highest degree poisonous for the smaller animals, man being less susceptible. One of its characteristic lesions in the human body is a form of pustule commonly known as malignant pustule, the pus in which is usually a pure culture of this organism. (See Anthrax.)

H. Bacillus Mallei.

—This is the organism which produces glanders in the lower animals and in man. That form of the disease known as farcy, in which the infected nodules rapidly break down, is likely to contain pus which will be more or less a pure culture of this organism.

I. Bacillus Lepræ.

—This is the microörganism which produces leprosy, closely resembling the tubercle bacillus. It is constantly and exclusively present in the lesions of leprosy, which are often of the suppurative type, the bacilli being enclosed within pus cells; it is also found in the fluid surrounding them. Although suppuration in these cases may be in a large measure due to secondary infection, it is positive that the leprous bacilli deserve to be grouped in this place.

J. The Bacillus Pneumoniæ of Friedlander.

—The bacillus pneumoniæ of Friedländer was at one time regarded as the cause of croupous pneumonia, which is now known to be due to the micrococcus lanceolatus. The Friedländer bacillus, however, is capable of producing bronchopneumonia, and is occasionally met with in empyema, suppurative meningitis, and inflammations about the nasopharyngeal cavity, of which it is known to be an occasional inhabitant.

K. The Bacillus of Rhinoscleroma.

—A distinctive organism has been described for this disease and given this name. It has such wide morphological differences, however, that it is possible that it is only the bacillus of Friedländer above mentioned. At all events, an organism of this general character is constantly found in this disease in the thickened tissues from the nose (Fig. 8).

L. The Bacillus of Bubonic Plague.

—This was recently discovered by Kitasato, and, in view of the recent ravages of the disease in the Orient, has assumed considerable importance. It grows upon most media, and is found in the blood, in buboes, and in all internal organs of patients suffering from this disease. The smaller animals are susceptible upon inoculation. Animals fed with inoculated foods die also, showing the possibility of infection through the intestine. When exposed to direct sunlight for a few hours the bacillus dies. The general symptoms of the disease are those of hemorrhagic septicemia and its consequences.

M. The Bacillus of Rauschbrand.

—This is seldom, if ever, seen in this country. It is known in England as “the black-leg” or “quarter-evil.” It is an anaërobic organism, frequently met with in cattle, which causes a peculiar emphysema of subcutaneous tissue, spreads deeply, and is followed by a copious exudate of dark serum with gas formation. The smaller animals are not ordinarily inoculable; but if to the culture material there is added 20 per cent. of lactic acid, their insusceptibility is overcome and they succumb to the disease. So, also, as in the case of the tetanus bacillus, by addition of the bacillus prodigiosus or of proteus vulgaris the disease may be produced in otherwise insusceptible animals.

N. The Bacillus Aerogenes Capsulatus.

—The bacillus aërogenes capsulatus seems capable sometimes of causing pyogenic and even fatal infection. Its presence is associated with gas formation. It grows as an anaërobe.

O. The Bacillus of Chancroid.

—The bacillus of chancroid identified by Ducrey, and briefly described in the chapter on that subject.

Fig. 7

Rhinoscleroma: infiltration of tissues about the nose. (Case reported by Dr. Wende, Buffalo.)

Fig. 8

Bacilli of rhinoscleroma. × 1000. (Fränkel and Pfeiffer.)

 

Busse was the first to call attention of clinicians and pathologists to the role played by yeasts in certain infections. Since the original observations of Busse in a case in which the organism produced a general infection, the lesions of which were a combination of tumor and abscess formation, various observers have noted the presence of pathogenic yeasts, usually in skin lesions. Gilchrist and Stokes were the first in this country to determine the nature of these organisms, and their observations have been followed by the detection of a large number of similar cases. In the skin lesions the organisms are found in minute abscesses; in the subcutaneous tissue and in the infections similar to those of Busse large abscesses surrounded by extensive masses of granulation tissue characterize the infection. The organisms can be detected in the pus by means of an examination of the fresh unstained fluid (Fig. 9).

Besides the micro-organisms everywhere grouped as bacteria, there are other minute organisms which have also the power of engendering pus. One of these is the ray fungus, known as the actinomycis, which causes the disease known as lumpy jaw or actinomycosis. Suppuration is always a concomitant of the advanced lesions of this disease, and, while it may be in many instances a mixed infection, it is not necessarily so. Moreover, the pus produced under these circumstances contains minute calcareous particles which are pathognomonic, by which a diagnosis can sometimes be made off-hand.

Besides these fungi, others, belonging rather to the class of vegetable molds, which are yet pathogenic for human beings, may be occasionally met with under these circumstances—e. g., the fungus of Madura foot, the leptothrix, and other molds from the mouth, while the different varieties of aspergillus may be found in pus about the ear or even in that from the brain.

The protozoa have the power of producing, if not absolute ideal pus, something so nearly resembling it that we may include them among the facultative pyogenic organisms. The best known of these protozoa are the amebæ, which are met with in the intestinal canal in some countries, occasionally in the United States, especially as the exciting causes of a peculiar type of dysentery often accompanied by abscess of the liver. In these abscesses the amebæ are found, and no other organisms. Another group of the protozoa, known to biologists as the coccidia, are also capable of causing pus formation, more particularly in some of the lower animals. Numerous other parasites, belonging higher in the animal kingdom, are undoubted exciters of pus formation, though it is not necessary to lengthen the list beyond those already mentioned.

Fig. 9

Blastomycetic pus (fresh). × 1000. (Gaylord.)

Protozoa have recently been established as the active agents in the production of smallpox and probably also of scarlatina. They have been seen so generally in and around cancer cells as to make it extremely probable that cancer is a protozoan infection. In syphilis also they are found as the spirochetæ, now regarded as its cause.

Protozoa are as ubiquitous as bacteria, but their recognition is as yet more difficult, as but little is known of them. The numerous stages through which they pass in completing their life cycles only complicate the subject, while the difficulties encountered in cultivating them are still to be overcome. As we become more familiar with them we shall more frequently find them to be pathogenic organisms.

Staphylococcus.—Dirty white, moderately thick, with sour-paste odor.

Streptococcus.—Thin, white, often with shreds of tissue.

Colon Bacillus.—Thick, brownish, with fetid odor, or thin, dirty white, with thicker masses.

Micrococcus Lanceolatus.—Thin, watery, greenish, often copious.

Bacillus Pyocyaneus.—Distinctly green or blue in tint.

Bacillus Tuberculosis.—Thick, curdy, white paste, or thin, greenish, with small, cheesy lumps or even with bone spicules.

Actinomycis.—Thick, brownish white, with small, firm, gritty or chalky nodules of yellow color.

Ameba Coli.—Thick, brownish red.

There is a practical side of great importance pertaining to the recognition of the nature of the infectious organism in many cases of suppuration and abscess. For instance, pus which is due to streptococcus invasion indicates a collection which should be freely evacuated and carefully drained. This is also true in essential respects of staphylococcus pus, particularly that due to the streptococcus aureus. Putrid pus from any source requires disinfection and free drainage, the former preferably perhaps by hydrogen dioxide. Pus which is due to the colon bacillus is not often extremely virulent, which accounts for so many cases of appendicitis recovering with or without operation. A collection of this pus needs little more than mere drainage and opportunity for escape. Pus from a recognizable tuberculous source may still contain living tubercle bacilli. This means either that the cavity whence it came should be completely destroyed and eradicated, or else that the margins of the incision or opening through which it has escaped should be so cauterized that infection of a fresh surface is impossible. The same is true of abscesses due to glanders bacilli and to certain cases of suppurating bubo following chancroid, where the whole course of events shows the virulent character of the organisms at fault.

Although it may be possible to produce in certain laboratory experiments metamorphosed material which very closely simulates pus, or, in fact, by injection of chemical irritants, to sometimes imitate the suppurative processes, nevertheless, the student should be brought face to face with the statement, to which for surgical purposes there is no practical exception, that suppuration, i. e., formation of pus, is due to the presence in the tissues of the specific irritants already catalogued and described, and of the peculiar peptonizing or other biochemical changes which bacteria exert upon living animal cells.

Coagulation Necrosis.

—Coagulation necrosis is the term applied to the characteristic changes occurring in the tissue cells when thus attacked, which may be summarized as a fading away of cell outlines, diminution in reaction to reagents, and a merging of cells and intercellular substance. Coagulation necrosis is not the only result of bacterial activity, but may be produced by other causes. Nevertheless, pyogenic bacteria do not exert their deleterious action upon the tissues without occasioning changes included under this term. In an area thus infected, as already described, leukocytes, i. e., phagocytes, are present in increased number for purposes already mentioned. As we approach the centre of activity phagocytes are more numerous than cells, and intercellular barriers completely break down. When bacteria are found in greatest number, there also occurs the greatest phagocytic activity, and there also will be found the evidence of suppuration, i. e., pus. As already indicated, the polynuclear leukocytes are most active in the process of defence. Where coagulation necrosis is most marked there has been the greatest activity of conflict with the greatest death of cells. Around these areas bacteria and cells are found in indiscriminate arrangement. Tissue vitality is impaired by intoxication of the cells by the excretory products of the bacteria, i. e., the so-called ptomains, toxins, etc., and their power of resistance is thus weakened. From the mechanical results of pressure tension around the centre of activity is increased, by which tension vitality is still more impaired and more rapid tissue death occurs. Thus there occurs migration or burrowing of pus; or, to state it more clearly, the tissues break down in front of the advancing destruction, and in the direction of least resistance. This is known as the pointing of pus, which brings it many times to the surface, and often in other and less desirable directions.

Abscess.

—An abscess is a circumscribed collection of pus. The term is used in contradistinction to purulent infiltration, in which the collection is not circumscribed, but is exceedingly diffuse and extends itself in various directions, the amount at any spot being almost inappreciable. Purulent infiltration is regarded as the more serious of the two conditions, as it is more difficult for pus to escape under these circumstances than when it can be evacuated through a single opening. The term phlegmon is one now generally used to indicate a suppurative process, usually of the general character of purulent infiltration rather than of abrupt abscess, but generally employed to include both conditions. The adjective phlegmonous is coupled with the names of other surgical infectious diseases to indicate that it is complicated by suppuration, e. g., phlegmonous erysipelas. Pus is a product of bacterial activity usually formed rapidly rather than otherwise, and abscess formation or phlegmonous activity of any kind is a question of but a few days. Empyema means a collection of pus in a preëxisting cavity.

The significance of this condition is well described in the story of inflammation and suppuration, to paraphrase Sutton, read zoölogically, as though it were the story of a battle: The leukocytes (phagocytes) are the defending army, the vessels its lines of communication, the leukocytes being, in effect, the standing army maintained by every composite organism. When this body is invaded by bacteria or other irritants, information of the invasion is telegraphed by means of the vasomotor nerves, and leukocytes are pushed to the front, reinforcements being rapidly furnished, so that the standing army of white corpuscles may be increased to thirty or forty times the normal standard. In this conflict cells die, and often are eaten by their companions. Frequently the slaughter is so great that the tissues become burdened by the dead bodies of the soldiers in the form of pus, the activity of the cells being proved by the fact that their protoplasm often contains bacilli in various stages of destruction. These dead cells, like the corpses of soldiers who fall in battle, later become hurtful to the organism which, during their lives, it was their duty to protect, for they are fertile sources of septicemia and pyemia. This illustration may seem romantic, but is warranted by the facts.

Around the margin of the site of an acute abscess a barrier is formed by condensation and cell infiltration of the surrounding tissues. This is not a distinct wall nor membrane, yet, nevertheless, serves as a sanitary cordon to confine the mimic conflict within reasonable bounds. This is the zone of real inflammation; within it there are tissue destruction and coagulation necrosis. By virtue of the peptonizing power of the pyogenic organisms the parts involved in this necrosis gradually liquefy the intercellular substance dissolving first. It is this which in the main forms the fluid portion of the pus. Various tissues show widely differing resistance to this softening process. In true glands the interlobular septa seem to break down first, and in this way suppuration extends around the acini or gland lobules, and thus pus may contain masses of easily recognizable size. These masses are ordinarily known as sloughs.

It is by virtue of the so-called lymphoid cells, which are those principally involved in producing the barrier or boundary of the acute abscess as above described, that granulation tissue is formed, which takes up the effort of repair as soon as pus is evacuated. This boundary has no sharp limit, but shades off into healthy surrounding tissues.

Under the term “abscess” is meant that which is described as acute abscess. Under certain circumstances, especially when they are produced by the facultative pyogenic organisms rather than the obligate, abscesses form more slowly, and may be spoken of as subacute. These are terms used in contradistinction to the so-called cold abscesses, which, although clinically bearing a certain resemblance to the acute, are in almost every pathological respect different from it. Cold abscesses will be considered under the head of Tuberculosis. It is possible to have an acute pyogenic infection of a cold abscess; in such case we have acute manifestations. Gravitation abscesses are those where pus forming in one part tends to migrate, usually in the direction in which gravity would take it, extending into portions deeper or lower. Perhaps the best illustration of this is the pointing of a psoas abscess below Poupart’s ligament. Metastatic abscesses are those which are formed as the result of embolic processes, each one being in miniature a repetition of a lesion which has occurred at some other part of the body. The underlying fact concerning metastatic abscesses is that the primary process has occurred in some other portion of the body, whence it has been distributed as above. These will be considered in the chapter treating of Pyemia.

The product of all acute suppurative lesions is pus. This is an opaque fluid of creamy consistence and whitish or grayish appearance, varying in density, met with in amounts from a minute drop to half a gallon or more. Under ordinary circumstances it is odorless, and its reaction, either acid or alkaline, is very faint. It is, like the blood, composed of a fluid and a solid portion. The solid portion consists of so-called pus corpuscles and other debris of tissue, which vary with the site of the disease and the parts involved. The source of the pus corpuscles has been cited and the statement made that they are in effect the bodies of phagocytes which have perished in the biochemical fight for existence of the parent organism. Cocci or bacilli are found in pus corpuscles and also in the surrounding fluid.

Pus should be without odor, but under certain circumstances it possesses an odor which will vary in character according to the source of the pus or the nature of its principal bacterial excitant. Pus from the upper end of the alimentary canal frequently has the sour smell of gastric contents; that from the neighborhood of the lower end, the fetid odor which is for the most part due to the action of the colon bacillus. Inasmuch as colon bacilli are found in widely distant parts of the body, they may also give an unpleasant odor to pus even from a brain abscess. When the pus has become contaminated with the ordinary saprophytic organisms, it may smell like any other decomposing material. The older writers called it ichorous pus, while sanious pus was supposed to be that more or less mixed with blood, undergoing ammoniacal decomposition or else strongly acid. Pus sometimes has a well-marked blue or bluish-green tint. This is due to the presence of the bacillus pyocyaneus, already described. An orange tint is sometimes given by the presence of hematoidin crystals, due to the original hemorrhagic character of the infected exudate. The former appearance indicates usually a slow course to the suppurative lesion, while the latter has been regarded by some as affording an unfavorable prognosis. Distinctly red pus, whose tint is due to the presence of a bacillus giving bright-red cultures on blood serum, has been noted in other instances. This can readily be distinguished from blood, because upon dressings it does not change color.

Pus may form superficially, when it is called subcutaneous suppuration, in which case there is a minimum of pain, because tension is not great and the distance to the surface is short. Collections which form beneath the fasciæ, especially the deeper fasciæ of the limbs and trunk, give rise to much more extensive disturbance, both locally and generally, and frequently do not point for many days; or, instead of pointing, burrow deeply and find their outlet at some undesirable point. These are known as subfascial collections. Subperiosteal abscesses give rise to still more pain, because of the unyielding character of their limiting structures, and the symptoms caused by them are acute and distressing.

An illustration of the pain which may follow deep suppuration may also be seen in the ordinary panaritium, or bone felon, where the path of infection is from without, but the destructive lesion is confined within absolutely unyielding tissues, at least at first. Along certain tissues infection spreads with rapidity. This is particularly true of the delicate areolar tissue seen between tendons and tendon sheaths, and the infectious process may follow this tissue wherever it shall lead, even along complex courses.

The question often arises, Can pus be resorbed? There is no question but that small amounts of pus are disposed of by phagocytic activity, and the disappearance of purulent infiltration, under the influence of favoring remedies, or even when let alone, is not infrequently noted. True pus resorption is a question of phagocytic possibilities, and can occur only in very limited degree, as a result upon which it is not safe to count, and which is capable of encouragement only up to a certain point.

One inevitable law seems to govern collections of pus, that when they advance or migrate in any direction it is in that of least resistance. This causes them to take peculiar and sometimes disastrous courses, but it is a law which is never violated. It leads to the bursting of abscesses into the brain, into the pleural cavity, into the peritoneal cavity, the bowel, and elsewhere; it leads to a condition where pus may travel along a path even a foot or more in length, rather than come to the surface, a distance of perhaps an inch, and affords one of the best reasons for early operative interference so that the disastrous effects of burrowing may be obviated. When the pus is limited to a drop or fraction thereof the abscess is called a furuncle, especially when in the skin. The average “boil” of the layman is a subcutaneous or subfascial abscess. When the infiltration is pronounced, and when there has been more or less extensive destruction of tissue, with perhaps formation of numerous outlets for the escape of pus and detritus, it is known as a carbuncle. (See Chapter XXVI.) In certain conditions small superficial furuncles or boils form, sometimes in great number and almost synchronously, or, as it were, in crops. This condition is known as general furunculosis.

Signs and Symptoms of Abscesses.

—The appearances by which pus may be suspected or detected are those of congestion and hyperemia, more or less abruptly circumscribed and markedly accentuated. Along with these there is more or less edema or edematous infiltration of the skin and overlying tissue, which permits of that peculiar appearance known as “pitting on pressure.” Often, too, there is a distinctly edematous swelling of the parts, especially around the margin, with brawny infiltration of the centre of the infected area. Numerous vesicles occasionally are noted upon the skin, which may be filled with reddish serum. When softening and pus formation occur, there is a condition which to the palpating fingers gives the characteristic sensation known as fluctuation. Fluctuation simply points out the presence of fluid beneath; but when in an area marked as thus described fluctuation is noted, it means the presence of pus. It is detected by manipulating in a direction parallel to and concentric with the axis of the limb or part. The pain is also in most instances significant; patients speak of it as having an intense and throbbing character. With these local signs occur symptoms indicating some degree of septic intoxication, i. e., pyrexia, chills, malaise, sweats, etc., which are corroborative indications, their intensity being a reasonably correct index of the severity and gravity of the local infection.

When a deep-seated abscess is suspected a careful blood count will often permit a diagnosis to be made. This is conspicuously true of cases of appendicitis. If leukocytosis is established there should be immediate operation. (See Chapter II.)

It is seldom that a superficial collection of pus can be mistaken for anything else. In small and superficial abscesses (boils, furuncles) as pus approaches the superficial layer (epidermis) of the skin it may be discovered through its thin covering. In deep lesions there is often a doubt, even on the part of the most experienced. The measure now usually resorted to for purposes of diagnosis and exact recognition is the exploring or aspirating needle. The old exploring needle was one of good size, having a groove along which, after introduction, pus might pass. Since the almost universal use of the hypodermic syringe, a small aspirating needle attached to the ordinary syringe is the measure commonly adopted. Such a needle may be introduced into the brain, into the liver, or into almost any and every soft tissue without danger, and if properly manipulated is almost sure to facilitate detection of pus. Exploration done with either of these means and for this purpose should always be conducted as an aseptic, even if a minor operation, in order that no extra infection may be added from without. The skin should be carefully washed, the needle sterilized, etc.

It is good surgery to resort to the knife either for the above purpose or in order that by a longer incision or by opening the cavity deep exploration may be made. Such explorations are of benefit even though a circumscribed collection of pus is not found, since by relief of tension and local abstraction of blood they act in a revulsive way and do much good. Acting upon the same principle the trephine or the bone chisel may be used for the purpose of opening the cranium and exploring for pus, or of opening into the medullary canal of the long bones and hunting there for that which is suspected.

Treatment.

—As soon as suppuration threatens speedy measures should be adopted, either for the purpose of bringing about resorption, or of favoring and hastening suppuration. In theory antiseptic applications are demanded; in practice they are sometimes of benefit. These may consist of mere soothing applications, as a lead and opium wash, or some other wet or dry astringent applied upon the surface; or they may consist of cold applications, which by their astringent action will limit the amount of exudate and prevent its further infection. Or advantage may be taken of the properties of moist heat, and the application of hot poultices or fomentations may encourage exudation, but particularly quicken superficial breaking down, and thus hasten the time when the phlegmon shall point, or come sufficiently close to the surface to show that its contents are pus and permit of evacuation. Such local applications, therefore, give relief from pain and hasten favorably the suppurative process. In cases of phlegmonous infiltration, the application of an ointment composed of resorcin 5, ichthyol 10, mercurial ointment 35, and lanolin 50 parts, or else the Credé silver ointment, is beneficial. Under the influence of these antiseptic and sorbefacient preparations, and of moist heat, many phlegmonous infiltrations assume a kindlier type, and may secure the actual resorption of pus.

Finally in almost every case pus must be evacuated. Here the universal rule may be applied, to which there are practically no exceptions, and which should be stamped on the mind of every student and young practitioner. It is—that pus left to itself will do more harm than will the knife of the surgeon if judiciously used for its evacuation. Action taken in accordance with this rule may be considered wise and timely. The operation of evacuation may at one time be a mere puncture, or possibly the aspirating needle alone will be enough; at other times it requires extensive and careful dissection and entails no little responsibility. This is particularly true in such deep-seated suppurations as those around the appendix and in the brain, while in the deep-seated bone lesions of this character the use of the bone chisel or the cutting forceps may be of use. But the rule holds good, no matter where the pus may be, and as long as good judgment is shown in the operative procedure nothing but good can come from recognition of this law. After the evacuation of pus the cavity should be cleansed and disinfected with hydrogen dioxide, perhaps even with caustic pyrozone, or, if these are not at hand, with other suitable antiseptic solutions.

Ordinary judgment should be exercised in evacuating every abscess, in order that opening be made at that point which in the common position of the body shall be most favorable to drainage by mere gravity alone. If circumstances compel opening when advantage cannot be taken of gravity, then one or more counteropenings should be made at points selected where drainage may be best effected, and where anatomical conditions do not make it injudicious to incise. Drainage should be favored by the introduction of a drainage tube or of other aids, such as gauze, strands of catgut, bundles of horse-hair, etc. Finally, a dressing should be applied which is both protective and absorbent, and in quantity sufficient to make compression of the walls of the abscess cavity—not sufficient to obstruct drainage, but enough to favor prompt adhesion of surfaces, which by speedy granulation shall ensure prompt healing.

Abscesses are found in proximity to large vessels or dangerous anatomical regions, when care must be exercised in opening them. Here careful dissection should be made under an anesthetic. This is true of abscesses in the neck and of those around the appendix, for example, where the general peritoneal cavity is shut off only by more or less delicate adhesions, and where the surgeon must literally feel his way with great precaution lest adhesions be torn and the previously protected cavity infected. At other times, especially in abdominal abscesses, it is necessary to pack sponges or absorbent gauze in and about the parts, so that any fluid which may escape may be absorbed by these dressings.

Accompanying Disturbances.

—The disturbance of function which accompanies all congestion and exudation, whether provoked by specific irritants or not, has been alluded to; but in cases of surgical infections, especially those which produce local suppuration, disturbance of function is much greater, while there are other disturbances which sometimes constitute the worst feature of these cases. The presence of pus is often indicated, especially when deeply seated, by one or more chills, and the occurrence of a chill is always marked to varying degree by pyrexia. It is conceded that the chill is an expression of a general septic disturbance; but it is necessary also not to forget that general septic disturbance is a frequent accompaniment of pus which is not evacuated as soon as formed. Moreover in certain cases suppuration and septic infection seem to occur synchronously, one being local, the other general.

Pus may also be suspected beneath a surface which is red, tender, swollen, edematous, and pitting on pressure. When fluctuation is added to these indications any element of doubt is thereby dissipated.

Other indications of the presence of pus are a well-marked leukocytosis, coupled with the iodine reaction indicating the existence of glycogen in the blood, the presence of indican in the urine, and the positive results frequently obtained by making cultures from the blood. When pyogenic bacteria are found in the blood the inference is very plain, and both treatment and prognosis are influenced. In such a case the introduction into the blood of an antiseptic such as Credé’s soluble metallic silver or of the antistreptococcus serum, is plainly indicated. The absence of bacteria from the blood, under these circumstances, does not disprove the presence of pus, but their presence gives a very serious character to the disease, and should lead to a most guarded prognosis. Invasion of the blood by staphylococci is nearly twice as serious as when streptococci gain entrance. Suppuration of the bones and of the tendon sheaths is liable to produce such invasion.

The other disturbance with which suppuration is so often complicated is septic infection. In fact it may be questioned whether pyrexia is not an expression of this condition. Any collection of pus, no matter how small, may show signs of septic infection; and, on the other hand, large collections may be formed without serious septic symptoms—in other words, suppuration and expressions of septic infection may be blended in almost every conceivable way. Sepsis as a distinct condition will be described in another chapter.

It is important to summarize what may become of pus when once it has formed and is not promptly evacuated. Pus when long present may be—

• A. Absorbed;
• B. Encapsulated; and
• C. Undergo various degenerations or chemical alterations.

A. The possibility of the absorption of pus, or, what is equivalent to it, its spontaneous disappearance, has been mentioned. While it does not usually take this course, it may thus disappear; as, for instance, in the anterior chamber of the eye in cases of hypopyon, or in various other localities, particularly when present only in small amounts. The absorption of pus is purely a matter, as far as we know, of phagocytic activity plus the power of the tissues to take up various fluids.

B. Encapsulation.—This occurs only when pus has been present for some time and when the virulence of the pyogenic organisms is not intense. We may get encapsulation of pus in any part of the body, the most typical illustration naturally being within the bones. Around the purulent focus, as around any other irritating foreign body, the capsule is formed by condensation of surrounding tissue. This is the way in which most cold abscesses with their limiting membranes are produced, those produced by tubercle bacilli having slight irritating properties. Inasmuch, then, as the biological activity in such a focus is small, there is time for such encapsulation; while by the membrane thus formed, or the sanitary cordon, already referred to, protection is afforded to the surrounding tissues. In such a collection fresh infection may incite acute disturbances again, and many abscesses which thus lie latent for a considerable length of time are fanned, as it were, into a conflagration, when a new and acute inflammation is produced.

C. Of the various metamorphoses and chemical changes that occur in that which was originally pus, the caseous and the calcific are the most common. These also are connected largely with the tuberculous process, although calcareous particles are found in the pus of actinomycosis. Under their respective heads these degenerations will be more particularly described.

Certain names have been given to collections of pus in different localities or under peculiar circumstances. A collection of pus in the anterior chamber of the eye is known as hypopyon; when in any preëxisting cavity, it is known as empyema of that cavity, the distinction between empyema and abscess being that “abscess” means a circumscribed collection where previously there was no cavity, while “empyema” implies a normal cavity, without respect to size or location, filled with this abnormal fluid. The term empyema, when not used in connection with some particular cavity, is understood to refer to a collection of pus in the pleural cavity. Other names also are used which are particulate and distinctive; in these the prefix pyo is used while the suffix indicates the part involved; thus we have pyothorax, pyopericardium, pyarthrosis, etc.

These are terms applied to more or less tubular channels abnormally connecting various parts of the body, or connecting some cavity with the surface of the body in a way anatomically quite abnormal. Or they may be regarded as tubular ulcers, or ulcerated tunnels, connecting as above. A more exact distinction between the two terms would imply that a sinus connects the surface with some deeper portion where a cavity is not normally present—i. e., with a focus of disease—whereas a fistula properly refers to a tubular passage connecting natural or preëxisting cavities in an abnormal manner. Thus we speak of buccal, rectal, vesicovaginal fistulas, etc., whereas a passage leading down to an old abscess or to a focus of disease in bone, for instance, is properly referred to as a sinus. It is possible for the margins of a fistula to become more or less cicatrized and cease to be ulcerous, whereas the entire track of a sinus is practically a continuous ulcer, only tubular in arrangement.

Causes.

A. Congenital.

—There are numerous points about the body where, as the result of arrest of development or failure to grow, fistulous passages which are comprised within the normal fetal arrangements, but which should close later, either before or at birth, fail to do so. Thus we have congenital fistulas of the neck, persistent urachus, persistent omphalomesenteric duct, etc. These are in no sense primarily connected with diseased conditions, but may become so secondarily.

B. Pre-existing Abscess with Unhealed Channel of Escape

—e. g., rectal, fecal, and other fistulas and sinuses which connect with tuberculous foci in any part of the body.

C. Previous Traumatic or other Destruction of Normal Tissues

—e. g., vesicovaginal fistulas due to tissue death from pressure, buccal fistulas from gangrene of the cheek, as in noma.

D. Foreign Bodies

—bullets, ligatures, etc.—which prove irritating or infectious enough to prevent absolute healing. More or less tortuous sinuses will generally be found leading down to the irritating material.

E. The Presence of Necrosed or Necrotic Material

—e. g., a sequestrum in bone, which is usually evidenced by the presence of one or more sinuses.

Treatment.

—If the determining cause is still acting, the treatment is to remove the cause. Consequently, when the sinus leads down to diseased bone or other dead or dying tissue, the complete evacuation of the cavity is necessary before the sinus may heal. If the cause is a foreign body, its removal should be at once insisted upon.

An excellent suggestion is to stain all fistulous tracks with methylene-blue; the blue trail after doing this may be followed, no matter how irregular its course (Fergusson). If the color is mixed with a little hydrogen dioxide, and this forced into a sinus mouth or a fistulous opening, it will carry the dye to all parts of the cavity. This may be used even in dealing with fecal fistulas or those extending deeply into the interior of the body or among the viscera.

Fistulas of congenital origin and those which connect two normal cavities of the human body are usually due to a cause which has ceased to act. Consequently we should endeavor solely to atone for the result. The direction and the course of a sinus may be learned by the use of a probe curved to suit and manipulated by a gentle hand, force never being required. Or sometimes, when the silver instrument fails to pass, a flexible bougie or catheter may be introduced. The character of the passage can be judged for the most part by the appearance of the discharges. With sinuses of recent origin leading down to recent suppurative foci it may be sufficient to enlarge the opening and to wash the cavity thoroughly. If a particle of gauze, tube, or sponge has been left therein, its removal is necessary to secure prompt healing. In cases of long standing antiseptic and stimulating substances should be injected or the interior should be cauterized with strong solutions of zinc chloride or silver nitrate, or with these melted upon the end of a probe. The chronic sinus, as well as the chronic rectal fistula, is usually an expression of local tuberculous disease. Accordingly these passages may be found lined with the same dense, fungating membrane which lines a cold abscess cavity—the membrane, protective in its purpose, to which I have given the name pyophylactic. Whenever such tissue and such membrane are met with they should both be extirpated thoroughly, since in this way only can absolute eradication of the tuberculous infection be relied upon. After such complete excision—which means usually laying open the entire sinus—the parts may be brought together with sutures (this, at least, is usually possible about the rectum) to secure primary union; otherwise, the whole sinus, as well as the cavity to which it has led, must heal by the granulating process, both being kept packed with gauze or some other desirable foreign body acting as an irritant, thereby provoking more rapid formation of granulation tissue. When it is necessary thus to pack a cavity, or when it is desired to keep its upper exit open lest it heal before the lower part, ordinary white beeswax, as suggested by Gunn, makes a serviceable material. This can be molded in hot water to fit the cavity; can be tunnelled or bored for drainage; can be diminished in size as the cavity heals, and is absolutely non-absorbent.

Finally there are numerous plastic methods which have been resorted to in various parts of the body, most of which are made to comprise, first, the absolute eradication of the diseased tract, and, later, the closure of the wound thus made by transplantation or sliding of flaps, or any other plastic expedient which may be considered best. These, as well as the special treatment made necessary for particular forms of sinus and fistula, will be dealt with under their proper headings.

CHAPTER IV. ULCER AND ULCERATION. — ULCERS. — PROCESSES OF REPAIR.

The term ulcer pertains to surfaces, and should be defined as a surface which is or ought to be granulating, i. e., healing.

While an ulcer may be the result of ulceration, it is not necessarily so, the term ulceration being one of very loose significance and applied to many different processes. The idea underlying ulceration is infection, and, when limited to its proper significance, the term should never be used for a process in which infection and consequent breaking down of tissue do not virtually comprise the whole process. Therefore, it is to be distinguished from certain disappearances of tissue alluded to under the head of Atrophy or Interstitial Absorption. It is not correct to say that the sternum ulcerates away, making room for a growing aortic aneurysm, the question of infection here not being raised. These distinctions should be accurately maintained and constantly borne in mind.

The causes of ulcers may be—

• A. Traumatic;
• B. Local; or,
• C. Constitutional.

A. Traumatic.

—This includes all surfaces which are granulating and healing more or less rapidly, or are displaying a disposition toward healing, and which may have been produced by wounds, burns, frostbites, etc. These include also ulcers due to pressure, as from splints, bandages, orthopedic apparatus, or from external friction. Ulcers which form around foreign bodies may also be included under this head, their essential cause being traumatic. It should include also destruction of the surface by various chemical agencies, such as strong caustics, and the consequences of intense heat or cold, including burns and frostbites.

B. Local.

—1. Among local causes may be mentioned local infections, with tissue death in consequence, such as occur in tuberculous, cancerous, leprous, syphilitic, and other specific manifestations where surfaces are involved.

2. Tumors, either benign or malignant, whose blood supply is cut off and whose surface is thereby predisposed to infection.

3. Perverted surface nutrition, for example, in connection with varicose veins of the extremities, where, aside from any perverted trophoneurotic influence, there is stagnation of blood, saturation of tissues with serum, and final leakage of the same, even to the surface. Varicose veins of the leg which lie near or underlie ulcerating surfaces become thrombosed and obliterated, so that such ulcers rarely bleed. On the other hand, a passive hyperemia here leads to edema, perversion of nutrition, failure to repair trifling surface injury, and a surface is left which of itself rarely, if ever, heals.

4. So-called pressure sores or bed-sores, which in some cases may be regarded as having a traumatic origin, but which, nevertheless, would not occur from purely traumatic influences without predisposing tissue changes. The bed-sore is probably the best illustration of this. Simple ulcer is known as bed-sore, while a sloughing ulcer of this kind is frequently alluded to as decubitus. Such ulcers are usually found over those regions of the body made most prominent by bony projections, upon which undue pressure is made when debilitated patients have lain for a long time in bed.

5. Ulcer is the frequent result of numerous skin diseases, into whose etiology as yet bacteria have not been introduced—e. g., pemphigus, eczema, etc.

6. Ulcer is the occasional result of embolic or other disturbance of the principal artery of the part, by which nutrition is cut off and tissue death results.

7. Bites of insects or other parasites or of noxious animals frequently lead to ulceration.

8. Certain more specific forms of ulcer are described by some writers, apparently with more or less reason, among them being chancroid, perforating ulcer of the foot, etc. (Chancroid is described in Chapter X.) Trophic ulcers of the fingers or hand are also seen, particularly after injury to or division of nerve trunks in the arm or forearm. Perforating ulcer of the foot is a circumscribed circular ulcer with thickened edges, often nearly concealed by overhanging skin. It may be found in any part of the sole of the foot, but is most common near the first joint of the great toe. The borders of the ulcer are usually anesthetic. It is frequently seen in diabetics. By some it is associated with trophic nerve disturbance; by others it is regarded as having a specific etiology of its own. The probability, however, is that it is simply a subvariety of pressure sore.

9. Since the introduction of the Röntgen or x-rays into surgical therapeutics a new local cause of painful and intractable ulcers should be enumerated. A too prolonged or injudicious exposure of a part to this peculiar influence induces first a dermatitis, which is not always immediate, but may be tardy in appearance, and which may be followed by desquamation or exfoliation that may proceed to absolute surface destruction and sloughing. These lesions are popularly spoken of as x-ray burns. The superficial ulcers thus produced may be extensive and are nearly always excessively sensitive and painful. The very structure of the surface vessels is affected and they undergo a species of sclerosis. A strong preparation of radium has been known to produce a similar effect.

C. Constitutional.

—1. Ulcers are frequently met with in certain constitutional conditions which are characterized by tendency to local manifestation at points of least resistance. Among these may be mentioned scurvy.

2. There are ulcers of apparently distinctive trophoneurotic origin, of which that mentioned above as B, 8—perforating ulcer of the foot—may possibly be one. These accompany certain nervous disorders of central origin, prominent among which are locomotor ataxia and tabetic disease of all forms.

3. Ulcers are produced sometimes as the result of specific or selective action of certain drugs, among them mercury and phosphorus being the most prominent. These manifestations are usually perceived in the mouth, and may be regarded as infections at points of least resistance. Nevertheless, they are commonly associated with the tendency of these drugs.

4. There are many constitutional conditions in which vitality is so lowered that a special liability to ulcer—i. e., infection and production of ulcer at many points—is noted. It is well, however, to mention that the common diseases in which this tendency is most often noted are typhoid, diphtheria, diabetes, and syphilis.

With this summary of the common causes of ulcer it is again stated that ulcers may be due to direct consequence of traumatic loss of substance or to the process of ulceration—i. e., as a consequence of previous infection, or as permitted by trophoneurotic disturbance and ischemia. Ulceration is a process of molecular death, in which cells die successively and more slowly, as distinguished from gangrene, in which there is simultaneous death of large aggregations of cells, by which a slough or its equivalent is produced.

Ulcers are referred to as healthy when the process of granulation is proceeding with average rapidity; indolent, when the reverse prevails; sloughing, when there is actual visible tissue death in connection with the ulcerative process; phagedenic, when the gangrenous tendency is well marked and the process exceedingly rapid; irritable or erethistic, when the surface is exquisitely sensitive; hemorrhagic, when bleeding easily; fungous or fungoid, when the granulations have risen above the surface and are increasing at too rapid a rate. There is a peculiar form of ulcer, seen mostly upon the face, to which the name rodent ulcer (also lupus exedens) has been given. This is now known to be a slowly growing form of epithelioma, and is described in Chapter XXV.

The best examples of the indolent ulcer are seen in connection with varicose veins of the extremities; of the phagedenic ulcer, in certain cases of chancroid; of the irritable ulcer, in ulceration of the cornea, when the pain and photophobia are intense; or in fissured ulcer of the anus, where the pain and sphincter spasm are sometimes agonizing.

Ulcers are described according to their shape as regular or irregular; as fissured, when they extend more or less deeply and abruptly into the surface involved; as fistulous when they have a tubular arrangement; as rodent, when they spare nothing in their course.

The borders of ulcers are described as healthy, indurated, tumid, edematous, undermined, livid, inflamed, etc., these adjectives explaining themselves.

The surfaces of ulcers are described as healthy when they have normal color and appearance, inflamed, excavated, covered with sloughs, callous, etc. The callous ulcer is one which exhibits little change from month to month; its surface is dirty, and its secretion thin and mucopurulent. It is usually sunk considerably below the surrounding level, while its border is firm and nodular. The best examples of this form are those accompanying varicose veins.

In size or area ulcers may vary from the slightest local destruction of tissue to an area covering an entire limb or a large part of the trunk. In depth they vary within lesser limits; while an external ulcer may connect with some deep lesion by means of a tubular passage or sinus. It thus appears that the term ulcer may be applied to the result of a natural effort to repair loss of substance without introducing the element of disease, or that it may be the consequence of local infection with local tissue disaster.

The character of the material discharged from an ulcer will vary according to the category in which it belongs. The healthy, healing, or granulating surface, often spoken of as ulcer, discharges a material in gross appearance much resembling pus from an acute abscess; in consistency, color, and other appearances it is the same. Nevertheless, its origin is essentially distinct. This material represents simply the waste of reparative material, sent up to the surface for the purpose of hurrying the process. Its fluid, like that of pus, comes from the serum of the blood; its corpuscular elements, like those of pus, are leukocytes or wandering tissue cells, which have been furnished in great numbers—in fact, in excess. As it comes to the surface—or as, rather, it is rejected from the surface, being superfluous in amount—it is likely to become contaminated with bacteria by contact infection, and consequently may be seen under the microscope to contain various microörganisms. This contamination, however, has been final, accidental, and irrelevant. This material is not pus; has no infectious properties, except those which may accidentally be conveyed to it; represents no warfare of cells, only excess of supply or overdemand; and should be spoken of as pyoid or puruloid material, and never confused with pus. In amount it will vary according to the activity of the reparative endeavor, and somewhat according to the amount of irritation of the surface by dressings which may be applied. If a granulating surface is absolutely protected from possibility of contact infection, it will never contain microörganisms; while this pyoid, if allowed to remain too long, especially when infection is permitted, may decompose and become irritating, and is a material to be gently dislodged by a spray or an irrigating stream with each dressing, which dressing should be made once in twenty-four to sixty hours.

An ulcer having been defined as a surface which is or ought to be granulating, it becomes necessary to define the granulation process and to show how healing is thereby achieved. Granulation tissue is a name applied to a new and temporary tissue of embryonic type, which acts as a scaffolding or temporary structure, permitting the construction of more permanent tissue. It is produced entirely by the activity of cells, which are the mononuclear and polynuclear leukocytes and the wandering cells already mentioned. They are frequently known as embryonal cells when performing this function; sometimes as formative cells. They have a distinct nucleus, which stains readily, and, having this resemblance to epithelial cells, they are often referred to as epithelioid cells—sometimes as fibroblasts, because they may later assume the dignity of connective-tissue cells. They assume a multitude of shapes. Between these cells as they are drawn toward the point at which they are most needed, perhaps by chemotactic activity, there is an intercellular substance which later becomes fibrillated. As these fibers develop the remaining cells become entangled between them, and in this way a new connective tissue is formed of cells of originally mesoblastic origin. Of such tissue the solid part of granulation tissue is built. This tissue is essentially different from the epithelium which it is expected will subsequently cover it. If a normal granulating surface is scanned with a magnifying glass of small magnifying power, it will be seen to consist of numerous minute projections, each of which is known as a granulation, consisting of the tissue above described, formed as a minute eminence around a budding capillary bloodvessel, from which a projection has arisen upon the exposed surface. This capillary bud is the result of karyokinetic activity on the part of the endothelium—namely, the hypoblastic cells of which it is essentially composed. In each of these cells, under certain circumstances, the karyokinetic threads already mentioned develop and become loosely coiled, while the chromatin in the nucleus increases in amount and the nucleolus disappears. The chromatin threads become thicker, arrange themselves equatorially around the poles of the nucleus, and gradually turn so as to point toward it, while a new membrane forms around each separate coil, and two nuclei are thus made out of one. While this is taking place within the nucleus the cell protoplasm undergoes active rotary motion, is finally segmented, and by the time the nucleus is divided is nearly ready for complete division of the cell. While nuclear division is usually bipolar, it may be multipolar; if a rearrangement of the protoplasm is delayed, the result becomes a multinuclear cell, known as a giant cell.

The consequence of this endothelial activity is new cell formation and the construction of a projection from the capillary which soon attains the dignity of its parent vessel, and, as connective-tissue cells form around it, soon becomes a granulation by itself, each granulation being marked by a capillary loop of its own. Healing by granulation or the granulation process, no matter how set up or caused, is essentially the formation of hundreds or thousands of these tiny structures, a new one being formed on top of those which precede it, while those first formed and deeper down undergo condensation and metamorphosis of tissues, by which they are converted into something higher in the tissue scale. Under ideal conditions true granulation building proceeds pari passu with epithelial reproduction around the margin of the granulating surface, so that by the time granulation tissue has completely filled the defect, no matter how caused, epithelial covering has been completely constructed and the healing process thus completed. These two processes, however, do not necessarily keep pace with each other. Should surface repair take place relatively early, we may have a depressed scar; while, on the other hand, should it not proceed rapidly enough, or, to state it in another way, should the granulating process be too rapid, we have such excess of granulations as shall rise considerably above the surrounding level, and may, under certain circumstances, become so exuberant that nutritive material cannot be formed rapidly enough, and those granulations farthest away from the centre of supply may die. Such exuberant granulation is often spoken of as fungoid, and constitutes that great bugbear in the eyes of the laity which is termed by them proud flesh. It has no further significance than that the supply has exceeded the demand and that the granulating process has been overdone. Such luxuriant granulations may be cut away with scissors or knife, may be burned away with caustic agents or the actual cautery, or may be disposed of in any other manner without harm and only with benefit; in fact, it is often necessary to suppress this exuberant tendency by caustics and pressure, in order that the desired epithelial covering may be properly formed.

Epithelium, being an epiblastic structure and capable of no other origin save from its kind, can only be supplied from those regions where it has preëxisted. Consequently, ulcers involving the external surface of the body demand a lively epithelial reproduction in order that they may have a normal covering. Epithelial activity sometimes becomes retarded, and is much slower toward the termination of the healing process than at the beginning. The epithelial covering of a healing ulcer is always marked by a delicate whitish or pinkish film, which proceeds from the periphery as well as from any little island of original epithelial structure left. It is well known that after a certain amount of this repair the process sometimes comes to a complete halt, and the various expedients for stimulating and promoting it, as sponge grafting and the different methods of skin grafting, have been devised solely to atone for such sluggishness or inability.

Ulcers of small size, which are more or less exposed to the air in healthy individuals, while also exposed to possibility of infection, nevertheless seem to escape it, owing to the defensive power of the blood serum and the active cells. Such discharge as naturally comes from them, when not excessive, undergoes evaporation until a point is reached where a dry crust or scab is formed. Under this scab granulation proceeds to a point where the pressure of the scab itself, presumably on the level of the surrounding parts, checks its activity, while at the same time epithelial reproduction goes on until it has been completed. Then the scab, being no longer of use, drops off or is detached by slight friction.

Such is granulation tissue: at first a mere trelliswork of temporary and delicate cell structure, traced in a certain amount of intercellular, homogeneous substance, into which the budding vessels project, the whole mounting, nearer and nearer to the surface, day by day, with variable rapidity, diminishing in this regard as the days go by, so that frequently the granulation process comes to an apparent halt before enough new tissue has been formed. While the superficial granulations preserve the characteristics above noted, those deeper down undergo firmer and more complete organization, and the delicate embryonic structures show the same tendency which they do in the growing embryo, by virtue of what Virchow has called metaplasia, to become converted into something higher and more dignified in the tissue scale. These cells do not specialize themselves to the extent of permitting complete repair of organs of special sense. Thus, while a wound in the cornea or retina may be completely healed, it heals by cicatricial tissue, and not by repair of the special structures involved. On the other hand, tissues of more common connective type—fibrous, bone, cartilage, etc.—are capable of regeneration; and it seems to be a part of the privilege of these new granulations to merge themselves into that kind of tissue necessary for filling the gap. Nevertheless the most common result of granulation is its metablastic conversion into fibrous tissue, which has the special characteristic of contractility without elasticity. As a result the scars contract, in consequence of which disfiguring results are sometimes the almost inevitable consequence of healing of extensive losses of substance. In certain instances it is possible by constant effort to overcome the unpleasant effect of this cicatricial contraction. For example, after extensive burn of the anterior part of the arm, the forearm will be gradually and permanently flexed upon the arm by virtue of contraction of the scar in front of the elbow unless some forcible means is practised for maintaining extension of the limb for at least a part of the time. So with many other injuries and the various mechanical or other expedients required to prevent the untoward result. Nowhere are the after-effects more disfiguring or serious than about the face, where the eyelids are drawn out of shape, the contour of the mouth altered, and where, sometimes, there are other extensive manifestations (Figs. 10 and 11).

Fig. 10

Cicatricial deformity following burn. (Original.)

Fig. 11

Cicatricial deformity following burn: side view of same case.

 

Fig. 12

Epitheliomatous degeneration of chronic ulcer, necessitating amputation. (Original.)

As a result of healing of the granulating surface there is what is known as a cicatrix or scar. This is composed of fibrous tissue, probably more or less distorted by virtue of its contractility, and of epithelial covering furnished from the margin of the original ulcer, constituting a thin, glistening membrane, applied closely to the scar tissue beneath, without intervening fat or tissue which permits of the play of the one upon the other. When this epithelial surface is abraded it is repaired with difficulty, and a raw or ulcerating scar is difficult to heal. Manifestation of perverted epithelial outgrowth is frequently provoked at these points by the action of continuous irritation. In consequence there is what is generally recognized as the transformation of a chronic ulcer, or the site of one, into an epithelioma, or possibly, by similar irritation of the connective-tissue elements, into a sarcoma. This is the so-called cancerous degeneration of previous ulcers, and is noted occasionally. The lesion is one which often requires disfiguring, or even mutilating operations in order to get rid of the malignant disease (Fig. 12.) All the scars thus resulting are liable to undergo a fibrous and degenerative change to which is given the name cicatricial keloid. It is marked by increase in size and density, by reddening which denotes increased vascularity, and extension into surrounding previously healthy tissue. By these changes a given scar is made much more prominent and disfiguring. It cannot be prevented by any ordinary treatment, and is often the bête noir of surgeons. (See also under Fibroma, and chapter on Diseases of the Skin.)

The surface of a superficial scar while thus covered with epithelium shows a complete lack of all the other skin elements. No hair grows upon such a surface, because the original hair follicles are destroyed; neither is it moistened by perspiration nor anointed by sebaceous material, because the secretory glands have also disappeared. It is a surface which often needs more or less protection, especially when in exposed situations.

Treatment.

—Here, as in all other instances, the first effort of the surgeon should be to remove the cause. This may be done by local, or may require constitutional measures. If a definite local cause can be established, its removal may be a slight or may entail a more or less serious surgical operation. Aside from this disposal of the exciting agent, treatment should be divided into the general and the local. General treatment is scarcely called for when dealing with healthy ulcers; but in all those instances where the constitutional condition of the patient is below par, or where there is a general poisoning or infection underlying the ulcer itself, prompt and energetic constitutional treatment should be at once instituted. In scurvy, for instance, the diet and hygienic surroundings of the patient should be rectified immediately. In syphilis no lasting nor deep impression can be made on local manifestations without general constitutional treatment. In tuberculosis and the other surgical infections much will be accomplished by internal medication, by proper hygiene, as well as by local applications or operation. The importance of these general measures is likely to be underestimated, and many fail to realize the advantage of combining suitable internal and external therapeutic measures.

Local Treatment.

—First of all may be mentioned the insistence upon repose which induces physiological rest. The ulcer may then show a tendency to heal. This may necessitate wearing a splint or restraining apparatus, or confinement in bed, depending upon the location of the ulcer. Physiological rest will be enforced sometimes by stretching a sphincter in order to temporarily paralyze it in cases of irritable rectal ulcer, where the principal pain is produced by the reflex spasm of its fibers. Again, the eye with irritable ulcer of the cornea is sometimes kept so tightly closed by the same kind of spasm there that it may be necessary to divide the lids, or the orbicularis muscle at the angle of the lids, in order to make access to the part. This is carrying out the principle of physiological rest, because it permits proper exposure and treatment.

The healthy and healing ulcer needs no treatment except protection. Epithelial covering will probably keep pace with filling of the depression by granulations, and all that is necessary to do is to prevent external irritation. Should there be excess of discharge, the simplest absorbent dressing, with enough antiseptic material to prevent putrefaction by contamination with the bacteria of the surrounding air, should be employed. The ulcer which is becoming tardy in its repair may be stimulated by silver nitrate, zinc chloride, or other caustic applications, which act as a spur to the sluggish granulations, destroying those with which it comes in contact, but stimulating those below to do their duty more promptly.

The conventional applications to ulcers fall usually under two categories—the watery solutions and the unguents.

Fig. 13

Cicatricial deformity following specific ulcer. (Original.)

Investigations in the laboratory have led to the employment of peptonized preparations, among which are peptonized cod-liver oil and some of the partially or predigested foods, such as bovinine, etc. These appear to have the power of digesting sloughs and of causing a speedy separation or disposal of everything necessary in the endeavor to secure a healthy condition of the ulcerating surface and give most satisfactory results. When sloughs are present it is an advantage to dust over them papoid, caroid, etc., which have the power of catalytic disposition of decomposing material without reference to the action of bacteria. Under their use there seems to be a solution and disposition of these dead products. With a foul ulcer—one from which the discharge is more or less offensive, due usually to decomposition of sloughing masses, not yet separated—the method of continuous immersion in hot water, when it can be performed, is always valuable. But nothing seems to equal brewers’ yeast for this purpose. It may be applied on absorbent cotton (which should be soaked in it) and covered with oiled silk. Its curative property may be ascribed to the nuclein which it contains in a nascent state. It will, when fresh, clean off a sloughing surface better than anything I ever used.

Many ulcers are surrounded with such firm, indurated borders that it seems impossible that any active regenerative process can arise from such source. Hence, incisions have been practised for centuries. These have been made radially from the centre or have been made parallel to the margin of the ulcer, or sometimes the firm, dense tissues have been minced or chopped by a series of cross-cut stabs or incisions; as the result of which renewed activity has arisen, and an impetus given to the healing process. These methods, however, have yielded to that alluded to above. The ulcer in which granulation has come to a standstill is often treated with the sharp spoon or curette. The result of this has been to provoke again a speedy renewal of granulation efforts, and treatment by curetting is standard and often useful. Actual cauterization of the ulcer with a view to such complete destruction of its covering and border as shall lead to their separation by the sloughing process is occasionally practised. This is perhaps best performed with the actual cautery. It lacks, however, the valuable features of the operative method, to be described below. Modern methods have made it plain that it is often an absolute waste of valuable time to resort to the older expedients of stimulation, incising the edges, etc., and that one can accomplish by an operation in perhaps three weeks what ten times that length of time would fail to do by older methods. The most effective method, therefore, in dealing with old and chronic ulcers is to anesthetize the patient, to excise the entire affected area—i. e., the surface which ought to be granulating and the firm border and tissue in its neighborhood—and then to cover the surface either with skin grafts, pared off with a razor according to the Thiersch method, or with a strip of skin whose full thickness is raised, which is taken from surrounding parts by some autoplastic or heteroplastic method. This line of treatment is so far preferable to all others that, except in case of refusal of the patient to submit to it, it is the one which must hereafter commend itself. It may afford opportunity for extensive plastic operations or for the exercise of the best discretion and knowledge of experienced men; yet cases are rare in which it cannot be successfully performed. These methods of skin grafting have so far supplanted the older method of sponge grafting that the latter is now seldom practised. It may possibly have a sphere of usefulness in certain ulcerated cavities, but under all other circumstances it must take a position far below the plastic methods in practical value.

Finally, ulcers of specific type—syphilitic, tuberculous, leprous, glanderous, etc.—need methods in which the first effort should be not so much to arrange for healing as to dispose of infectious material. The knife, the scissors, the sharp spoon come first into use here, the surgeon bearing in mind that almost all this material is more or less infectious, and that inoculation of his own hands is possible as the result of carelessness. After taking away with instruments all the granulation tissue, with its surroundings, which seems to expose to danger, it is well to cauterize the part with the actual cautery, nitric acid, bromine, or zinc chloride.

The markedly hemorrhagic ulcer, whose surface bleeds on the slightest contact or disturbance, is often a cancerous ulcer, though not necessarily so. This ready bleeding is usually the effect of the fragility of the walls of the new-formed bloodvessels. In many instances it is sufficient to scrape until harder or more resisting tissue is encountered. Hemorrhage may be profuse for the moment, but it is easily controlled. Caustics may then be applied or not, according to the judgment of the surgeon.

Another method is to treat such a surface with the actual cautery. Another is to operate, even in the presence of incurable disease, in order to check a tendency to fatal hemorrhage before the disease has expended itself. In a general way, in regard to small, ulcerating, cancerous surfaces, it may be said that if they bleed excessively or are unduly irritable, it is preferable to attack them by operative measures in spite of the impossibility of effecting a cure.

There are other methods of treating ulcers, but they have mainly been abandoned for those mentioned.

CHAPTER V. GANGRENE. — A. Traumatic — B. Local Causes. — C. Constitutional Causes. — D. Infectious Causes. — Gross Appearances. — Signs and Symptoms. — Treatment.

Gangrene is known also as necrosis, although this term is usually limited to gangrene of bone. It is known also as mortification, and to the older writers, especially when soft parts die and separate in sloughs, as sphacelus. Gangrene means death of tissue in visible and more or less circumscribed masses. It is distinguished from ulceration not on account of molecular disintegration, particle by particle, but because of death in toto and synchronously of a large, perhaps innumerable, number of cells. Gangrene is described as due to causes which may be:

, including the so-called thermal causes as essentially mechanical injuries. Under this head are included cases where injury is the primary cause, whether this injury is the crushing of a limb, the separation or occlusion of its main bloodvessels, the division of its main nerves, or the crushing or pulpefying of its entire structure by machinery or accident; also those so-called thermal cases which are due to intense heat or intense cold. To these might be added the chemical causes, comprising injuries by powerful caustics, alkalies, or acids, which are known to cause speedy death of every living tissue with which they come in contact.

Gangrene from frostbite is often of the moist type. There is scarcely a limit to its extent, either in area or depth. It is due primarily to thrombosis, which is followed by a purplish color of the skin, by loss of local warmth, and numbness. Naturally it involves the ears, nose, fingers, and toes. But after alcoholism and exposure one or more entire limbs may be involved. With moist gangrene there is danger of septic infection (q. v.). After formation of a line of demarcation the line of amputation may be made to follow it closely, but the best results are obtained by higher division, at points of election, where tissues are less sensitive and less infiltrated.

—These are largely connected with ischemia. Gangrene from edema—itself the result of passive hyperemia and exudation—is not infrequent, the most common expression of this condition being seen perhaps in the external genitals of the male. Embolism due to valvular heart disease, thrombosis due usually to a preceding phlebitis, but possibly to marasmic origin, especially met with after confinement, with disturbance in the uterine sinuses, shutting off the circulation by endarteritis, which thus assumes the form obliterans, are some of the local causes which concern the bloodvessels alone. In fact, the majority of cases of spontaneous gangrene are probably due to changes in the vessels, endarteritis being the cause of a condition known as atheroma of vessels, in which fungoid outgrowths, or, rather, ingrowths into the vessel lumen, are common. Any one of these, if detached, may serve as an embolus. The degenerative excavations in the thickened walls of the bloodvessels, which discharge more or less cholesterin and other debris, and which have been known as atheromatous abscesses (misnomer), are frequently the precursors of the disease under consideration. As the result of these changes alone, without reference to formation of emboli, vessels may become completely occluded, especially when slightly injured.[2]

Extravasation of blood is another cause connected with the bloodvessels, this coming usually from traumatic rupture, possibly from idiopathic causes. At any rate, the tension in the part may threaten its life because of the pressure which overcomes the circulation of blood. Ligation of the main trunk of an artery is sometimes followed by gangrene, no matter how carefully done, collateral circulation being insufficient to sustain the nourishment of the part. In certain fractures, simple as well as compound, the blood supply of a part is rudely broken off by injury to a bloodvessel in such a way as to cause local or general death, either of a bone or of the entire limb. Flaps made for plastic purposes, arranged without sufficient regard to their proper blood supply, or so dressed after operation as to sustain undue pressure, are often so shut off from the heart as to die for want of blood. Finally, gangrene may be the result of pressure either from splints, bandages, etc., or from tumors increasing in size, or possibly, as in certain pressure sores, etc., from the mere weight of the body. Here, too, chemical agents must be mentioned, referring now to the peculiar action of certain foods or drugs, particularly ergot. Thus antiseptic solutions, particularly carbolic acid, may be made strong enough to destroy the vitality of certain tissues. Carbolic gangrene (Warren) is a possibility not to be forgotten.

Extravasation of urine, unless promptly recognized and appropriately treated, or especially as occurring when the urine is peculiarly toxic (ammoniacal) and the patient’s vitality reduced, as in confirmed alcoholics, is almost sure to produce gangrene which may easily terminate fatally.

Fig. 14

Raynaud’s disease: digiti mortui. (Original.)

Fig. 15

Raynaud’s disease: perforating ulcer of foot. (Original.)

 

—Among these are to be mentioned particularly that symptom-complex ordinarily known as diabetes or glycosuria. This means a depraved condition of the system in which gangrene is threatened or permitted under circumstances which otherwise would have little or no disastrous effect. Thus diabetic gangrene has come to be one of the recognized manifestations of the general disease. That the trophic nerves have a more or less pronounced effect in determining gangrene in certain cases seems to be now quite well established. It is well known how quickly bed-sores form after injuries to the spine, while in certain nervous affections a minimum of friction of the skin may determine its death, particularly about the labia or scrotum. It is said that the insane, when made to sleep by chloral, may develop decubitus from pressure in a single night. There is also a well-known form of symmetrical gangrene, known sometimes as Raynaud’s disease, which is characterized by symmetry of lesions and absence of definite pathological changes (Figs. 14 and 15). The so-called digiti mortui, or dead fingers, and erythromelalgia are examples of this character. A condition almost leading up to gangrene, but perhaps not absolutely terminating in such a way, has been known as local asphyxia, which seems to be a condition of arterial spasm with venous congestion and slight edema. While the aged will often recover from a legitimate surgical operation without disturbance, it is, nevertheless, true that senile gangrene commencing in the toes has for its cause some very trifling injury or lesion, such, e. g., as paring of a corn, or the like. This shows a weakened local and general resistance, as well as the wisdom of redoubling aseptic precautions in operations upon such patients.

As constitutional causes also should be included the deleterious effects of certain drugs, particularly ergot, mercury, and phosphorus.

—In the instances already mentioned reference to the infectious microörganisms has been avoided. There remain to be considered types of gangrene due to the activity of certain microörganisms—hospital gangrene, phlegmonous erysipelas, malignant edema, gangrenous emphysema, noma, ainhum, etc.

Gangrene as the result of infectious processes is seen in phlegmonous erysipelas, where death of tissue seems to be due to the combined influence of the invading organisms and of mechanical agencies—i. e., tension produced by stasis and exudation, with such stretching of tissues or overcrowding with inflammatory products as to virtually strangle them, in consequence of all of which they die. Gangrene of an entire hand may thus result, or, more commonly, the gangrene is limited in extent to the more superficial parts, so that sloughs separate. A specific form of gangrenous inflammation known as malignant edema, due to a peculiar anaërobic bacillus, will be treated of separately under a distinct heading. Quite like it in several respects is the gangrenous emphysema of certain writers, known also as the fulminating form, or, as the French call it, the “gangrène foudroyante.” More or less emphysematous condition may accompany malignant edema; yet that we do have gaseous forms of gangrene without the specific bacillus of malignant edema is established. At least sixteen cases of so-called gaseous gangrene due to infection by the bacillus aërogenes capsulatus are on record, of which twelve were fatal. Most of them followed surgical injuries—e. g., compound fracture.

Fig. 16

Noma. (Original.)

Hospital gangrene, so called, has been in years past the terror of military surgeons and camp hospitals. As a type it has almost completely disappeared from observation, and, in its old manifestations at least, is now practically never seen.

Noma, known also as gangrenous stomatitis, cancrum oris, and gangræna oris, is a term applied to a form of tissue necrosis affecting the cheeks or parts about the face of young children, occurring frequently as a complication of the exanthemata. A similar condition occasionally involves the external genitals. From the fact that it seldom passes across the middle line, it has been regarded by some as of neurotic origin. Naturally bacteria are always found in the decomposing tissues; but whether there as cause or as result is not yet established. The probability is, however, that we have to deal with a specific form of infection. The loss of substance is usually so great as to determine complete perforation of the cheek, so that the jaw bones may be laid bare. The gums and alveolar processes also frequently share in the process, and the teeth occasionally drop out. Death of tissue is rapid, and septic infection may accompany it to such an extent as to cause the death of the patient in a few days. While most vigorous measures are necessary for combating it, the patients are often so reduced as to preclude the possibility of doing much, and death is the termination of noma. Free incision, even complete excision, is called for, perhaps with combined resort to the actual cautery or such remedies as bromine (strong or diluted). Antistreptococcic serum has also been used with success. Obviously it must be used early if success is expected. Should patients recover, there is extensive deformity as the result of cicatricial contraction.

Along the coast of Africa and in the West Indies there occurs among the negroes a peculiar gangrenous affection of the toes known as ainhum. This may assume either the moist or the dry type of gangrene, but the result is gradual separation of the part, usually by the dry process, as if it had been strangulated by a ligature. The disease is slow and may extend over ten years. The cause is unknown.

Finally, gangrene is the termination of the infectious process in several other zymotic diseases, among the best illustrations being that afforded by diphtheria. The formation of diphtheritic ulcers in the mouth and the vulva, about the eyes and elsewhere, as the result of separation of sloughs, is too frequent to pass unnoticed, yet at the same time does not essentially differ from the separation of sloughs due to any other specific cause. All these acute zymotic diseases, therefore, need to be regarded as among the possible causes of gangrene by infection of tissues.

The symmetrical gangrene, often paroxysmal, affecting the fingers and toes, described by Raynaud and often called by his name, is due to vasomotor spasm, and is accompanied by neuralgia and sensory disturbances, with coldness of the part and discoloration suggestive of impending gangrene. (See above.)

Billroth and others have also described a spontaneous or angioneurotic gangrene of the extremities, occurring during youth, in abrupt distinction to senile gangrene, whose course is tedious and painful, which will usually necessitate amputation. The cause of this condition has been found to be a well-marked arteriosclerosis and thrombosis, both in the arteries and veins. This form of gangrene occurs most often in the frigid zone—e. g., in Northern Russia.

There are also forms of visceral gangrene, traumatic and non-traumatic, which often constitute fatal maladies. The latter are mainly due to thrombotic or embolic lesions, for example, the gangrene of the mesentery, already alluded to when discussing thrombosis (q. v.), clinically described under Surgical Diseases of the Mesentery.

—In a general way tissue death, known as gangrene, assumes two opposite types—the moist and the dry. In moist gangrene, aside from those appearances which indicate commencing putrefaction of tissues, and the loss of heat due to stoppage of the blood supply, one of the most characteristic features is the formation of a so-called line of demarcation, i. e., a line which separates the dead from the living tissues. While this is usually plainly indicated by a red line which abruptly separates the discolored, usually dark, dead portion from the bright red, congested appearance of the living tissues, it is noted that this area of redness shades out into a more and more natural appearance as we pass upward, while below the line is seen a surface, usually covered with blisters, from which exudes a foul-smelling, altered serum, while the gangrenous portion assumes a dark, finally an almost black appearance, retaining only the crude outlines of its original shape. Along with this the objective evidences of putrefaction are unmistakable, appearances and odor being characteristic. With all there are more or less constitutional disturbances, and a recognizable, often a profound, condition of septic infection, due to the fact that along the line of demarcation absorbents are still active and that the poisonous products of putrefaction are being absorbed into the general system. Consequently collapse, profuse perspiration, septic diarrhea, etc., are noted. In gangrene from frostbite the process is slower than in the traumatic forms. In gangrene from extravasation of urine the separation of sloughs is extensive, and sloughing of the scrotum with exposure of the testicles is a frequent result. In decubitus, or bed-sore, the process is still more slow, but always of the moist type. After a variable length of time there is separation of slough and a resulting large, often foul, ulcer.

Dry or senile gangrene presents a very distinct contrast to the moist type. It occurs generally in patients over fifty, often as the result of causes which are slow of action. As a result of the shrinking and corrugation of the tissues, with the dryness of the same by evaporation, there is a peculiar appearance known as mummification, the foot, for instance—the feet are usually first involved—resembling the foot of a person who has been embalmed, except that it is discolored. It is possible sometimes to have a combination of moist and senile gangrene, especially when there has been infection by which putrefaction is permitted. When from the outset putrefactive processes are prevented, the gangrene of this type is almost invariably dry. In practically all of the cases of this character there will be found evidences of vascular disease, usually in the femoral artery and its branches. Gangrene of the foot alone is most commonly due to endarteritis, while gangrene of the foot and leg together are usually due to embolism or thrombosis.

While disease of the vessel walls is usually of the type either of endarteritis or arterial sclerosis, peculiar to the closing years of life, and commonly affecting the lower extremities, gangrene due to embolism of arteries or thrombosis, or both, may occur in the young, and in the upper extremities as well, in the latter case the emboli being detached from the heart, while thrombosis may be caused by a tight splint or bandage, or even the use of crutches. I have repeatedly amputated the arm as well as the leg for gangrene of this type.

—The appearance and the odor of a part will indicate impending or actual traumatic gangrene. The pallor, the coldness, the dryness of senile gangrene are also characteristic. In the latter form constitutional symptoms are not indicative nor essentially of septic type. As soon, however, as a process of spontaneous separation begins putrefaction is inevitable and sepsis unavoidable. In moist gangrene there is seldom acute pain. This is one of the predominating subjective features of the senile form. Hemorrhages occur, sometimes terminating fatally, in the moist forms when large vessels are eroded. This is particularly true of the phagedenic or hospital form. A recognition of their possibility may enable us to avoid sudden death from this source.

—Threatening gangrene should be attacked and the cause removed. Threatening bed-sores may be avoided by equalizing surface pressure, which can be done with the water-bed; by protecting the skin or by stimulating and toughening it with alcoholic and astringent lotions; by frequent changes of position; by attention to the heart, which should be stimulated to a point that may make it capable of forcing or distributing blood equally over the entire body. So, too, with limbs which are enveloped in dressings or splints; it is well to leave exposed the tips of the toes or fingers in order that discoloration of the same may be recognized and the threatening disasters averted. Local gangrene as the result of pressure by tumors, aneurysms, etc., cannot always be averted.

For gangrene there is but one relief, the removal of the dead and dying tissue. The method and location of the operation must be determined by the general character of the cause. For a case of acute traumatic gangrene amputation at the nearest point of election above the injury will often suffice. In case of gangrene from frostbite the tissues in the neighborhood of the line of demarcation are so affected or their vitality so compromised that to separate the tissues along the lines at which nature is endeavoring to remove them is not enough, and to go an inch or so above this line is to operate in tissues which bleed readily and heal badly. Consequently it is often advisable to select a point at some distance above. It is especially in diabetic and senile gangrene that surgeons have laid down the rule that if amputation is done at all it must be high. For gangrene of the toe, as the result of disease of the vessels, it is best to amputate above the ankle; whereas if any greater portion of the foot is threatened, amputation should take place above the knee. The tibial arteries have been found so brittle as to snap under a ligature, and the femorals so disorganized as to require handling and ligating with the greatest caution. These high amputations are therefore necessitated by the condition of the vessel walls. While amputation for traumatic and acute cases is, in the majority of instances, if not too long delayed, successful in saving life, in the senile and particularly in the diabetic forms it is, in the majority of cases, a disappointment.

PART II. SURGICAL DISEASES. — CHAPTER VI. AUTO-INFECTION, ESPECIALLY IN SURGICAL PATIENTS.

One of the greatest advances made in pathology has been the establishment of the fact that a great many of the morbid conditions from which the human race suffer are those due to causes arising entirely from within their own systems and in consequence of deficiencies of elimination or of perverted physiological processes which, in large degree, are themselves the result of errors and indiscretions in diet, in manner of life, in habits, etc. That these general facts have been recognized for centuries is perhaps a credit to the powers of observation of practitioners of past generations. Exact knowledge, however, has come only with exact laboratory methods of research and most painstaking study of the secretions and excretions, both under normal and morbid conditions. The subject of auto-intoxication has been too commonly relegated to the domain of internal medicine, and has been supposed to be one in which the surgeon need take only passing interest.

The alkaloids are by no means the only poisonous products which the human body may produce and retain. That most important excrementitious material of all—i. e., carbon dioxide—could not be retained in the organism for more than a few moments without death as the inevitable consequence. The various soluble ferments elaborated by certain glands may exert deleterious influence, both local and general; and in the saliva are also found products which are not ferments. The biliary acids also, if they do not find free escape, may produce fatal poisoning. So also leucin, tyrosin, and all the excrementitious products which arise from insufficient liver activity, are capable of producing forms of intoxication—such, for example, as eclampsia, etc. The character of the solvent has much to do with toxicity. Thus aqueous extract of putrid matter is more poisonous than that of fecal matter, while alcoholic extract of fecal material is more toxic than that of putrid. All the alkaloids produced within the body are not poisonous. Some are found in the normal tissues, and they are, perhaps, only one of the results of the disassimilation of animal cells. Nor are all these poisons of bacterial origin, although many are formed only in the presence of microbes.

From these constantly menacing sources of intoxication man escapes by virtue of his intestinal, cutaneous, pulmonary, and renal emunctories. For instance, the usefulness of the perspiration is shown by the odor which it assumes under the influence of certain disorders. Among hypochondriacs and the inactive fatty acids are eliminated by the skin. Hence the odors of hospital wards, asylums, prisons, etc. So, too, in the case of many who suffer from deep-seated, indolent ulcers, the odor of the skin is suggestive of the presence of pus. During twenty-four hours there is eliminated from the lungs 1100 grams of carbon dioxide, water, etc., which sometimes contain ammonia and various volatile fatty acids; all of which will explain fetor of breath when it is the result of incomplete nutrition and destruction of food. Of the organs of elimination, the most important is the kidney, which does not reabsorb a part of its own products, as does the intestine. The kidneys eliminate fluids and solids, not gases. The most important of the toxic principles contained in the urine are:

1. Urea, which plays an important and useful role in the economy, since it possesses the property of forcing the renal barrier and removing along with itself the water in which it is dissolved and other toxic matters. Urea is toxic, but only in the sense that any other substance, even water, may be—i. e., it is toxic only in large doses, less than sugar, and no more than the most inoffensive salts. This is contrary to generally received views, but is established by the researches of Bouchard.

2. A narcotic substance, and

3. A sialagogue substance, whose composition is unknown;

4, 5. Two substances having the property of causing convulsions, one having the power of contracting the pupils. The composition of both is unknown.

6. A substance which produces heat by diminishing heat production—possibly a coloring matter. That coloring matters are absorbed by charcoal and that urine thus decolorized is rendered less toxic are no proof that the coloring matters themselves are responsible for this toxic action. There is no doubt that numerous alkaloidal bodies possessing a high molecular weight are precipitated by means of carbon or charcoal, and to these bodies may be attributed a portion of that toxic action previously considered as due to coloring matters.

7. Potassium salts, which are really convulsing agencies, are the most toxic perhaps of any of the poisons contained in the urine. Chloride of potassium, for instance, is toxic at 18 Gm. for every kilo of animal.

Salivation and myosis, as well as diarrhea, are often noticed in so-called uremia. In that form known as hepatic uremia, when the liver no longer forms urea, the kidneys scarcely act. In other words, if urea is no longer present in the body, the kidneys are deprived of their principal stimulation to physiological activity. Consequently urea, for so long a time the bugbear of physicians, is shown to be most dangerous when absent. When urea is deficient, blood serum or water in which the other toxic substances are dissolved should be withdrawn. This is best done by venesection, whose value in so-called uremia experience amply corroborates. When kidney activity ceases, intoxication is likely to be produced by potassium salts. Ptomains, amido bases, etc., are proved to be present in normal urine and are known to produce toxic effect. These ptomains increase enormously in pathological urines, and to this increase, rather than to that of potassium and coloring matters (which remain fairly constant), may be attributed the higher toxicity of pathological urine. In certain cases, however, as in that of jaundice, the toxicity of the urine is partly due to decomposition of tissue cells, whereby potassium salts and organic decomposition products are liberated and excreted in the urine. The toxicity of the urine also increases with the increase of indican, which is indirectly a product of intestinal fermentation.

The osmotic pressure of the blood has much to do with the general subject of auto-intoxication, since it surrounds and permeates all the organs of the body, which are necessarily in equilibrium with it. Their individual cells functionate, then, in accordance with it, and variations in such pressure must affect their activities. It is a special function of the kidneys to eliminate enough of the accumulated metabolic products in the blood to keep this osmotic pressure at its normal. Should investigation or symptoms of disease show a wide divergence from this standard, the inference is plain, i. e., that there is renal insufficiency from impairment.

This test may be made with a small amount of blood by cryoscopy (determination of freezing point). So, too, a determination of electrical conductivity may, in a similar way and for a similar purpose, be made of clinical value. Unfortunately, these investigations are not exactly simple in character, and are not available outside of well-equipped hospitals.

Correct performance of hepatic function is also necessary that surgical cases may progress without disturbance. Bile escapes direct absorption by the blood, but not all contact with it, since in the intestine it is in contact with mesenteric capillaries, but must pass again through the liver, which takes it up again and pours it once more into the intestine.

Bile in the blood is always dangerous, although its toxicity is much smaller than has been supposed. Of all the bile thrown out into the duodenum, we are only able to account for about one-half. Its coloring matter and biliary salts are metamorphosed. Yet in certain morbid conditions bile, as such, may be reabsorbed in the liver along the margin of the hepatic cells. In these cases, if the kidneys remain permeable, auto-intoxication is simply threatened; if they have ceased to be permeable, actual auto-intoxication is the result.

Putrefaction of intestinal contents affords another source of auto-intoxication. This comes both from imperfect metamorphosis of food and from bacterial infection. Here the conditions are most favorable. Nitrogenous substances become peptonized, and peptones form the best culture media for microbes. Water is present in sufficient quantities, and a constant temperature of 37° C. is maintained. The digestive tube is always open, and invaded at frequent intervals. By such mechanism are formed those products whose effects are revealed in the so-called putrid fever of Gaspard. Brieger has shown that alkaloids are developed during the act of peptonization. Fecal matter contains also excretin, whose toxicity has been amply proved, and several other alkaloidal substances, soluble in various media, varying in toxicity. The potassium and ammonium salts contribute largely to the toxicity of feces; bile also, but in lesser degree. It has been shown that the aqueous extract of putrid matter is very toxic, while that of fecal matter is otherwise.

The most serious features of the conditions grouped under the heading of Bright’s disease are their so-called uremic features. These happen at the period when retention of toxic products is peculiarly harmful. As long as the urine is ample in amount and density—i. e., containing enough toxic materials in solution—there is no danger of intoxication. But when it no longer eliminates in twenty-four hours what it should, then we see the chronic and paroxysmal nervous accidents, the edemas, fluctuations of temperature, etc. Oliguria with urine of increasing density and general edema of the tissues may be noticed, although the other secretions continue natural and the tongue moist. As long as the normal amount of solids is eliminated, this form of “uremia” may be due to mere accumulation of water and may not be serious. Ordinarily, uremic patients are those whose urine has lost its toxicity. Usually on the day in which so-called uremic accidents happen the urine quite ceases to be toxic and is scarcely more so than distilled water. Urea alone is not to be held guilty for this condition. In order to kill a man with urea it would require the quantity which he makes in sixteen days. Nevertheless, it may become harmful after undergoing transformation into ammonium carbonate or other substances.

Among the most poisonous substances in the urine are the extractive and coloring materials. Normal urine loses one-half of its toxicity by decoloration; bile acts in the same way. Urea alone represents about one-eighth of the total toxicity of urine. Ammonia is toxic, but present in small amounts. The coloring matters of the urine cause two-thirds of its toxicity, the remainder of which is to be ascribed to its mineral salts, which it contains in the following proportion: A liter of urine ordinarily contains 44 Gm. of solid matter, of which 32 are organic, 12 mineral. Of the latter, potassium salts constitute 3 Gm., sodium salts 7.5 Gm., and other earthy salts constitute the remainder.

In these conditions physicians have relied largely upon purgatives, hoping thereby to remove urea from the blood. But intestinal elimination has no elective affinity for it, and removes it only in its normal proportion with the balance of the blood. Purgatives, however, help, first, by dehydrating the tissues—i. e., removing water with toxic material in solution. But they should be followed by restoring to the tissues pure water. By bleeding more extractives are removed than by any other channel, except by the kidneys. A bleeding of 32 Gm. removes from the body as much toxic matter as would 280 Gm. of a liquid diarrhea or 100 liters of perspiration. This much may be removed by two leeches. It is especially in the subacute nephritis of scarlatina, etc., that bleeding finds its greatest indication. If the kidneys are chronically diseased, the utility of bleeding is doubtful. Between the arterial capillaries of the bowels, however, and the liver is found a mass of blood accumulated in the portal vessels. This may be regarded as a reserve which can be thrown into the general circulation when needed, in order that thereby arterial tension may be augmented and the function of the kidney increased. Cold injections into the bowels will often accomplish this, and serious anuria frequently disappears after their use. It is advisable, also, to make use of urea by subcutaneous administration, as the most powerful diuretic known, surface friction, caffeine, digitalis, etc., being far behind it in efficiency. In the form of intoxication noted in the eclampsia of puerperal patients inhalations of chloroform are valuable. Potassium salts should, under these circumstances, never be employed. An exposure of urine in compressed air will diminish its toxicity, on account of contact with the oxygen; the most toxic bacteria are those which grow without oxygen. Consequently patients inhaling this gas may overcome this kind of auto-intoxication.

The value of an active liver is not appreciated by most surgeons to the full extent. The blood of the portal vein is so much more toxic than that of the hepatic vein that it is evident that the function of the liver is to purify and remove the toxic material from the blood that comes from the intestines. This has been called by Flint and others the depurative action of the liver. The activity of the liver also may be proved by grinding up a freshly removed liver with alkaloids, whereby the latter are chemically changed.

That the facts above stated, or others related thereto, have not been lost sight of by surgeons is shown by such expressions as septic enteritis, enterosepsis, etc., which are used by various writers. In previous publications the writer has made a separate topic of so-called intestinal toxemia, which he has preferred to introduce here as one of the many possible auto-intoxications. It is a condition not always permitting of exact definition, nor, still less, can the exact toxic agency be indicated in a given case. Nevertheless, it has been made plain that there is perhaps no condition which so predisposes to sapremia, septicemia, or even pyemia as this vague condition of intestinal toxemia, which, notwithstanding, is so often present. Many surgical patients present forms of blood poisoning in which the poison has not proceeded from the wound, for which the surgeon is not responsible, except that he may have neglected to avail himself of certain precautions.

The auto-intoxications, then, which have peculiar interest for the surgeon may be conveniently classified as follows:

1. Those caused by failure in the function of particular organs; e. g., myxedema, cretinism, and cachexia strumipriva from thyroidal failure; pancreatic diabetes, where the islands of Langerhans are invaded (interstitial pancreatitis, q. v.); Addison’s disease from adrenal failure (this being at present the prevailing belief).

2. Those caused by general disturbance of metabolism, where its incomplete or abnormal products reach the general circulation, e. g., oxaluria, gout, diabetes. (See Diabetic Gangrene.)

3. Those caused by retention in particular organs or tissues of disturbed metabolic products, e. g., the toxemias following serious burns and many septic conditions.

4. Those due to excessive formation of more or less normal products, e. g.:

(a) Hydrothionemia, i. e., the presence of hydrogen sulphide in the blood. This results from one form of gastro-intestinal putrefaction and causes violent symptoms with evidences of hydrogen sulphide poisoning. It is seen in some cases of gastric dilatation, especially those caused by pyloric obstruction (q. v.).

(b) Acetonuria and Acetonemia.—The former sometimes follows chloroform anesthesia, and occurs especially in diabetes (particularly after removal of the pancreas in experimental animals). Acetone per se is nearly or quite harmless, but its congeners, diacetic and beta-oxybutyric acids, are very toxic. The danger in so-called acetonuria is from acid intoxication by these acids, which has been described as “excessive acidosis,” and its co-existence with glycosuria makes diabetes certain, while prognosis is grave in proportion to its presence. Prominent among the symptoms produced by it are delirium and coma.

When either or all of these three substances are present in the blood its alkalinity is reduced and its ability to absorb carbon dioxide impaired; hence, acetonemia is evidenced by carbon dioxide poisoning. To the brain symptoms above noted is added a peculiar odor in the breath—sweetish or ethereal. This has been noted in pyemia. This condition may set in after various operations, but whether due to disease, the traumatism itself, or to chloroform may not always be determined.[3]

(c) Cystinuria.

(d) Coma of cancerous cachexia (coma carcinomatosum).

(e) Exophthalmic goitre, from excess of thyroidal activity (thyroidism).

Besides the above there is auto-intoxication proceeding especially from the gastro-intestinal and hepatic systems. Of the former, the best surgical examples are seen in the tetany which occasionally takes its rise from a dilated stomach, and which may be cured by a pyloroplasty or a gastro-enterostomy; in the nephritis which follows stercoremia of intestinal obstruction; and in oxaluria, with its painful, serious, and often deforming or crippling joint affections. Of the latter we have examples in the cholemia of acute atrophy or of biliary obstruction, and in the uremia of hepatic origin which occasionally terminates a surgical case.

In addition to the above there should also be mentioned the auto-intoxications of pregnancy, with the consequent salivation, peripheral neuritis, pigmentations of the skin, icterus, and pruritus, which are mainly attributed to perverted action of the liver or kidneys.

The practice of preparing patients for operation by a course of purgatives, emetics, etc., is based upon the recognition of certain principles. The general symptoms included under the name enterosepsis, stercoremia, copremia, are due to the activity of the colon bacillus, which seems to be made more virulent by certain conditions of diet or retained fecal excretions, and to such an extent that it wanders widely from its normal habitat and may be found in distant parts of the body. Enterosepsis may be mistaken for surgical fever, and is to be distinguished from it, perhaps, only by the study of the excretions of a case and establishing the fact that they are free, and that consequently pyrexia, etc., cannot be due to diminished elimination. Aside from the migrations of the colon bacillus, it is also possible for auto-intoxication to occur. Thus that which is stercoremia one day may later become a genuine septicemia, vital resistance being so lowered as to permit of local infection. The various conditions are so often merged that it is difficult to separate and identify them. Nevertheless, enterosepsis differs from sapremia in that in the one instance the putrefying material is contained within a normal cavity, whereas in sapremia it is contained within an abnormal cavity, in either case corresponding to a septic suppository, varying, however, in the place of insertion, also in the nature of the surrounding tissues, which in the latter case are more capable of absorption and of becoming infected than in the former.

A determination of indol and indican is often of the greatest value, both in determining the extent of infection and the presence of pus. Indol is set free under the following circumstances: (a) Suppuration in a closed cavity. (b) Continued suppuration in a cavity with an outlet. (c) Ulceration or necrosis of tissue. The degree of indicanuria will depend on the length of time pus has been present, the possibility of absorption from the tissues surrounding it, and its degree. When pus is fully formed in a serous sac the indican reaction becomes intense according to the length of time pus has been present. This is particularly true in the empyemas of childhood. In continued suppuration with a free outlet the production of indol will be great; but the amount finally eliminated will depend upon the character of the surrounding tissue. When solid tissue, like bone, becomes affected, the elimination of indol is intense. Rapid biogenic degeneration of tissue causes an increased amount of indol to be deposited in the liver, and it is possible at postmortem, by simple extraction with absolute alcohol, to take from the liver this excess deposit in the shape of its oxidation product, indigo blue. Lardaceous degeneration is characterized by marked and persistent elimination of indol, which seems to be a product of tyrosin. It occurs frequently in the liver, in which indol is notably deposited. Its primary factor is deposited by the blood, in which latter indol circulates and is oxidized. Lardaceous material gives a red or blue color with oxidizing agents, which latter yield with indol an indigo red or blue.

The practical outcome of such a chapter as this is, then, to insist as strongly as possible on the preparation of patients, whenever this is feasible, for an ordeal which comprises the combined effect of anesthesia and consequent disturbance of secretion and elimination, with loss of blood and of strength, and subsequent confinement in bed, with, moreover, all that this entails in further impairment of activities of important organs. It is not always possible, practically rarely so in emergency cases, to adopt these precautions; in which cases they must be atoned for, as far as possible, by extra attention in the same directions after the emergency is passed or has been met. In the former case, however, the functions of the skin, the kidneys, and the abdominal viscera should be regulated, the first by hot-air baths; the second by this same measure in conjunction with copious draughts of pure water, the correction of hyperacidity of the urine, and the administration of whatever drugs may be of benefit as diuretics, etc.; and the third by a course, perhaps covering several days, of gentle or active purgation, by which the alimentary canal will be entirely emptied of all that may serve to act as a source of poisoning. In addition to this, in certain cases careful massage will dislodge from the muscles and other tissues material which they ought not to retain, and which will be washed away, as it were, by the extra amount of fluid which this preparation, necessitates. Again, the activity of the heart should be stimulated, perhaps by digitalis, but preferably by that best of all tonics, strychnine, which is to be administered hypodermically in average doses of a thirtieth or twenty-fifth of a grain, morning and night. When these precautions are taken, patients will successfully pass through trying ordeals without anything which may give rise to alarm. When they are not possible, the risk of operating, even in a small way, is materially enhanced. So, too, after operations when these precautions have not been taken, it is necessary to give careful attention to atoning for their lack by such active purgation as a now reduced patient may bear—by hot-air baths, if feasible, and by the administration of such intestinal antiseptics as charcoal, naphthalin, corrosive sublimate, bismuth salicylate, salol, etc., for the purpose of reducing to the lowest possible minimum the opportunity for formation of poisons which will disturb the proper repair of injury.

CHAPTER VII. THE SURGICAL FEVERS AND SEPTIC INFECTIONS. — SURGICAL FEVER, KNOWN ALSO AS TRAUMATIC FEVER, OR ASEPTIC WOUND FEVER. — SAPREMIA. — SEPTICEMIA. — PYEMIA. — ERYSIPELAS. — RELATION OF LYMPH NODES AND GRANULATION TISSUE TO INFECTION.

Formerly the surgical fevers were all grouped together, and a certain amount of febrile disturbance was looked for after any injury. But with the introduction of antiseptic methods and the healing of wounds by primary union, with absence of all septic phenomena, and the use of the clinical thermometer, it is noted that there is a certain rise of temperature more or less quickly after an operation or reception of a wound, with fever of mild grade, persisting for several hours or two or three days, and with other accompaniments. This phenomenon has been carefully studied, and so separated from the septic fevers as to deserve a distinct recognition under the names above given, of which the most common in this country is surgical fever.

As long as this fever is free from indications of septic character it is without significance and needs only symptomatic treatment. It begins usually within the first twenty-four or thirty-six hours, after which the temperature may rise, progressively or with a morning remission, to a height of 102° or possibly 103°. In children we are more likely to get extremes in this regard than in healthy adults. It will be followed by some disturbance of alimentary function, glazing or drying of the tongue, deficiency in urinary secretion, and subside generally spontaneously—invariably so if cathartics, diuretics, cool sponge baths, etc., are used. It is usually due to the retention of blood clot, ligatures, etc., or tissues which have been ligated and whose stumps remain; in all instances there is some foreign material to be removed. This means unusual phagocytic activity, perhaps temporary leukocytosis, with active metamorphosis of clot and other material, of all of which the elevated temperature is an accompaniment and expression. It is not unlikely that the antiseptic materials used may sometimes occasion this pyrexia.

Iodoform and carbolic acid are among the drugs in common use which are known to be irritating and capable of producing toxic symptoms. Often after the use of the latter the urine will be discolored and will furnish the clue to the fever. In young children particularly, and not infrequently in adults, mental disturbance, even active delirium, may characterize the case. This is not always to be explained by cerebral anemia due to loss of blood during the operation or accident, but is probably due to drug toxemia or to intoxication from materials furnished by the altered tissues.

Surgical fever of strict type may merge into a more or less continuous fever as the result of intestinal toxemia permitted by failure to evacuate the bowels, and this intestinal toxemia may be a predisposing cause of genuine septic infection. Consequently a surgical fever which does not disappear within two days is to be viewed with suspicion, especially if it does not subside after the administration of cathartics.

Some surgical fevers are accompanied by eruptions, a number of which may be due to drugs and some to intrinsic poisons. Thus carbolic acid and iodoform give rise occasionally to erythematous eruptions, and the concomitant administration of drugs like potassium iodide, quinine, antipyrine, and copaiba may produce urticarial or other manifestations. Again, it is known that certain toxins—produced, e. g., by the bacillus pyocyaneus—are capable of causing dilatation of the superficial vessels and various flushes or eruptions. To one of these, which dilates the capillaries, Bouchard has given the name of ectasine. Consequently it by no means follows that every eruption or rash following operations or injuries is of a specific character. On the other hand it seems to be established by numerous observers—among whom Paget is perhaps the most prominent—that surgical patients, particularly the young, are particularly liable to infection by scarlatina; and in the experience of Thomas Smith, of forty-three children whom he cut for stone, ten had scarlet fever. Therefore, in spite of the fact that a certain number of cases of eruption may have been mistaken for scarlet fever, it is undoubtedly true that in surgical and puerperal cases patients are more than usually liable to this invasion. The use of antitoxins or serums is also occasionally followed by intense urticaria.

The subject of surgical fever may then be epitomized as consisting of elevation of temperature with certain accompanying disturbances, which appear to be essentially due to the results of tissue metabolism, including also metabolism of blood clot, ligatures, etc. It is not a necessary nor conspicuous accompaniment of all surgical cases, and in some individuals, even after grave operations, it will scarcely be noted. It is more likely to be extreme in children than in adults. As a result of excessive loss of blood it may be postponed. It may be complicated and prolonged by any one of the auto-infections, particularly that already mentioned in the preceding chapter as intestinal toxemia, as a result of which septic infection may ensue, and that which was at first a legitimate surgical fever may thus become merged into a septic condition. In the absence of auto-infection, and with appropriate treatment, surgical fever should quickly subside until it becomes indistinguishable about the second or third day.

Proceeding then in the order of pathological complexities, the first of the surgical infectious fevers to be considered is sapremia.

The term sapremia will be used here as indicating a condition which is often likened to an intoxication produced by a supposititious septic suppository. The term was first used by Duncan, and was largely confined to puerperal cases. Some of the most ideal cases of sapremia are those of puerperal origin.

In each of the three conditions comprised under the general term of septic infection it is not now a question of particular organisms, but of intoxication by products which are more or less common to at least several of them. In a general way, they are mainly due to the activity of the organisms already grouped as pyogenic. Those which produce pus are capable of causing septic infection. In addition to these, it is probable that certain of the saprophytes or ordinary putrefactive organisms may produce the same effect.

Symptoms.

—In sapremia the symptoms begin promptly, depend for their intensity upon the dosage of poison, and recede quickly as soon as the source of poisoning is removed or its activity subdued. An instance of the possible causes of sapremia will perhaps best illustrate its pathology. Take, for example, the act of delivery of the full-term fetus. At the completion of this operation there is left a fresh, bleeding wound of large area which is more or less exposed to putrefactive agencies. This is reduced with the contraction of the uterine walls to a comparatively small cavity containing more or less freshly coagulated blood. As long as this clot does not putrefy it is disintegrated inoffensively, to be discharged in large part with the lochia. If germs of putrefaction enter, either during the act of labor or afterward, and linger, putrefactive processes are set up in the clot with the prompt production of certain toxins and ptomains. There is here then a septic suppository with conditions favorable for absorption by the containing tissues. How quickly the poisoning may show itself, and how soon it may subside after removal of the putrefying clot, daily experience may tell.

Sapremia then is intoxication produced by absorption of the results of putrefaction of a contained material within a more or less closed cavity, whose walls are capable of absorption of noxious products as they form. As long as putrefaction is essentially limited to the contained mass, and does not spread to and involve the containing or surrounding tissues the case is one of sapremia. As soon as the process spreads from the containing tissues the case merges from one of sapremia into one of septicemia. That this may occur in any case without prompt intervention will be readily understood. Sometimes patients may die of sapremia, though rarely, and in such case ordinarily as the result of gross neglect. Once the septicemic process is begun, however, its spread cannot always be checked, and the case which one day is sapremic and redeemable may later become septicemic and practically lost.

The symptoms of sapremia are not essentially different from those common to septic infection, save that ordinarily they are, at least at first, milder. There are flushing of the face, dry tongue, mental disturbance, pyrexia, while usually all the symptoms are ushered in by a chill, which may have been preceded only by slight malaise. These are followed by nausea and vomiting, with headache, and often, later, by diarrhea or active purging. Later delirium may occur, possibly even fatal coma. On postmortem examination there are few changes revealed; alterations in the blood, a failure to coagulate, and some softening of the spleen and liver would probably be the only ones.

Treatment.

—The treatment should be prompt and the cause removed. In puerperal sapremia the uterus should be emptied, antiseptic douches given, irrigating as often as necessary to prevent offensive odor to the discharge, and combating general signs of poisoning by plainly indicated measures. Heart depression should be overcome by diffusible stimulants and hypodermic injections of strychnine in doses of ¹⁄₂₅ grain or more. The bowels should be unloaded by a mercurial followed by a saline cathartic; suppression of urine treated by venesection and hot-air baths or sweats; diuretics should also be prescribed, and fluids administered copiously. If the patient is restless, an opiate should be given; if delirious, necessary restraint should be resorted to.

Essentially the same measures should be pursued in a surgical wound or in a case of compound fracture, or any injury where retained material may be undergoing changes already alluded to. General measures should be the same. Purgatives are advisable in these cases.

Chronic Sapremia.

—Chronic sapremia is a better name for what used to be known as hectic fever. It is characterized by rapid, feeble pulse, a temperature but little elevated in the morning and rising to 102° or 103° in the latter part of the day, with profuse perspiration, or sometimes colliquative sweats that leave patients exhausted. There is usually a distinctive flushing of the cheeks. Emaciation is a marked feature in most instances. Hectic means simply habitual fever. It is met with particularly in tuberculous cases, whether of lungs or bones or joints, in empyema, psoas abscess, and most all chronic pyogenic infections. It is frequently followed by or associated with amyloid or waxy degeneration of the liver, kidneys, and spleen. This process commences in the walls of the bloodvessels and by its spread to the surrounding connective tissue leads to notable enlargement of these organs, with albuminuria, edema, ascites, and the usual associated phenomena.

Treatment.

—Treatment, in addition to that already indicated above, should be addressed to removal of the cause. In all instances it should comprise attention to elimination, digestion, nutrition, and fresh air. By such measures even distinct amyloid changes may be arrested, or possibly improved.

Cryptogenetic or Spontaneous Septicemia.

—Cryptogenetic or spontaneous septicemia is a term applied to those cases in which the port of entry of the germs is no longer visible—e. g., a hypodermic puncture—or cannot be positively determined. On careful study this may be found to consist of a small focus where pus is forming within narrow confines and under great pressure. Under these circumstances, as Kocher has shown, toxic virulence is rapidly augmented. This is doubtless one reason why the septic features of many cases of osteomyelitis and appendicitis are so pronounced.

According to the views thus enunciated, the difference between sapremia and septicemia is not one of character as much as of location. In septicemia the putrefactive action is no longer confined to material enclosed by (yet not of) the tissues themselves, but has spread from this to the surrounding living cells, which are being attacked by bacterial enemies; in other words, we deal with infection of living tissues rather than with mere intoxication. This is a progressive invasion of tissues by continuity, with a constantly proceeding systemic intoxication by poisons produced in larger quantities. So rapid may this action be—as may be seen in malignant diphtheria—that the individual speedily succumbs before evidences of abscess or local gangrene appear. On the other hand, providing that the toxic action is less pronounced or the patient’s vitality more enduring,—i. e., his tissues more resistant—abscess, phlegmon, or local gangrene may result in the destruction of tissue being limited to the environs of the parts first involved. Bacteria are also found in the blood.

While septicemia then may be a direct continuance of an original sapremia, it is not intended to intimate that it may not originate de novo; that is, many cases may begin as a pronounced septicemia from a local infection. This is the case, for instance, with the majority of dissecting wounds, etc.

Symptoms.

—In septicemia there is a period of incubation, usually two or three days, often longer. If this follows an operation, the mild fever which would indicate the slumbering fire is usually regarded as surgical fever. But when this rises and is followed by prostration, with alimentary disturbance, loss of appetite, headache, etc., followed by typhoidal symptoms, the alarm is sounded and should be quickly heeded. Usually, but not always, there is a preliminary or premonitory chill, after which prostration will be more marked than before. The severity of the symptoms cannot be foretold from the size, location, or character of the wound. The character of the fever is essentially continued, usually with morning remissions. Gussenbauer has called attention to a class of cases in which subnormal temperature is caused by the absorption of ammonia compounds. To these he has given the name ammoniemia. This condition may be seen in connection with gangrenous hernia, and has even been mistaken for shock (Warren). (See also acetonemia, in previous chapter.)

In septicemia from infection of a visible portion of the body there are usually seen evidences of lymphangitis and perilymphangitis of septic character. These will be evidenced by tender and purplish lines, extending subcutaneously along the course of the known lymphatics or in connection with the more prominent subcutaneous veins. The lymph nodes, into which these visible vessels as well as the deeper ones empty, become enlarged and tender; the whole lymphatic system participates; the spleen in aggravated cases becomes notably enlarged, and even the bone-marrow more or less involved. Diarrhea is commonly an early but controllable symptom. A hematogenous icterus of mild degree is another frequent accompaniment. The conjunctiva becomes discolored and the skin slightly so. Should the blood be examined marked leukocytosis will be noted, and should cultures be made from it, in many instances at least, the organisms at fault can be detected and recovered from it. The vigor of the heart muscle is seriously impaired; the pulse becomes rapid and weak. In scarcely any form of septic infection is this more prominent than in diphtheria; and microscopic examination shows the rapid disintegration of the cells of the heart muscle, as well as those of other parts of the body, even to the almost complete molecular disintegration of the nuclei. Erythematoid, pustular, and even hemorrhagic eruptions are met with upon the skin, some of which are probably to be explained by thrombosis of the dermal capillaries. Certain complications are not infrequent, among which inflammations of the pericardium and endocardium—e. g., ulcerative endocarditis—are frequent. As the case becomes aggravated the temperature rises irregularly; the hot, dry skin becomes cold and clammy; prostration and indifference more marked; diarrhea more colliquative; icterus more pronounced; urine more reduced in quantity or suppressed; and these symptoms are succeeded by indifference, mental apathy, stupor or delirium, and finally death, the patients being comatose and collapsed.

While these are the general indications of septicemia, the wound or site of injury has undergone changes which are also characteristic. They comprise the edema and redness of wound margins, which may be seen even in sapremia, followed by increasing tumefaction, escape of foul-smelling discharge, and finally by sloughing and gangrene of the parts involved. On microscopic examination the capillaries are filled with infective thrombi and vessel walls infiltrated with microörganisms, which abound also in the lymph spaces. Bacterial infection can be traced in microscopic sections from the infected area, from the point in the neighborhood of the wound where microbes infest the tissues to points remote from it, where they are sparsely found, if at all. The same evidences of infection may be traced along the lymphatic vessels, and often the veins.

Postmortem Evidences.

—The postmortem evidences of septicemia are indicative on first sight: the blood is of the consistency of tar and does not coagulate; evidences of putrefaction are plain to sight and smell; the serous membranes, particularly the pia mater, are often extravasated; the muscles are discolored and of a darker hue than natural, edema of the lung is frequent; the intestines reveal a gastro-intestinal catarrh, the duodenum and rectum showing punctate hemorrhages; the spleen is darkened, enlarged, and softened; the liver shows similar signs, less marked, and at times an emphysematous condition due to putrefactive gases. Cultures can be made from the fluids and tissues of organs thus affected. It is also of importance to emphasize that such material is powerfully and often fatally infectious; some of the worst forms of dissecting wounds and instances of fatal infection have come from carelessness in making these postmortem examinations.

So far as concerns the character of the wound, which is most likely to be followed by septicemia, there is but little to be said. Wounds made by infected tools, the butcher’s knife, the anatomist’s scalpel, etc., are the most dangerous. All forms of phlegmonous erysipelas, many cases of gangrene following frostbite, nearly all instances of traumatic gangrene, most cases of carbuncle, and, in fact, all similar lesions, are likely to be followed by septicemia. The so-called spontaneous cases have an equally infectious origin, though one which is concealed. In unrecognized instances of appendicitis, for instance, and in many other conditions, although the path of infection may not be easily traced, it is, nevertheless, always present, and can be found if diligent search is made. The nasal cavity, the tonsils, the teeth, the middle ear, the deep urethra, and the rectum are often overlooked as offering possibilities for septic infection which may follow this general type.

Treatment.

—This should be both local and general. Local treatment should consist in complete and absolute removal of the active cause. This comprises the reopening of wounds, evacuation of clot, cutting or scraping away of sloughs and gangrenous tissue, with cauterization of the exposed living tissue, in order that absorption may be prevented, and will often include amputation or extirpation of a part. For tissues which are not too completely riddled by disease, and lost beyond possibility of redemption, continuous immersion in hot water offers the best possible prospect. By it putrefaction seems checked, the separation of dead from living tissues is accelerated, relief of pain or discomfort is afforded, and disinfection of material which is foul and infectious is guaranteed. An excellent local application is the mixture of resorcin 5 parts, ichthyol 10 parts, ung. hydrarg. 40 parts, and lanolin 45 parts, already mentioned in Chapter IV, or the application of brewers’ yeast. (See chapter on Ulcers.) Of great value also will be found the silver ointment of Credé (Unguentum Credé). This permits of absorption of silver through the unbroken skin (as in the case of ung. hydrarg.), and the dissemination throughout the system of the antiseptic virtues of the silver itself. To ensure its greatest efficiency this ointment should be thoroughly rubbed in, especially over parts which are not too tender. Many cases of septic infection promptly yield under the influence of the argentine preparations which Credé has lately introduced.

In suitable cases also the subcutaneous injections of antistreptococcic serum will be followed by beneficial effects. The earlier the injection is given the better the prospect of benefit. Evidence is strongly in favor of this serum as a prophylactic measure, especially before operations, when septic pneumonia or other septic accidents are feared.

Another measure of great utility in selected cases is the intravenous infusion of a solution of Credé’s soluble silver, made with 1 gram of silver in 1000 Cc. of sterilized water at a temperature of 105° to 110°. In cases of profound toxemia a small amount of blood may be withdrawn (50 to 400 Cc.), for reasons stated in Chapter VI. No hesitation need be felt in introducing 500 Cc. or even 1000 Cc. of this solution. It is the ideal way of bringing a powerful non-toxic antiseptic into immediate contact with pathogenic microbes.

There have been recent suggestions as to the intravenous injection of very dilute formalin solution, in order to take advantage of its remarkable germicidal activity; it has been employed in a few cases, especially of puerperal sepsis, with success, 1 Cc. of standard formalin solution is mixed with 800 Cc. of sterilized salt solution. It has been shown that if 50 Cc. of this is thrown into the veins of an average adult it will form with the 5000 Cc. of blood a mixture of 1 to 200,000, in which strength it may be expected to prove an efficient bactericidal agent. Indeed, a smaller amount or a weaker preparation would probably suffice. Barrows has reported success following two infusions, two days apart, of first 500 Cc., then 750 Cc. of a 1 to 5000 formalin solution. Still, these injections may be followed by cramps in the arms, cardiac discomfort or distress, and blood (or blood cells) in the urine. It would probably be well to limit this use of formalin to those cases at least in which the presence of cocci in the blood can be demonstrated by culture or other method.

An excellent method in the local treatment of parts which admit of it (hands and feet) is their exposure to dry hot air in the Kelly heater or some similar apparatus. Hot air will be borne at a temperature of 210° to 220°, which may be destructive to germs while still tolerable for a short time by the tissues. Clinton, of Buffalo, with whom this method is original, reports that the temperature within the tissues thus treated is raised to about 107°, which is above the thermal death point of the ordinary pyogenic organisms, and that this method gives better results than any other of treatment of septic infection of those parts which can be subjected to it.

The general treatment of septicemia is, in the main, stimulant and tonic. Fever is not to be treated with arterial sedatives nor often with antipyretics. It is a symptom of poisoning, and its too prompt suppression prevents both the recognition of the intoxication and the measure of its degree. Pyrexia then is best combated with cool sponge baths and stimulant measures of a general character. The principal reliance must be upon nutrition and stimulants. Assimilation may be impaired when gastro-intestinal catarrh is as prominent a feature as it is in many of these cases. Consequently the simplest and most assimilable food, often that which is predigested, should be administered. Milk, eggs, beef peptonoids, and fruits are among the most appropriate. The best stimulants and tonics are alcohol and strychnine. Strychnine is preferably administered hypodermically in doses of ¹⁄₂₅ grain from two to four times a day. Heart depression is best combated by this measure, or by quinine in large doses, while digitalis and atropine may be added. For internal use alcohol is, par excellence, the remedy. This is administered in doses only to be measured by their effect. In fact, the administration of alcohol in these cases is a matter of effect, and not of dosage. Aside from these measures the intestinal antiseptics should be administered, among these being corrosive sublimate, ¹⁄₁₀₀ grain, every three or four hours, salol in large doses, bismuth salicylate, or naphthalin—any or all of these in connection with powdered charcoal. Intestinal pain and frequency of stool can be more or less controlled by opium, while disinfection of the alimentary canal is only to be accomplished by the above remedies, in connection with flushing of the colon with saturated boric acid solution or something of that kind. Pain is to be controlled by morphine administered subcutaneously.

No special attention need be given to the so-called septicopyemia. It represents a mixed condition of septic intoxication, local infection, and destruction, with metastatic abscess, and is a term appropriately applied to cases which combine the significant features of each type.

The derivation of the term pyemia, which came into general use in 1828, is misleading. Although septic fever always accompanies suppuration, it is not certain that pus as such circulates in the blood, as the term pyemia implies, the error having arisen originally from mistaking the contents of breaking-down thrombi for pus from ordinary sources. While a recognition of the etiology of the disease is new, the disease itself has been recognized for many centuries.

Pyemia is only met with in connection with suppuration, as far as known, never without it. In those cases which appear to be free from suppuration pus will be found. Pyemia may be described as septicemia plus thrombotic and embolic accidents, which lead to distribution of infectious material to all parts of the body. This distribution is made by the bloodvessels, although to some extent the lymphatics undoubtedly participate. When pyogenic organisms reach bloodvessel walls they tend to set up a mycotic phlebitis, which, by virtue of the coagulating blood, becomes soon what is known as thrombophlebitis. Infection proceeding through the vessel walls, the endothelial lining is loosened, while to these rotting spots leukocytes adhere and coalesce into a more or less homogeneous mass. This so-called white thrombus becomes also infected with bacteria; portions of it, loosened and dislodged, are carried by the returning blood stream to the right side of the heart, whence they are distributed through the lungs. Dislodgement may be made by mere force of the blood stream, or may be assisted by movements of the part or handling of the same. These particles of thrombi are loaded with the infectious organisms which began the disease, and wherever one settles a reproduction of the original thrombophlebitis is rapidly produced. In this way numerous infected thrombi are formed within the vessels of the lungs, which, again, loosen, and are now swept into the left side of the heart, whence they are distributed with arterial blood in all directions. While it is true that they are equably distributed, it is also positive that certain tissues seem more capable of lodging and being attacked by the contained organisms than are others. When it is once appreciated that each particle of infected clot is capable of setting up, either in the lungs or in the other tissues, upon the second distribution, other abscess formations analogous in etiology to that from which came the first disturbance, then the fundamental idea of metastatic abscess is fully impressed. The term metastasis may be regarded as synonymous with transportation, and metastatic abscesses are those produced by transportation of infected particles from one part of the body to another. Wherever they lodge similar trouble will result. Contiguous minute metastatic abscesses quickly coalesce, and in this way large collections of pus are formed. The blood also contains organisms not attached to thrombi, and from the blood of the pyemic patient cultures can at almost any time be made. Until this is done it will be virtually impossible to incriminate any particular organism as the one at fault. Thrombo-arteritis is the equivalent in the arteries of thrombophlebitis in the veins, and is accompanied by the same detachment of endothelium, adhesion of leukocytes, etc. Whenever such a lesion occurs in artery or vein, coagulation necrosis takes place and suppuration occurs around it. The metastatic abscess is thus the result of breaking down of this affected tissue, and is often called miliary abscess. Particles of infective thrombi cling also to the valves of the heart and a septic endocarditis may result.

The possibility of so-called spontaneous or idiopathic pyemia is occasionally discussed. This means a pyemia whose cause is concealed. The explanation will be found sometimes in an acute infectious osteomyelitis, sometimes in ulcerative endocarditis, or inflamed appendix or other portion of the peritoneal cavity. Again, it may proceed from middle-ear disease, in which there is so little discharge as scarcely to attract attention. Thus causes which predispose to suppuration (see Chapter III) come into play here, and the influence of exposure, fatigue, starvation, etc., is not to be ignored in furnishing an explanation for the so-called idiopathic cases.

In the majority of instances, however, pyemia follows surgical operations and injuries, among which are compound fractures, deep injuries with small superficial evidence thereof, compound injuries of the skull, and injuries by which veins are exposed. Inasmuch as the typical pyemic manifestations require a certain length of time for their development, the onset of this disease is more delayed than in the case of septicemia. While the case may be manifestly one of septic infection of unrecognizable type, the characteristic indications of pyemia seldom appear in less than ten days, and frequently not for several days longer.

Symptoms.

—The symptoms of pyemia do not essentially differ from those of other septic infections. The principal difference is in the frequency of chill and range of temperature. Chills are more common at the inception of the condition, and more frequent throughout its continuance than in other septic conditions. The chill may be slight or assume the proportions of a rigor, and each chill is followed by colliquative sweat and exhaustion. In other words, chills which are infrequent in septicemia are common in pyemia. There is reason to believe that with each fresh distribution of emboli we have one or more chills as the objective evidence thereof. Distinctive also of pyemia is the temperature curve, which much resembles that of intermittent fever, without the regularity of change characteristic of malarial fevers. It is without regular remissions, and has been referred to as irregularly intermittent. The first rise is abrupt and usually excessive, while with each fresh chill or series of chills similar abrupt alterations will be noted. These occur so frequently and fluctuate so irregularly that in order to note them accurately the temperature should be taken at least every two hours. The temperature seldom drops to normal.

As the lungs fill with the first crop of infected emboli, and the first series of metastatic abscesses form there, there is more or less dyspnea and sense of oppression; there may be also pulmonary complications—pleurisy, bronchitis, etc., even pulmonary edema. Frequently there is expectoration of frothy and discolored sputum; occasionally there is blood in the sputum. A peculiar sweetish odor of the breath has been noted by many observers in this disease, and is supposed to be idiopathic and characteristic. (See acetonemia in previous chapter.) With the dispersion of the second crop of emboli from the lungs there is apt to be icterus, with evidence of metastatic abscess in the liver, and collection of pus as the result of coalescence of small abscesses. The sensorium is not so affected in pyemia as in septicemia, and in the former disease patients are more likely to be alert and active in mind. General hyperesthesia and restlessness are common. Colliquative sweats are also a feature of pyemia. There is the same liability to eruptions, etc., which may mislead or complicate the diagnosis. A dermatitis is seen sometimes in pyemia, the lesions assuming a papular or pustular form, due to local infections of the skin. Purpuric spots are also seen, and vesication is not infrequent. Within the mouth sordes collect upon the teeth or gums; the tongue becomes dry and brown and heavily coated. Diarrhea is less common in pyemia. The urine is usually scanty and high colored, containing solids in excess; albumin is sometimes found therein, as well as peptone. The presence of peptone in the urine is probably an indication of the breaking down of pus corpuscles in various parts of the tissues.

A significant objective evidence of pyemia is met with in the metastatic collections of pus within the joints, which occur relatively early, and which, if multiple, may lead to a correct diagnosis. One of the earliest joints to be involved is the sternoclavicular, although none of the joints are free from the possibility of invasion. The articular serous membranes seem to have the property of carrying and holding the infective thrombi better than any other tissue in the body. The pyarthrosis of pyemia is for the most part painless, yet implies loss of function of the affected joints. The distention of these is usually evident to the eye, the fluctuation pronounced, tenderness not extreme, but the swollen part merges into tissues which are edematous and reddened. When pain in the limb is extreme, it is usually because of metastatic abscess within the bone-marrow cavity. In other words, we now have a metastatic osteomyelitis.

In all cases of pyemia prostration is marked, yet the pulse is seldom weak, at least until toward the close of life. As cases progress from bad to worse subsultus tendinum is often noted.

The appearance of the wound or site of operation does not differ essentially from that already described under Septicemia. There is usually, however, less discharge, granulations are smoother and dryer, and if tissues are gangrenous they are not as wet and nauseous as in the other case. Evidences of thrombophlebitis and lymphangitis will proceed from the wound toward the body, as in other instances of septic infection.

Prognosis.

—Prognosis is usually bad. While recovery may follow where metastatic infiltration has not been too general, the ordinary case of pyemia will die within twelve to fourteen days after diagnosis. Sometimes the entire process is much slower, and isolated cases occur which can be designated as so-called chronic pyemia, which differs but little from the acute form. A case of pyemia should not fail of recognition because there is no evidence of infection from without. A fatal case of pyemia has been known to occur from a suppurating soft corn which was not discovered during life; also from peridental abscess, etc., which had been overlooked. Death is the result of tissue destruction and septic intoxication.

Postmortem Appearances.

—In the vessels these consist essentially of thrombosis, examples of which may be seen, for instance, in the cranial sinuses and in the large veins. Aside from these, with the enlargement and softening of the spleen, the liver, and lymphatic structures, already described under Septicemia, the principal objective evidences consist in the discovery of metastatic abscesses in many or all parts of the body. As stated above, there is no tissue or organ in which they may not be found. The mechanism of their production has been already described. Infarcts may also be met with, in the kidneys especially, the liver and spleen as well, and indicate areas already cut off from blood supply by thrombo-arteritis, in which abscess formation would have occurred had time been given. In the liver large abscesses may be found; joint cavities may be filled with pus; the lungs are usually the site of innumerable small abscesses. The other postmortem changes commonly noted are not difficult of explanation, but are not so characteristic or pathognomonic as to call for further mention. In a joint which has become filled with pus there usually has been loosening of the cartilage and more or less disorganization of all the joint structures, which appear to have undergone rapid ulcerative destruction and putrefaction.

Treatment.

—Treatment of pyemia is in large degree unsatisfactory. That which used to be the terror of surgeons in the pre-antiseptic era is now, thanks to Lister and others, almost abolished. Pyemia is a rare disease in modern surgical practice. Its possibility should be borne constantly in mind, however, and the necessity for careful antiseptic or for a rigid aseptic technique is in large degree based upon fear of pyemic consequences.

When once established, the disease is to be treated on lines nearly similar to those laid down for septicemia, including resort to the ichthyol or silver ointments, and to intravenous infusion of silver solution. (See p. 89.) Amputation or extirpation of the part from which infection has first proceeded may be of avail. Among the most successful measures for surgical treatment of this disease is to expose the infected area, open the involved veins, and either excise them or scrape them out and disinfect them. This treatment has been successful in cases of cranial infection following middle-ear disease, etc. (See chapter on Cranial Surgery.)

Disinfection of the infected area and immersion in hot water should be practised. Metastatic abscesses should be opened and drained, and every accessible collection of pus evacuated, either by the knife or aspirator needle—e. g., in the liver.

The medicinal treatment is practically the same as in septicemia, while the surgeon’s mainstays are alcohol and strychnine. These, with cathartics and intestinal antiseptics, will practically sum up the drug treatment, the surgeon meantime not neglecting the matter of nutrition, crowding it in every assimilable form.

Erysipelas is an acute infectious disease characterized by its tendency to involve the skin and cellular structures, to extend along the lymphatic vessels, to involve wounds and injuries under certain conditions, accompanied by more or less fever of septic type, leading frequently to septic disturbances of profoundest character, yet tending in the majority of instances to spontaneous recovery. It has been observed probably from prehistoric times, but has not found a proper description nor appreciation until perhaps within the past century. It occurs in so-called traumatic and idiopathic form—which latter means that the site of infection is not discovered—and also in a virulent and contagious type, which leads to the appearance of a number of cases over a large territory; it often appears in the epidemic form. On account of the reddening of the skin it goes by the name of the rose among the German laity. It may assume the type of an infectious dermatitis, subsiding without suppuration, or a similar lesion of exposed mucous membrane may be noted, or, occasionally, its virulence seeming greater, its lesions are met with in more deeply seated parts, accompanied by suppuration or even gangrene, and it is then called phlegmonous. In a small proportion of cases the infectious organism appears to be transported from one part of the body to another, and thus we have metastatic expressions of this disease. The most common examples of this are seen in erysipelatous meningitis after erysipelas of the face or scalp, and erysipelatous peritonitis after the disease has manifested itself on the truncal surface. It is of a type which makes itself almost interchangeable with puerperal fever; and when epidemics of erysipelas have involved certain states or areas, it has been noted also that nearly every obstetrical case developed puerperal septicemia.

Etiology.

—There is more than passing interest connected with this last statement. It is now definitely established that the infectious organism is a streptococcus which is allied to, if not identical with, the streptococcus pyogenes, the ordinary pyogenic organism of this form. This specific organism has been separated, studied, and its role assigned by Fehleisen, and the organism is frequently called Fehleisen’s coccus. Preserving always its morphological characteristics, it acts, as do many other pathogenic organisms, within wide limits in virulence. Cultivated from some cases, it scarcely seems infectious, while from others it is fatal.

Pathology.

—The disease manifests a tendency to travel via lymphatic routes. As long as it is confined to the skin and superficial tissues it has the appearance of an acute dermatitis. When it migrates deeper it generally leads to suppuration, another reason for believing that the streptococci of erysipelas and of pus production are the same. In the affected and infected area the minute lymphatics will be found crowded with the cocci, which are seen much less often in the small bloodvessels; also in the tissues beyond the apparently infected area they may be found dispersed less freely. The bacterial activity seems most active along the advancing border of the superficial lesion. Here the phenomena of hyperemia and phagocytosis are most active. Even in the vesicles that are characteristic of the disease the organisms may be found.

The discharges from this region are infectious, and caution should be observed in dressing such cases. A finger pricked by a pin from a dressing may subject the individual to loss of life. The dressings containing the discharges should be burned immediately.

The path of infection is usually through a wound, and as soon as discovered a case of erysipelas should be separated from all surgical cases, or if the erysipelatous patient cannot be isolated, he should be removed from proximity of other wounded individuals.

Erysipelas which follows injury, however slight, is termed traumatic. The terms “idiopathic” or “spontaneous” should be restricted to those cases in which the path of infection is not discovered.

Symptoms.

—With the exception of the local appearances, they are essentially the same in both of the above-mentioned forms. The characteristic feature of the disease is a dermatitis with its peculiar roseate hue, which it is impossible to describe in words. In tint it differs slightly from that noted in certain cases of erythema. It is, however, accompanied by an infiltration of the structures of the skin, so that the area which is reddened is at the same time elevated above the surrounding surface. Its edges are often irregular. As exudate takes the place of blood in the tissues, the red tint merges into a yellow. At this time there is more induration of the skin and tendency to pit on pressure. Vesication of this involved area is now frequent, the vesicles often coalescing and forming large blebs and bullæ, which fill with serum that may become discolored or purulent. When exposed to the air, unless the tissues become gangrenous, this serum usually evaporates and forms scabs. This disturbance of the skin is always followed after a number of days by desquamation. This infectious dermatitis shows a constant tendency to spread in all directions. Its most characteristic appearances are limited to the margin of the enlarging zone, while in its centre there may be evidences of recession of the disease. If it commences in the vicinity of a wound it will probably spread in all directions from it. Beginning in the face, it usually spreads upward; in the trunk, in all directions; if on the extremities it tends to migrate toward the trunk. Wandering erysipelas is a term often applied to these phenomena. The metastatic expressions of the disease have been described.

When this affection attacks a recent wound the local appearances are not essentially distinct from those mentioned under Septicemia. The wound margins separate to a greater or less extent, the surfaces slough, and a characteristic seropurulent discharge occurs. Granulating surfaces usually become glazed—often covered with a membrane resembling that of diphtheria; deep sloughs may occur, undermining of wound edges, even hemorrhages from destruction of vessel walls. In rare instances, however, under the influence of the microbic stimulation granulations proceed faster than normal.

Whether the disease proceeds from an injury or not, the constitutional symptoms vary but little. There is usually a period of malaise with nausea, followed by alimentary disturbance, coating of the tongue, elevation of temperature, sometimes with occurrence of chill. Complaint of pain or unpleasant sensation will lead to examination of the area involved, when the above symptoms will be noted, with evidences of lymphangitis and enlargement of lymph nodes. When chill occurs it is followed by pyrexia. Temperature fluctuates, with a tendency to assume the remittent type. When the disease subsides spontaneously it is by a gradual process of betterment and subsidence of temperature. In other instances the constitutional symptoms assume more or less of the septicemic or typhoid type, and it is seen that the patient’s condition is practically one of mild septicemia, which often proves fatal.

When the disease assumes the phlegmonous type the constitutional symptoms become more and more typhoidal and the septicemia becomes most pronounced. Locally exudation goes on to the point of threatening, even of actual, gangrene, unless tension is relieved by incisions. Pain is usually intense, partly because of confined exudates beneath resisting structures. More or less rapidly the local and constitutional signs of pus formation are noted, and unless these are observed and acted upon early there will not only be suppuration, but more or less actual gangrene, so that not only pus, but sloughs of tissue will be discharged through the incision, or will, when this is delayed, make their escape by death of overlying textures.

In all phlegmonous cases there is practically coincidence of septicemia, already described, and of the local appearances above noted. In proportion to the extent of the lesion in these phlegmonous cases, and failure to afford relief, will be the opportunity for septic intoxication.

The mucous membrane does not always escape, and even in the nose, the pharynx, the vagina, and the rectum a distinctive erysipelatous lesion may be found. The disease may travel from the pharynx through the nose and involve the face, or through the Eustachian tube to the ear and thence to the scalp, or vice versa. Erysipelatous laryngitis is to be feared on account of edema of the glottis, which would soon be fatal unless overcome by intubation or tracheotomy. An infectious exudation into the lungs is also known to follow erysipelas, and has been considered an erysipelatous pneumonia. The cellular tissue of the orbits may also be involved, when abscesses will occur, which should be opened early; the parotid and other salivary glands may become involved, usually in suppuration.

Many cases are accompanied by much gastric irritation, which it is difficult to explain. Ulcers are sometimes found in the intestines, as after burns. These usually give rise to bloody diarrhea. The cerebral symptoms may be simply those of delirium from irritation or of meningitis from infection. Strange phenomena have followed the disease in certain instances—cessation of neuralgic and of vague, unexplainable pain, improvement in deranged mental condition, spontaneous disappearance of tumors, etc. Advantage has been taken of this last in the treatment of these cases. (See Cancer.)

It is quite likely that some of the worst forms of phlegmonous erysipelas are due to mixed infection. To inject the bacillus prodigiosus together with the streptococcus of erysipelas will greatly enhance the virulence of the latter, so that reaction may proceed even to gangrene.

Postmortem Appearances.

—These are not distinctive, but are a combination of local evidences of suppuration and gangrene, with the deterioration of the blood, the softening of the spleen, etc., which are characteristic of septic poisoning. Only in the skin, and then under microscopic examination, can any pathognomonic appearance be discovered. This will consist in the crowding of the lymphatic vessels and connective-tissue spaces with cocci, in the evidences of rapid cell proliferation, in the quantity of exudate, in vesication, sloughs, etc.

Diagnosis.

—Diagnosis of erysipelas should be made mainly from various forms of erythema, from certain drug eruptions, and from other forms of septic infection which do not assume the clinical type of erysipelas. The gastric symptoms of this disease are sometimes produced by certain poisonous foods or the distress which is produced by medicines, such as quinine, antipyrine, etc.

Prognosis.

—The majority of instances of idiopathic erysipelas run a certain limited course, although the eruption may spread to almost any distance upon the body. When the disease attacks surgical cases, and especially when it involves wound areas, the prognosis is not so good. When the disease assumes an epidemic type and involves cases of all kinds, it will be found to have a virulence that may make it a most serious affair. In proportion to the extent to which it assumes the phlegmonous type it will be found locally, if not generally, destructive. The ordinary case of facial erysipelas will recover with almost any treatment. Nevertheless meningitis may develop, and even a mild case is to be treated with care and caution.

Treatment.

—Danger comes from two sources—septic intoxication and local phlegmons or gangrenous destruction. Each is therefore to be combated. Treatment should consist of isolation. There is no specific internal treatment for this disease. Tincture of iron, which was long vaunted as such, has proved unsatisfactory, and is of benefit only as a supporting measure in a limited class of cases. Constitutional measures should be employed: First, for the purpose of maintaining free excretion by bowels and kidneys; second, for the purpose of supporting and maintaining strength; third, for tonic and stimulant measures in prostrated and debilitated patients; and, fourth, for the purpose of combating intestinal sepsis or intoxication from any other source. The robust patients with this disease need no particular tonic. The aged, the enfeebled, the dissipated, the prostrated individuals, and the confirmed alcoholics are those who need vigorous stimulation, partly by alcohol and quinine, and partly by strychnine, preferably given hypodermically, and by the other diffusible stimulants by which they may be kept alive. Pilocarpine, given subcutaneously and pushed to the physiological limit, has been praised by some. If along with prostration there occur restlessness and delirium, then anodynes and hypnotics are serviceable, and should be administered to meet the indication—morphine hypodermically and any of the agents which produce sleep are now most beneficial. Finally, if there is any drug which can be administered in doses sufficient to saturate the system with an antiseptic which shall at the same time not prove fatal because of toxicity, this is the ideal medicament for constitutional use only. Such a drug is not known, but it will be well to give some near approach to it internally, as by administering corrosive sublimate, salol, naphthalin, or something else of this character in doses as large as can be tolerated.

Should patients become violent it may be necessary to resort to mechanical restraint—a strait-jacket, a restraining sheet, a camisole, etc.

Nourishment must be kept up by the administration of the easily assimilable and predigested foods.

Locally the number of remedies that have been resorted to is legion. In a mild case of spontaneous erysipelas—i. e., where no infection can be traced—it will sometimes be sufficient to put on a soothing application, like a lead-and-opium wash. It often gives relief to have the part protected from air contact, which may be done by a soothing ointment or by dusting the part with a powder, such as bismuth oleate or subnitrate, zinc oxide, etc., these being rubbed up with powdered starch; or by a film of rubber tissue or of oiled silk. Brewers’ yeast applied on compresses and covered with oiled silk is efficacious.

Even before the bacterial origin of the disease was accepted it had been suggested to use antiseptic applications, either in watery solution or combined with oil or some unguent; this is now the ideal method of local treatment, the difficulty being only to find that which shall be efficacious as an antiseptic, yet not injurious in other ways. Compresses wrung in solutions of various antiseptics are often serviceable. The following preparation has given satisfaction: Resorcin (or naphthalin) 5, ichthyol 5, mercurial ointment 40, lanolin 50. The proportions of these ingredients may be varied, and the amount of ichthyol sometimes increased, especially when the skin is not too tender. The affected parts are anointed with this, and then covered with oiled silk or other impermeable material, simply to prevent its absorption by the dressings; the parts are then enveloped in a light dressing and bandaged. Credé’s silver ointment has also proved useful. As the disease becomes mitigated the ointment may be reduced with simple lard, and discontinued when local signs have disappeared. Absorption of any of these preparations may be hastened by scratches over the affected area with the sharp point of a knife.

Treatment of threatening phlegmon, or phlegmonous erysipelas, must be more radical, and consists of free incision down to the depth of the deepest tissues involved. In treating dissecting and other septic wounds of the fingers incision should be made to the tendon sheaths, even to the bone. It is only by such radical measures that worse disaster may be avoided. Some aggravated local cases are treated by a series of deep incisions with the use of the curette, the surface after careful clearing being kept buried under an antiseptic solution (silver lactate 1 to 500) or ointment.

In connection with erysipelas and the role of the lymphatics, it is advisable to consider the relation and behavior of the lymph nodes and granulation tissue to infecting agents. Depending on the virulence of the infectious material, the site of infection, and the variety of the microbe will be its arrival in these protective filters. Then follows a series of cycles of maximum and minimum activity in the nodes, during the former the bacteria almost disappearing. The more pathogenic the microörganism the more certain the destruction of the lymph node, or perhaps of the individual. The well-known enlargement of the nodes is due almost solely to an increase in their lymphoid elements. Halban, who demonstrated these cyclic variations in the contents of the lymph nodes, is inclined to insist on an intimate relation between them and the temperature variations noted in cases of septic infection.

When granulations are present the lymph sacs are closed, as by a sanitary cordon. Unless this tissue is broken they are proof against ordinary infection. It is well known that erysipelas will appear about an old wound or sinus that has been rudely probed. Even virulent organisms spread upon healthy granulating surfaces fail to infect. Strong carbolic and other toxic agents can be used in and about such granulating cavities with an exemption from poisoning that otherwise would produce dangerous effects.

CHAPTER VIII. SURGICAL DISEASES COMMON TO MAN AND DOMESTIC ANIMALS. — TETANUS. — HYDROPHOBIA. — GLANDERS AND FARCY. — ANTHRAX. — MALIGNANT EDEMA. — ACTINOMYCOSIS. — MADURA FOOT.

Synonyms: Trismus, Lockjaw.

Tetanus is an acute infectious disease, of relatively infrequent occurrence, invariably of microbic origin, characterized by more or less tonic muscle spasm with clonic exacerbations, which, for the most part, occurs first in the muscles of the jaw and neck, involving progressively, in fatal cases, nearly the entire musculature of the body. Certain races of people seem predisposed, and in certain climates and geographical areas the disease is exceedingly prevalent. Negroes, Hindoos, and many of the South Sea Islanders show a peculiar racial predisposition, and, in a general way, inhabitants of warm countries are less resistant. This is shown partly by the fact that in various European wars the Italians and French have suffered more than the soldiers of more northern climes. Tetanus is by no means confined to adult life, since infants are far from exempt, and in the tropics the trismus of the newborn is the cause of a high mortality rate. In Jamaica one-fourth of the newborn negroes succumb within eight days after birth, and in various other hot countries the proportion is at times equally great. One plantation owner states that fully three-fourths of the colored children born upon his plantation succumbed to the disease. The peculiar reason for this infection will appear later when speaking of tetanus neonatorum. Men seem more commonly affected than women, probably because of their occupations, by which they are more exposed. Military surgeons have had to contend with the disease in its most virulent form, and it has been noted that soldiers when worn out by fatigue or suffering from the disaster of defeat seemed more liable to the disease. In 1813 the English soldiers in Spain suffered from tetanus in the proportion of 1 case to 80 wounded men. In the East Indies, in 1782, this proportion was doubled. Quick variations of heat and cold, such as warm days and cold nights, coupled with the other exposures incidental to military life, seem to exert a great effect. Curiously enough, the wounded in many campaigns who have been cared for in churches have suffered more from the disease than those cared for in any other way. Tetanus, however, is by no means necessarily confined to any one clime or race, but may be met with anywhere, at any time, providing only that infection has occurred. A celebrated Belgian surgeon lost by tetanus ten cases of major operations before he discovered that the source of the infection was his hemostatic forceps. As soon as these were thoroughly sterilized by heat he had no further undesirable complications. If the disease can be conveyed by the instruments of a careful surgeon, how much more so by the dirty scissors of a careless midwife, etc.

It is true, also, that the popular notions of the laity concerning the liability to tetanus after certain forms of injury are not ill-founded. Small, ragged wounds of the hands and feet are those which ordinarily receive little or no attention, and are among those most likely to be followed by this disease. The toy pistol, which, a few years ago, was such a prevalent and widely sold children’s toy, was the cause of many a small laceration of the hand, due to careless handling and the peculiar injury produced by the explosion of a small charge of fulminating powder in a paper or other cap. It was not the character of the laceration or injury thereby produced, but the fact that such injuries occurred in the dirty hands of dirty children, which were most likely to become infected, that has caused the so-called toy-pistol tetanus to be raised almost to the dignity of a special form of this disease. During the month of July, 1881, in Chicago alone, there were over 60 deaths from tetanus among children who had been injured in this way by these little toys. This led to their sale being suppressed by law.

Etiology.

—Two theories have had strong advocates, one being that which would account for the disease by irritation of nerves; while the second, the humoral, would explain the disease by alterations in the blood. Each has had its most ardent defenders, but both have now completely yielded to the investigations of a few observers, among whom Kitasato and Nicolaier are the most prominent. These ardent workers were, in 1885, able to clearly establish the parasitic nature of this disease, and to isolate and investigate the organisms by which it is produced.

Fig. 17

Tetanus bacilli, showing spore formation. (Kitasato.)

The bacillus of tetanus is a somewhat slender, rod-shaped organism, with a peculiar tendency to spore formation at one end, which gives it a drumstick appearance. It is essentially an anaërobic organism, and can never be cultivated in contact with the air. In laboratory experiments it is grown in the depths of a solid culture medium or else in fluids and on surfaces in an atmosphere of hydrogen gas. It is one of the apparent contradictions of bacteriology that this organism, which can only be grown as an anaërobe, nevertheless abounds in earth, particularly the rich, black loam which best supports luxuriant vegetable life, and that it practically inhabits the upper layers of the soil, which accounts for the fact that so many contaminations and infections have occurred from stepping upon planks or boards with nails projecting, or from introduction of splinters, or from lacerations of the hands and feet which are so often followed by contact with such materials. There is nothing about a rusty nail wound which, by itself, predisposes to tetanus, but the rusty nail upon which a person steps is either itself infected or leaves a rent or wound which may become infected within the next few moments, and which is not likely to receive the careful attention which it should. Verneuil has of late laid stress upon the fact that in localities where horses are kept tetanus is more prevalent, and that the infectious organism abounds in and upon stable floors, about barn-yards, and wherever the excretions of a horse may be found. Bacteriologists are aware that in the intestines of herbivorous animals the bacilli (anaërobic) of tetanus and malignant edema are often found. Verneuil has further shown that almost the only instances of tetanus which occur on shipboard are upon those ships which are used for transportation of horses and cattle. His statements are at least interesting, if not absolutely well-founded. At all events, tetanus is certainly of telluric origin.

A French veterinary surgeon of twenty-five years’ experience had not seen a single case of tetanus until 1884, when he “removed a tumefied testicle from a horse, with the ecraseur, and it died of tetanus; in the following six months he castrated five, and all died; another castrated fifteen in one day, and all died but one; another in ten days castrated six bulls and operated on three fillies for umbilical hernia, when five of the bulls and one of the fillies died.” This will illustrate how the infectious agent may be conveyed by instruments, etc.

The tetanus bacillus manifests other peculiar properties, for some of which it is most difficult to account. Upon susceptible animals it is violently infectious, but is rarely found at any distance from the tissues in which it has first lodged. In laboratory investigations the period of incubation is seldom longer than forty-eight hours. Another peculiarity of the organism is that it generates certain poisons of active properties which may be separated from pure cultures, by whose injection the peculiar spasms of the disease itself may be reproduced. These have been isolated, especially by Brieger, who has given to them the names of tetanin, tetanotoxin, spasmotoxin, etc. It has been estimated that about ¹⁄₃₀₀ Gm. of the pure toxin of tetanus would be a fatal dose for a man. This toxin seems to have a specific affinity for the ganglion cells of the anterior horn of the spinal cord, with which it unites with great force. Herein lies the secret of its disturbing power.

It is peculiar that some time may elapse after its injection before the appearance of the first symptoms. Diphtheria toxins appear to be prompt in their action, and thus display quite opposite characteristics. Experiment would seem to show, moreover, that the tetanus toxins do not reach the cord through the blood stream, but appear to slowly pass along the axis cylinders. Sensory nerves do not transport the toxins to the cord. The toxin enters the nerve termination, first of all, at the site of the infection, where it is most concentrated, which will explain why the spasms most frequently begin in the vicinity of the infection, or are the most marked there. Most of the toxin is taken up by the blood and lymph and distributed all over the body, and then passing along the motor fibers it enters the cord and leads to general convulsion. When the toxin is injected directly into the cord the symptoms begin at once. Therefore, for protective purposes, much may be expected from the administration of the antitoxin in cases of suspicious injury or those where experiment has shown there is reason to fear the development of tetanus. There does not appear to be on record a single instance in which a person who had been given antitoxin soon after receiving such a wound has developed tetanus, nor does the antitoxin by itself seem to have done any harm. Obviously, then, the earlier antitoxin is used in the case the better. It may be recalled that there are no diagnostic symptoms of tetanus until the first spasm develops, usually after the expiration of from five to twelve days. By this time the nerve cells are thoroughly saturated with the poison and considerable time may elapse before the antitoxin can reach these cells by a more indirect route.

Tetanus Neonatorum.

—Tetanus neonatorum, or tetanus of the newborn, a condition already alluded to, is a remarkably fatal affection, very prevalent among the negro race, especially in hot climates. It nowise differs from traumatic tetanus, but is such in effect, since the infection in these instances always follows the division of the umbilical cord, which is usually effected with dirty scissors in the hands of a dirty midwife, while the thread with which the cord is tied is itself a possible source of infection, as well as the rags which are used to cover the umbilicus in the first dressing. It is generally fatal, because of the weakness and lack of resistance of these little patients. It occurs usually within a week after birth, if at all.

Tetanus Cephalicus.

—Tetanus cephalicus, called also tetanus hydrophobicus and head tetanus, is only a peculiar manifestation of this same affection, confined mainly to the head and usually following injuries to this region. The muscle spasms are mostly confined to the facial, pharyngeal, and cervical muscles, sometimes extending to the abdominal. These manifestations may be reproduced in animals by inoculating them on the head rather than upon the extremities. It is the least fatal form of the disease.

Symptoms.

—There is always a period of incubation, usually three or four days, occasionally a week in length, but rarely longer.

It is generally held that the longer the period of incubation the more hopeful the prognosis. While for the great part the disease assumes an acute type, a chronic tetanus is described and occasionally seen. The first warning of the disease usually comes as more or less stiffness of the cervical and maxillary muscles, which is likely to be referred to by the patient as a “sore throat,” because of the consequent difficulty in deglutition. A complaint to this effect should be regarded as a warning, especially if on inspection no visible reason for it can be detected in the pharynx. This complaint is usually made in the morning after an ordinary night’s rest. This muscle stiffness will be followed by increasing tonic spasm in the muscles of the jaw, making it difficult to open the mouth, while the head and neck gradually become stiffened and fixed by spasm of the cervical muscles. These muscles may now be felt more or less rigidly contracted, as if by voluntary effort, and the condition, which is at first not painful, becomes after some hours a source of discomfort, perhaps of actual pain, to the patient. If the disease pursues the usual course, the other muscles of the body become gradually affected, usually in the order of their proximity, but not necessarily so. The abdominal muscles are firm and board-like, and the dorsal muscles more or less contracted, sometimes to an extent which causes arching of the spine. Should the original wound or port of entry for infectious germs have been in the hand or foot, the muscles of this limb become contracted, more or less rigidly, holding it in a position which is not easily changed, even by efforts of the attendant. Sensation is also often more or less perverted. In this condition of tonic rigidity the muscles remain, to relax usually only with death.

The most characteristic features of the disease, however, are the peculiar clonic exacerbations, which convert spastic rigidity into violent and convulsive muscle activity, so that the limbs and even the frame of the patient are more or less contorted, the muscle exertion being sometimes painful to witness. Notable effects are thus produced; the mouth is peculiarly puckered, and its corners drawn upward and backward by the risorius muscles, giving to the face that peculiar expression known as the “sardonic grin.” When the abdominal and flexor muscles of the thighs are involved, and the body is more or less curved forward, this condition is known as emprosthotonos; when the muscles of the back especially are involved, with the extensor muscles of the thighs, as opisthotonos; and when the body is bent to one side or to the other it is called pleurosthotonos. It is said that opisthotonic convulsions occur to such an extent in some instances that the heels touch the head. At all events, the patient’s body is frequently raised from the bed, so that he rests upon the head and feet.

Another characteristic feature of the disease is the reflex irritability, or hyperesthesia, by which these convulsive attacks apparently are produced. Into this condition the patient falls more or less rapidly within the first day after the inception of the disease, and to such a height may it be augmented that the slightest movement in the room, jarring of the bed, or displacement of clothing, even noise or a flash of light, may immediately bring on a convulsion. Rupture of muscles has been reported during some of these violent convulsions.

Fig. 18

Characteristic tetanic spasm in a rabbit twenty-six hours after inoculation with pure culture of tetanus bacilli. (Tizzoni and Cattani.)

During the course of this disease the jaws are so fixed that patients speak with extreme difficulty and the tongue cannot be protruded. The mind is clear until the end. The pain is rather the acute soreness due to intense muscle strain. There is spasm of the sphincters, by which urine and feces are often retained. There is nothing characteristic about the temperature, which is seldom much augmented. Attempts to swallow give pain, and are resisted because of the renewed muscle spasm which is likely to follow the irritation inseparable from the act itself. As the result of spasm of the glottis peculiar respiratory sounds may be noted.

Until the last only the voluntary muscles are involved. Finally, however, there are spasms of the accessory respiratory muscles and of the diaphragm. Death is usually produced by involvement of these muscles analogous to those of the others, and results usually from apnea or suffocation. During the last hour or two perspiration may be copious and the temperature may rise.

Chronic tetanus is characterized throughout by a milder and much more prolonged series of symptoms. The period of incubation is much longer, and, while the general program of the acute form is adhered to, it is of less severe degree and is spread over a longer time; in fact, cases covering two months or more are reported. In chronic tetanus the prognosis is much more hopeful than in the acute form.

The wound is but slightly, if at all, affected. In some cases it will be found to have healed before the onset of the disease. If suppurating or open, its evidences of repair will be found unsatisfactory and some indications of septic infection may be noted. Pricking or needle sensations may be subjective phenomena.

Prognosis.

—Prognosis is almost invariably bad; if patients live more than five or six days it is thereby improved.

Postmortem Appearances.

—These are rarely distinctive. In most instances there are evidences at least of hyperemia, if not of more active changes, in the upper portions of the cord. Less often slight changes have been noted in the brain, consisting, in some measure, of disintegration and softening. Evidences of ascending neuritis in the nerve trunks leading to the injured area have been claimed in some instances. Few if any distinctive postmortem changes can be described as due to this disease.

Diagnosis.

—The diagnosis should be made as between strychnine poisoning, hysteria, hydrophobia, tetany, and, in the beginning, from pharyngitis, tonsillitis, etc. When the disease is fully developed it is not likely to be mistaken for anything else.

Tetanus may be simulated by hysteria, but in this event the phenomena will be so uncertain, and the evidences of organic disease so essentially lacking, that it is not likely that mistake can occur.

Treatment.

—If any case can be imagined in which efficient treatment is most urgently demanded it is one of tetanus. In scarcely any disease, however, is drug treatment so unsatisfactory. In the rare instances in which patients have recovered it is questionable whether it is not due to individual resistance rather than to medication. Treatment may be subdivided into local, constitutional, and specific. If there is still an open suppurating or discharging wound, it is, of course, essential to cleanse this out, basing this advice in some measure upon general principles—largely upon the fact, already stated, that ordinarily only the immediate surroundings of such a wound are found infected by the bacilli themselves. Consequently thorough scraping, excising, and cauterization, either with powerful caustics or the actual cautery, are indicated. Since the specific germ is an anaërobe, hydrogen dioxide may be used locally with great advantage, mainly because it oxidizes the albuminous material upon which the bacilli thrive. If it is in a finger or toe, amputation may be the simplest method of eradicating the local lesions.

Constitutional treatment may be divided into nutrition and medication. The tendency too often in these cases is to be careless or indefinite with regard to the excretions and the nutrition of the patient. If, for instance, each attempt at catheterization throws him into convulsions, the bladder may become overdistended and burst. So, too, there is apprehension usually in regard to fecal evacuations. At the same time these patients are allowed to almost starve because of the difficulty of feeding them. It is advisable to resort to chloroform to permit the introduction of the stomach tube—through the nostrils, if necessary—by which nutrition may be introduced into the stomach without causing the violent convulsions that would occur without an anesthetic. At the same time the catheter may be used.

In the way of active medication there is no agent so efficacious for controlling the tetanic spasms as chloroform, which may be administered occasionally, or more or less continuously, according to the wishes of the attendant. By its use the severest spasms can be kept in abeyance, and the horrible character of the disease somewhat mitigated. Of the other medicaments used, most of them are of the nature of nerve sedatives, such as chloral, the bromides, Calabar bean, cannabis indica, opium, etc. Hot-air baths or diaphoretics, by which copious perspiration may be induced, have yielded good results.

Specific treatment means in these instances taking advantage of the well-known properties which the blood serum of an animal artificially immunized against the disease possesses. This is in accordance with experimental labors with a number of different diseases, of which tetanus is one. It is, in effect, similar to the serum therapy of diphtheria.

The most hopeful of remedies is antitoxin. More lives can be saved by this preparation, if used early and freely, than by any other known remedy. Moschcowitz, in 1900, collected 338 cases, with a mortality of 40 per cent. In many of these cases it was not used early. It is of importance, however, to use it at the very outset, and to repeat its use as soon or as often as may be indicated by any exacerbation of symptoms. In one instance under my observation twenty-three phials of antitoxin were used before muscle rigidity subsided; in another case double this amount was used. Without quoting figures it is safe to say that the former great mortality rate of tetanus has been reduced at least 50 per cent. by its use, and that further reduction can be effected by its early and prolonged use.

The use of antitoxin nowise takes away the necessity for proper physical care of the laceration or the wound. Every particle of affected tissue should be cut away, all the principles of physical cleanliness adhered to, and proper antiseptics used.

When the antitoxin is used in the presence of the disease it should be injected into the spinal canal, as it is known that the cerebrospinal fluid may contain a considerable amount of the toxin and is of itself highly poisonous. Therefore after inserting the needle into the canal it is well to withdraw a considerable amount of the fluid before injecting the antitoxin. If this method is pursued the material is brought into more immediate contact with the anterior horns of the cord than could be effected in any other way. After withdrawing all the fluid that will run through the needle without applying the syringe—probably 150 to 200 Gm.—10 to 15 Cc. of the antitoxin may be slowly injected, the process consuming from three to five minutes. Then a further injection should be made along some of the large nerve trunks, preferably those leading to the part involved. This injection should be made with a finer needle, such as that with which cocaine solution is injected during anesthesia for the prevention of shock. This is a more effective and less serious matter than trephining the skull for the injection of fluid upon the surface of the brain. This may be done while the patient is under the influence of the anesthetic administered for the purpose of giving proper attention to the wound. The antitoxin should be injected into the nerve trunks after their exposure. At the same time it is well to make intravenous saline injections at more than one point. After from twelve to fifteen hours the injection of antitoxin and perhaps of saline solution should be repeated, if necessary, under such light anesthesia as can be produced by ethyl chloride. Recently a substitute for antitoxin has been suggested in an emulsion of brain tissue which has been shown to have a specific affinity for the tetanus toxin. It has been seen that when these two substances have been thoroughly shaken together the toxin is removed from the fluid and confined in harmless form within the brain-tissue cells.

In injecting the antitoxin into the spinal canal no harm will ensue if a little blood flow through the needle, showing that the cord itself has been touched.

When there is need to employ this material the brain of a freshly killed small animal should be removed under antiseptic precautions. 10 Gm. or 15 Gm. should be emulsified in about 30 Cc. of sterile salt solution, which should then be strained through a sterile cloth under light pressure. This is then injected as near the wound as possible and the procedure repeated every day as long as indicated. This method can only be expected to neutralize toxin that has not yet entered the nerve cells. Nevertheless, Russian observers have reported thirteen recoveries out of sixteen instances in which the method was practised.

When no other means are at hand a 1 per cent. carbolic acid solution may be injected after the same fashion, using such an amount that about five grains are administered during twenty-four hours to an adult. This is the method especially favored by the Italians, and is due especially to Baccelli.

Matthews has devised a method which seems quite effective in experimental animals. It consists of the use of a solution of the following: Sodium chloride 4 Gm., sodium sulphate 10 Gm., sodium nitrate 3 Gm., calcium chloride 14 Cgm., water 1000 Cc. This is intended for intravenous injection, and must be introduced very slowly. The performance should be repeated twice during the first twenty-four hours and once each succeeding twenty-four hours. It produces profound diuresis, i. e., a washing out of tissue cells, as he calls it.

Hydrophobia is an acute specific or infectious disease, as far as known never originating in man, but transmitted to him, usually through the bite or by inoculation from the saliva of a rabid animal—in this country usually the dog, although the wolf, the cat, the skunk, and even certain of the domestic poultry, are capable of conveying the disease. Chickens are said to be immune save when their vital resistance is lowered by starvation. Chicken blood injected into other animals seems to antidote the virulence of the virus. It can also be inoculated in other animals, like rabbits. The virus is ordinarily conveyed in the saliva of the rabid animal. This may be wiped off as the teeth of the animal pass through the clothing of the injured individual; consequently, infection does not certainly follow such bites. But those upon exposed portions of the body, where animals generally bite, are almost invariably followed by infection. Hydrophobia is frequently spoken of as rabies, sometimes as lyssa. While rare in this country, it is by no means uncommon in Central Europe, especially perhaps in Russia, where bites from infuriated wolves are common. In the United States infection comes almost invariably from the rabid dog, in which this disease presents two types.

The so-called furious form is that which is marked by frenzy and canine madness, the objective symptoms being more pronounced and alarming, though not less dangerous than the other variety. After the period of incubation, which varies considerably, these animals show depression and uneasiness, and even thus early their saliva is infectious. Their sense of hunger becomes perverted; they exhibit unusual tastes, secrete saliva abundantly, which becomes very tenacious and even frothy, exhibit a dry and edematous condition of the faucial mucous membranes; the character of the bark is altered, while they are usually infuriated at the sight of other dogs. In this stage there is usually insensibility to pain. Finally, come more or less paralysis of deglutition, quickened respiration, dilated pupils, and frenzy and madness of manner, by which they attack indiscriminately men and other animals. To this stage of furious excitation succeeds one of paralysis, and death follows from exhaustion. These manifestations usually last about a week.

Dumb hydrophobia is the more common form. Here paralysis appears much earlier and involves especially the lower jaw; the tongue falls out of the mouth; and the posterior extremities are quickly paralyzed. This form is much more quickly fatal than the other.

Animals thought to have hydrophobia should be kept by themselves in a secure enclosure and carefully watched, especially those known to have bitten men or other animals. If a suspected dog have been killed before the suspicion has been confirmed, the head and upper part of the neck should be removed for examination. Veterinarians claim that what they call the plexiform ganglion permits an almost certain diagnosis to be made. The presence of foreign bodies in the stomach of the animal is a corroborative feature. Diagnosis by subdural inoculation requires two or three weeks, and in at least one case a human patient died while waiting for diagnosis to be thus established.

Hydrophobia in man is rare in this country, yet is occasionally observed. Its etiology is as yet obscure. That a contagion vivum is present is positive, but its nature is uncertain. Negri, of Pavia, has recently described certain bodies observed in the nervous system of animals dead of hydrophobia which may offer the solution of the problem that has so long been sought. They are found in the protoplasm of nerve cells, but not in their nuclei. They are round or oval in shape, vary in size from 25 microns down to those which can be barely seen with the highest powers. They take ordinary stains.

Negri maintains that these bodies are parasites and he has invariably failed to find them in animals which did not have rabies. His work has been confirmed by a number of his colleagues, and bids fair to furnish a reliable and rapid means of diagnosis. The fact that the virus of hydrophobia will pass through a porcelain filter nowise contradicts the view that these bodies may be parasitic, for it is quite possible that they undergo different stages of development, in some of which they are small enough to pass even barriers of porcelain.

In fact it seems to have been positively demonstrated that these bodies described by Negri, in 1903, are diagnostic for rabies. They are most likely to be found in the horns of Ammon or the cerebellum. When found here, careful examination must be made of the Gasserian ganglion, where may be found the lesions first described by Van Gehuchten and Nelis, which consist of a proliferation of the endothelial cells to such an extent that the ganglion cells are first invaded and then destroyed, their places being taken by the new cells.

The Negri bodies have been generally regarded as protozoa and the specific cause of the disease. At all events, it seems possible always to successfully reproduce the disease in rabbits or guinea-pigs by inoculation with these bodies.

If examination shows neither the Negri bodies nor the lesions in the ganglion the presence of the disease can scarcely be suspected, and could only be proved by animal inoculations, which, however, would be advisable in doubtful cases where human beings have been bitten.

Symptoms.

—The period of incubation in man is variable, ten weeks being perhaps the average. It is shorter in children, as also when the bites are numerous. It is even stated that it may be as long as a year or more, during which time the poison seems to lie latent. When the active symptoms supervene there are, locally, discomfort about the wound, itching, heat, and peculiar unpleasant sensations. It is said also that vesicles may make their appearance in the neighborhood of the original lesion. As in animals, so in man, the disease may assume either the furious or the paralytic type. These cases are nearly all marked by mental depression and apathy, with complete loss of courage. The earlier symptoms are connected perhaps with the respiration, which is infrequent, while inspiration is halting and speech is interfered with. The facial appearance is often changed to one of anxiety, even despair. The muscles of deglutition are next involved in a combination of spasm and paralysis, and the act of swallowing is interfered with, sometimes made almost impossible. Although patients can swallow their own saliva, they find it difficult to swallow any foreign substances, such as water, etc. This is not due to the fear of water, as the term “hydrophobia” would imply—this being an absolute misnomer—but is due to reflex spasm excited by the attempt. It is accompanied by more or less sense of suffocation and palpitation of the heart. Indeed, a paroxysm of this kind may be precipitated by the attempt to swallow, so that the patient instinctively refuses water or any other fluid. Reflex excitability is also very great, and a breath of air or a trifling disturbance may precipitate a paroxysm, almost as in extreme cases of tetanus. As the case progresses the saliva becomes more tenacious and viscid, faucial irritation more marked, and the attempts to expel the secretion, along with the disturbed respiratory efforts, have given rise to the foolish lay notion that these patients bark like dogs. The paroxysms, as the case progresses, become more marked, the patient more restless, until, later, furious mania or muttering delirium is present, to be followed by prostration and paralytic phenomena, muscle tremor, etc., and death.

The paralytic form in man, as in dogs, is marked by the much earlier paretic phenomena, anesthesia, and, finally, respiratory paralysis which terminates the case. Curtis and others have insisted that the hydrophobic paroxysms are not convulsions in the ordinary sense of the term, but are due to temporary inhibitions of the most important respiratory and cardiac centres as the result of peripheral impressions. He likens them to the shock of a shower bath.

Postmortem Changes.

—Postmortem changes are indistinct and only suggestive. They consist for the greater part of a sort of vacuolous degeneration of the ganglion cells of the nerve centres—most prominently in the medulla, next in the hemispheres, and then in the spinal cord. There is hyperemia, with minute ecchymoses, with infiltration of the adventitia of the vessels and perivascular extravasation. The changes met with in the other viscera bear no constant relation to symptoms. Nevertheless, Gowers holds that because of the location of the lesions and their intensity in the neighborhood of certain nerve nuclei we have here a distinguishing anatomical character of the disease.

The toxin (as we may call it for the lack of a better term) seems to be transmitted much as is that of tetanus (q. v.), along the afferent nerves to the cells of the anterior horns of the cord.

Diagnosis.

—As between hydrophobia and tetanus diagnosis is not difficult, as already described. In certain hysterical individuals nervous paroxysms, largely due to fright, may be precipitated by dog-bites and other incidents or accidents. In these cases there is rarely such a period of incubation, and in a true hysterical case there will be no such mimicry of this awful disease. A condition known as lyssophobia (fear of hydrophobia) has been described. It is seen in hysterical subjects. It is said to have even been fatal, but this must have been from other complications.

Treatment.

—There is no authenticated case on record of recovery after medication by drugs. It is probable that recovery has never followed anything but the modern inoculation treatment.

The only successful treatment for this disease has been elaborated as the result of the labors of that indefatigable French savant, Pasteur, and is among the glorious triumphs of laboratory research, against which it is so often charged that it is not practical in its results. It is in some respects a curious commentary on the study of infectious disease that we can secure and work with the peculiar virus of hydrophobia, and at the same time be utterly unacquainted with its true character. To this fact is due the modern cure. It is based upon the fact that the virus is not only in the saliva, but also in the nervous system of animals suffering from this disease, and that its effects are intensified and hastened by inoculation directly into the cerebral substance. Accordingly, when a diagnosis of hydrophobia can be reasonably well established, no time should be lost in sending the patient to one of the “Pasteur Institutes,” to be found now in most of the great centres, there to undergo a regular course of treatment. It was reported that in the Institute in Paris, between the years 1886 to 1894, there were treated a total of 13,817 cases, and that the mortality was 0.05 per cent. Of course but a small proportion of these really had or would have developed the disease.

Virus obtained from the brain or cord and inoculated into the dura of another animal quickly precipitates the disease. It is, moreover, modified in virulence as it passes through successive animals of certain species—for example, monkeys. It is increased by passage through rabbits, and the period of incubation thereby shortened. The weakest virus can by proper handling and manipulation in this way be so intensified as to produce disease within seven days after inoculation. Desiccation reduces the virulence, and preparations from the cord of an infected animal may be attenuated to almost any desired extent by drying. By inoculating a dog or a rabbit with virus prepared from this weakened source, and daily making injections from stronger and stronger preparations, it is in the course of a couple of weeks rendered practically immune to the disease. Animals thus made immune are trephined and the virus injected beneath the dura, by which more certain results are obtained. The treatment consists in using a section of a rabbit’s spinal cord, 0.5 Cm. in length, rubbed up in 6 Cc. of sterile salt solution. Half of this amount is injected each day into the flank of the patient. The cord first used is one that is thirteen or fourteen days old, which has been kept suspended in a sterile flask, over caustic potash, in order to assist in its desiccation. The next day a cord one day younger is used, and so on until by the twelfth day of treatment the cord is one only two days old, and at the end of two weeks a fresh cord can be used which would convey the disease had it been used first. If this course of treatment can be carried through before the first symptoms of the disease appear, the antidote has gained complete mastery over the infecting agent and the patient is saved.

Glanders as it is known in man is a specific infectious disease, transmitted usually from the horse, characterized by rapid formation of specific granulomas, particularly in the skin and mucous membranes, which quickly break down into ulcers, and by the general toxemia characteristic of any acute infection. In German it is known as Rotz, in French as morve, while its old Latin name was “malleus” (hence we speak of the bacillus mallei). It was also known in former days as equinia. In horses the disease has also been known as farcy, because of the peculiar subcutaneous nodules which farriers and hostlers, almost from time immemorial, have called “farcy buds.” The disease, while capable of transmission from man to man, is generally produced by contagion from some of the domestic animals, most commonly the horse, although sheep and goats are known to occasionally have it, and dogs are susceptible, though seldom showing manifestations of it.

Like some of the other infectious diseases glanders appears to be variable in its manifestations. While infection occurs probably through some superficial abrasion, it is almost certain that it may also occur through the unbroken mucous membrane of the respiratory organs. It is said to be also capable of transmission from mother to fetus in utero. So far as known in man, infection occurs practically invariably through some slight abrasion, either of the skin or the mucous membrane of the nose, the eye, or the mouth. The discharges from the nostrils of affected animals are extremely virulent, and infection comes usually from this source. It is said to have been communicated from one patient to another by eating from the same dish or by drinking from a pail used by a diseased horse.

Glanders is due to the specific bacillus known as the bacillus mallei. It is shorter and plumper than the tubercle bacillus, in length about one-third the diameter of a red corpuscle. It is a non-motile organism, occasionally spore-bearing, not very resistant, belonging to the facultative anaërobic forms, growing best at blood temperature, taking stains easily, and losing them in the same way.

Symptoms.

—Glanders is seen usually in workers and hangers-on in stables. The acute—the common—form has a period of incubation of from three to seven or eight days, after which both local and general symptoms supervene. About the infected region a form of cellulitis appears, assuming often a more or less phlegmonous type, with implication of the adjacent lymphatic nodes and evidences of periphlebitis and perilymphangitis. Over the affected area vesicles appear, which become hemorrhagic and later suppurate. A wound which has healed may reopen. Almost always there are accompanying constitutional disturbances of septic type, occasionally chills, pyrexia, etc. It is rather characteristic of glanders to have severe pain in the muscles and extremities, with epistaxis and formation of metastatic tumors and edematous swellings in various parts of the body. Frequently, later in the disease, appears a somewhat distinctive eruption, papular in character, merging into pustular. Hemorrhagic bullæ are also often seen. Pustulation and edema of the face change its appearance. There are also edema of the eyelids and mucopurulent discharge from the conjunctivæ and the nose. This latter discharge is often ozenous in character. Upon inspection of the nasopharynx and oropharynx a similar condition will be noted. In connection with these local signs more or less general furunculosis also will be observed. Obviously, as these local conditions intensify and multiply, septic disturbance will be increased, and the patient dying of acute glanders dies generally of septicemia or intoxication and exhaustion combined.

A chronic form is known, distinguished mainly by slowness or tardiness of lesions, though the local changes are not particularly different in character. There is perhaps more tendency to suppuration and less to lymphatic complications. The nodule which breaks down will leave a foul ulcer, the discharge from these lesions being extremely infectious.

Diagnosis.

—This is not always easy, but may be based in suspicious cases to some extent upon the occupation of the patient. The presence of multiple lymphatic lesions and subcutaneous nodes, especially when breaking down as above described, and accompanied by ozenous discharge from the nose, should at least be suggestive, and will serve to distinguish between this disease and, for instance, typhoid fever. The chronic type of glanders might be mistaken for syphilis, and here is where the real difficulty of diagnosis will probably occur. In doubtful cases the crucial tests are the microscopic examination of discharges, after staining for bacilli, and the cultivation test.

Prognosis.

—A generalized attack of glanders is a matter of gravest import, especially when acute. Scarcely more than 10 or 15 per cent. of such cases recover. In the more chronic manifestations the prognosis is more favorable, half of the patients making a final recovery.

Treatment.

—All infected animals should be isolated and destroyed, their carcasses being burned. If possible, the infected wound or abrasion should be induced to bleed freely, and then cauterized with an active caustic. By prompt interference with the first manifestations it may be possible to cut short the disease. This would necessarily be done by excision, cauterization, packing, etc. Bayard Holmes has reported a case in which, during two and a half years of chronic manifestations of this disease, he anesthetized the patient twenty times for the purpose of opening new foci or scraping out old ones, finally obtaining a permanent cure. There is no specific treatment, but the septic symptoms should be combated as indicated in the chapter on Septicemia.

By making a glycerin extract from the filtered and evaporated culture of the glanders bacillus it is possible to prepare a toxalbumin analogous to tuberculin, which reacts in a similar way. By it animals may be fortified against inoculation, and by its use a peculiar reaction is produced in those affected by the disease. It is known as mallein, and by it are tested all horses used for the preparation of the diphtheria antitoxin, in order that all possibility of glanders may be eliminated. It is probable that it might be made of therapeutic value in treating the disease when actively present in man.

Anthrax is more commonly known as splenic fever, malignant pustule, or woolsorters’ disease; in Germany as Milzbrand, and in France as charbon. It is an infectious disease of cattle, which has devastated many parts of Central Europe, and has been frequently met with on the Continent among men, though but rarely in the United States. All the domestic and nearly all the experimental animals are subject to it. Gronin has stated that in the district of Novgorod, in Russia, during four years more than 56,000 cattle and 528 men perished from anthrax. Poultry and dogs are not strictly immune, but possess a low susceptibility to the disease. It generally prevails in low districts and in marshy grounds.

The disease is the result of the invasion of the bacillus anthracis, which is a relatively large-sized bacillus, varying in breadth from 1 to 1¹⁄₂ and in length from 5 to 20 microns. It is easily cultivated outside the body, and multiplies with great rapidity in the bodies of susceptible animals; it is the type of spore-bearing bacilli, and is so readily recognized and worked with that it is commonly used in laboratory investigations. The demonstration of its specificity we owe to Davaine, in 1873, although he had described it in 1850.

PLATE IV

FIG. 1

Anthrax Bacilli. Spore Formation. (Karg and Schmorl.)

From an agar culture twenty-four hours old. About the margin of the photograph are a number of free spores, × 600.

FIG. 2

Anthrax Pustule. Removed from Arm of Man. (Karg and Schmorl.)

Marked edema of the skin, causing elevation and separation of the papillæ. In the edematous exudate a large number of anthrax bacilli and leukocytes. × 50.

Anthrax bacilli may enter the body through the respiratory organs, through any abraded surface, and possibly even through the alimentary canal. They may also pass through the placenta and affect the fetus in utero. They are too large to pass through the walls of the capillaries of ordinary size; consequently they plug them and produce a mechanical stasis which is rapidly followed by gangrene. From the kidney structures and capillaries, however, they may escape, as bacilli are found in the urine in certain cases of anthrax. (See Plate IV.)

In man the disease occurs usually as the so-called malignant pustule, or woolsorters’ disease, the latter name being given because of the liability of those individuals who come in contact with the carcasses and hides of diseased animals or their immediate products. The period of incubation is brief—on the average two or three days. The first lesion appears usually on the face, hands, or arms, and is characterized by local discomfort with formation of a small papule, which rapidly becomes a vesicle with an areola of cellulitis about it. This is rapidly followed by induration and infiltration, and these by local gangrene, the result being the separation of a core-like mass, similar to that of carbuncle. The affected area is usually discolored, often quite black. The process is not usually accompanied by suppuration, nor is there the pain of true carbuncle. The lesions tend to spread peripherally, but there is more or less vesication of the surrounding skin. On account of the local ischemia there will always be edema of the affected region, and sometimes the swelling and local disturbance become extreme. These peculiar lesions have given rise to the common name malignant pustule, which is well deserved. At last a line of demarcation becomes manifest, and if the disease progresses favorably the included area is sloughed out, leaving a surface which it is hoped will soon become covered with reasonably healthy granulations.

Absence of pain, and usually of pus, are significant features of anthrax. Should mixed infection occur, however, we are likely to see pus formation. When the disease partakes less of the characteristics of malignant pustule and more of a general infection, the local symptoms may not predominate, but, on the contrary, septic indications may become serious and even fatal. The evidence of more or less toxemia is usually at hand, however, and the toxin of anthrax is almost as destructive of muscle cell integrity as is that of diphtheria.

The local lesions may be single or multiple, but will be met with almost always upon exposed areas of the body.

Postmortem Appearances.

—These will depend upon the clinical course of the disease. In the sloughing tissues the bacilli are very numerous, while around the margin more than one bacterial form will probably be met—i. e., mixed infection. Should saprophytic organisms complicate the case, they may have replaced the anthrax bacilli by the time the examination is made. The latter abound, however, in the blood, and may usually be found occluding the capillaries of the liver, spleen, kidney, etc. In intestinal infection, particularly in animals, the mesenteric nodes are involved. Inasmuch as septic features accompany all fatal cases, putrefaction will be found to begin early, and the changes in the blood and the gross changes in the other organs will resemble sepsis rather than anthrax.

Prognosis.

—Prognosis for man is not usually unfavorable, the majority of cases recovering with more or less local destruction of tissue. Should, however, infection become generalized, the case will probably terminate fatally. Cases assuming the type of splenic fever are of much more serious character, and their prognosis graver.

Treatment.

—This should be both local and constitutional. The former should consist of the most radical possible attack and include complete excision of the infected area, with the use of active caustics or the actual cautery. In fact, the latter instrument offers a most valuable means for combating the destructive tendency of the disease. Sloughing and separation of the cauterized mass may be hastened by warm antiseptic poultices. Subcutaneous injections of 5 per cent. carbolic solution have been given, with apparent benefit, in a number of cases, but should only be relied upon in the treatment of the milder manifestations.

Benefit will accrue from the use of the ichthyol-mercurial ointment whose formula was given under treatment of Erysipelas. It has been suggested to treat these cases by the employment of the bacillus pyocyaneus, since it is known that this organism when injected with the anthrax bacillus materially attenuates its effect.

Prophylaxis.

—Prophylaxis is most important. The bodies of all infected animals should be burned, not buried, since the resistant bacilli are often brought to the surface of the soil by earth-worms. Every discoverable source or medium of infection should be destroyed or sterilized.

This disease has been recognized for some time, mainly by French and Continental clinicians, and under such names as gangrène foudroyante, gangrène gazeuse, gangrenous septicemia, and gangrenous emphysema. The name malignant edema was given by Koch, who identified the infecting organism. It is one of the most dangerous forms of gangrenous inflammation, and occurs sometimes after serious injuries, and, again, after most trifling lesions, such as those inflicted by the dirty pointed implements of the gardener, etc., or even the stings of insects. Two cases are on record where the disease followed a puncture of the hypodermic needle for the administration of morphine. In one of these the organism was found in the solution; in the other it probably had been deposited upon the skin.

Malignant edema is essentially a specific form of gangrene (see Chapter V), and is mentioned here rather because of its specific character. It is characterized by rapidity of spread and the specific nature of the exudate, as well as by the speedy destruction of the tissue involved, and by more or less gas formation. It is not the same as the gaseous phlegmons described by some German surgeons, yet partakes of their general character. Gas phlegmons have been rarely noted, their peculiarity being formation not only of pus, but of more or less offensive gases, which escape when the phlegmon is incised. The gases are mainly due to the presence of bacillus aërogenes capsulatus, and gas phlegmons, as such, are to be regarded as instances of mixed or rarely pure infection.

Malignant edema is known by the brownish discoloration of the overlying skin, which is streaked with blue where the overfilled veins show through it, while the underlying tissues are sodden with fluid and more or less inflated by the gaseous products of decomposition, so that the finger detects a firm crepitus, as is common in subcutaneous emphysema. From the wound, if there is one, flows a thin, foul-smelling secretion, which may also be expressed from the deeper layers. That the neighboring lymph spaces and nodes are actively involved is evident from the enormous swelling of the latter, as well as from the general condition of the patient. The rapid elevation of temperature with but trifling remissions remains constant until shortly before death. The tongue early becomes dry and cleaves to the palate, its surface being covered with a thick, foul fur. Patients early become apathetic, complaining only of pain and burning thirst. Delirium and coma usually precede death, which may occur in fifteen to thirty hours. After death the cadaver bloats quickly and putrefaction goes on with amazing rapidity.

Postmortem Appearances.

—At the seat of the lesion even muscles and tendons will be found macerated, bone denuded and surrounded by a putrid fluid, the entire region presenting a notable swelling and infiltration of soft parts with reddish fluids and stinking gases. The overlying skin will be stretched, and superficial blisters may deepen the intensity of the process. The veins are clogged with decomposed blood and broken-down thrombi, and in the heart and large vessels will be found putrid liquid as well as gas, to whose presence early and sudden death is probably due.

Prognosis.

—This is unsatisfactory, especially when the bacillus of malignant edema is alone at fault. Patients may escape with their lives, but always at the expense of more or less tissue destruction.

Treatment.

—This should consist of extensive incision to permit escape of fluids and gases and relieve tension; of such antiseptic applications as can be made available; of immersion of the affected part in a hot antiseptic bath; and of such vigorous stimulation by the most powerful measures—strychnine, alcohol, etc.—in order to support the patient through the period of profound depression characteristic of the disease.

PLATE V

Actinomycosis. Ray Fungus in Man. (Gaylord.)

This also is a subacute but always destructive infection by a specific microörganism, though not a bacterium. Known always as actinomycosis in man, the disease, which is most common in cattle, is called lumpy jaw or swelled head, and years ago was usually regarded as cancer or as a malignant affection.

Many museum specimens labelled as cancer of the tongue, jaw, etc., have been shown to be instances of actinomycosis of these parts. It is occasionally met with in man, so that there are at least four hundred cases on record in this country and in Europe. The organism was recognized a half-century ago by Langenbeck and Lebert, but was not scientifically described until many years later. The names of Bollinger, Israel, and Ponfick will always be connected with these researches.

The organism belongs among the ray fungi, is known as the actinomycis, and occupies an uncertain place in classification. It is large enough, when entire, to be perceived by the naked eye, has ordinarily a yellowish tint, a tallowy consistence, and may be seen under the microscope to consist of a cluster of branching prolongations, club-shaped at the end, radiating from a common centre. They give it a sunflower appearance. It is stained with difficulty, the best stain being a combination of picrocarmine and an aniline dye. In tissue sections the Gram stain is the best. It is cultivated with difficulty, but can be grown upon solid media and may be inoculated. (See Plate V.)

As met with in tissue or in pus these fungi constitute small granulations, giving usually a gritty sensation to the finger, which is due to the presence of calcium salts. The recognition of this calcareous material is of importance, since it may enable a diagnosis to be made offhand, in a case which otherwise might puzzle one.

The disease is very common among cattle in certain regions, and causes the condemnation of many animals in every large stockyard establishment where inspection is careful and scientific. It occurs oftener in young than in old animals, and most frequently in those which come from valley regions and marshes. In animals infection occurs almost invariably through the mouth, which is easily explained by the fact that, in grazing, the lips, tongue, and gums are likely to be irritated and infected at any time from soil containing these fungi along with growing grain. The path of infection is usually by the mouth, while accident seems to determine whether the infection shall manifest itself mainly in the intestinal canal or the respiratory tract. In animals there is less tendency to suppuration than in man, the infection in man being usually a mixed one. The name lumpy jaw, so generally given to the affection, is indicative of the most conspicuous lesion in cattle, for the organism, having once invaded the gum, for instance, passes quickly to the bone, or, having involved the tongue, is not slow to infect the lymphatics of that region. In consequence we have tumors, often of inordinate size, which may involve the bones or the soft parts and cause great disfigurement, along with necrosis, leading eventually to the death of the animal. These tumors are essentially granulation tumors due to the presence of a specific irritant—the actinomycis—which acts here as do the tubercle bacillus, the lepra bacillus, etc., in other infectious granulomata.

In man the disease is generally accompanied by abscess formation, the pus containing the distinctive yellow gritty particles which are found in no other disease. The strong resemblance between the lymphoid cells of this form of granuloma and the embryonal cells of sarcoma has permitted the perpetuation of confusion between these two neoplasms.

Fig. 19

Actinomycosis in man. (Lexer.)

Large abscesses form as the result of the coalescence of small ones, and by the time the disease is recognized extensive destruction and loss of substance may have taken place. In man it is not alone about the mouth that the disease is noted, although primary lesion here is by no means infrequent. It leads to affections similar to that already spoken of in cattle, with a progressive infiltration and breaking down, including actual necrosis of bone, etc. The pus will escape at various points, and may give to the surface an appearance as of many craters with a central cause. When the disease has involved the lung, either directly or indirectly, the fungi and the calcareous particles may be found in the sputum. Should there be suspicion of this involvement, the sputum should always be examined. Even in the heart substance tumors of this same character have been found. The first case noted in man had undergone extensive vertebral caries. Intestinal infection is possible, in which case multiple lesions will form in the intestinal walls, which may contract adhesions to the abdominal parietes and discharge externally through them. The appendix has been found involved in such lesions. Infection of the skin has also been described, though this occurs more rarely.

Diagnosis.

—Actinomycotic lesions have been mistaken for cancer, sarcoma, tuberculosis, syphilis, etc. In man it will always be characterized by more or less suppuration, and in the purulent discharge from the infected focus the yellow calcareous particles should enable recognition of this disease at once.

Prognosis.

—As long as the focus is accessible it is a purely local matter, and prognosis is as favorable as in local tuberculosis; but, inasmuch as in many cases infection has proceeded to a point where the surgeon cannot safely follow it, prognosis must be guarded. Actinomycosis is free from acute manifestations, for the main part free from pain, pursues a chronic course, and is characterized, as are the other slow infections, by progressive emaciation, prostration, etc. As it is essentially a chronic condition, time is afforded for careful study in doubtful cases, for microscopic examination, etc.

Treatment.

—This must consist of extirpation of all infected tissues and areas. If this can be done thoroughly there is a prospect of positive cure. Free incision, wide dissection, the use of the actual cautery, etc., are always called for in these cases. If it involves the tongue alone, there is an excellent prospect; if but a portion of the jaw is involved, a complete excision of one-half or more may be followed by excellent results. If, however, the lung, liver, vertebrae, or other vital and inaccessible parts are involved, surgical measures may afford amelioration, but can hardly be expected to cure.

Iodine, alone or in combination, has been found efficacious in the therapy of actinomycosis. In diluted solutions used locally, or as potassium iodide given internally or injected into tumors, it doubtless has a beneficial effect during the period of its administration. Recent reports and experiences show that great value attaches to the use, as suggested by Bevan, of copper sulphate in the treatment of actinomycosis, its use having been suggested by the fact that copper is used to destroy rusts (fungi) on grain. One-half grain (3 Cg.) may be given internally three times a day, while the sinuses are irrigated with a 1 per cent. solution. I have seen apparently complete cure of an aggravated case follow its use. Incidentally it may be stated that Bevan advises its use also in cases of blastomycosis.

While madura foot is not a disease from which domestic animals suffer, its general characteristics make it a proper subject for brief consideration. It is essentially a disease of the tropics and subtropics, and is often seen in some of our new possessions.

It commences as a painless swelling upon either aspect of the foot, in which hard nodules form, which later soften, ulcerate, and discharge puruloid material containing granules in which the microscope reveals mycelia of the peculiar fungus that produces the disease. In some cases these particles are black, in others colorless. The disease is of slow progress, and the lower limbs become weak, atrophied, and finally useless Death results from exhaustion or some terminal infection.

The principal lesion is the slowly growing gumma or granuloma, whose presence is unmistakable. This is due to the presence of a fungus, called by Vincent the streptothrix maduræ. Thus in its pathology the disease much resembles actinomycosis. The habitually bare feet of most of the inhabitants of the tropics and the habitat of the fungus explain the site of the primary lesion.

Treatment.

—The only treatment is extirpation of the growth—i. e., amputation.

PLATE VI

Tuberculosis of Testicle.

Miliary Tubercle with Caseation and Giant Cells. (Gaylord and Aschoff.)
a, seminal tubules; b, giant cells; c, caseated tubercles.

CHAPTER IX. — SURGICAL DISEASES COMMON TO MAN AND THE DOMESTIC ANIMALS ( Continued ). — TUBERCULOSIS. — COLD ABSCESSES. — THE GUMMAS OF TUBERCULOSIS.

The most important and frequent of the infectious diseases common to animals and man is tuberculosis. This appears usually as a subacute or chronic affection, although in a small proportion of cases it assumes an acuteness of type which may make it fatal within as short a time as fourteen or fifteen days, or even less, from the first recognizable symptom. Tuberculosis is more prevalent than any other form of disease, and is the cause of death of a proportion variously estimated at from 20 to 30 per cent. of mankind. It is a disease which perhaps concerns the surgeon more than the physician, inasmuch as it is also the most common of the so-called surgical diseases. Its frequency varies in different parts of the country. In the average surgical clinic of the United States probably 20 to 25 per cent. of cases are manifestations of this affection.

Surgical tuberculosis covers the entire range of diseases formerly described as scrofula. The term scrofula is now expurgated from medical terminology. All of the active manifestations formerly regarded as scrofulous are known to be due to tuberculosis.

To the presence of tubercle bacilli in the tissues is due that distinctive aggregation of cells which constitutes the so-called miliary tubercle. Its presence and arrangement are apparently the direct outcome of the irritation produced by these minute foreign bodies, and its method of grouping is so characteristic that it may be everywhere and usually easily recognized. Its centre is composed of one, possibly several, giant cells, whose nuclei are generally arranged around its margin, with perhaps degenerative changes going on in the interior of the cell itself. In this giant cell, as well as outside of it, may be seen one or several tubercle bacilli. Around this centre are clustered a number of large cells known as epithelioid, which may also contain bacilli. These cells are probably derived from epithelium when at hand, or from the endothelium of the vessel walls, or from the fixed tissue cells. Outside of these are other, usually spindle-shaped, cells, contained in a connective-tissue network and regarded mostly as lymphoid cells. When tubercle is experimentally produced the bacilli seem more numerous than they do in instances of spontaneous disease. This little aggregation of cells constitutes a mass which may be recognized by the naked eye—a minute, usually white point or nodule, which is known as a miliary tubercle. It is subject to any one of several changes to be presently considered, and it is usually found in large numbers. The punctate appearance of miliary tuberculosis is perhaps best seen upon the cerebral membranes or the peritoneum in cases of acute miliary tuberculosis. By coalescence of a number of these nodules larger tubercles are formed, and by combination of coalescence and caseous degeneration are produced the large cheesy masses which were formerly called yellow tubercle. (See Plate VI.)

The epithelioid cells are by some regarded as modified leukocytes; by others as the product of division of the fixed cells. The giant cell is probably the result of irritation in one of these cells, the stimulus being sufficient to provoke division of the nucleus, but not of the entire cell. As the principal cellular activity occurs in the interior of this nodule the result is a condensation about the periphery which furnishes eventually a sort of capsule, the tissues being hardened and condensed as if for this special purpose. The effect of this is to interfere with vascular supply and finally to shut it off completely. As long as no pyogenic infection occurs, the original tubercle may gradually shrivel down and disappear or caseous degeneration may occur, and it may persist as a cheesy nodule for an indefinite time. As such a tubercle grows old the cells lose their identity, refuse to take stains, and a slow or quiet coagulation necrosis results. In this nest sometimes calcium salts are precipitated, the result being a calcareous nodule. On the other hand, during the active stage of this tubercle formation cell resistance may be lowered, either from general or constitutional causes; the original focus disintegrates; tubercle bacilli are liberated, and are now carried hither and thither, metastatic tubercles being the result of their dissemination.

Spontaneous healing of tubercle is possible, and may be due to three different causes:

• (a) Necrosis and exfoliation of diseased tissue (e. g., in lupus);
• (b) Cicatricial formation;
• (c) Retrograde metamorphosis.

Looked at from another point of view, the possible fates awaiting the miliary tubercle are the following:

• (a) Absorption;
• (b) Encapsulation;
• (c) Cheesy degeneration;
• (d) Calcareous degeneration;
• (e) Suppuration.

Absorption.

—Absorption of tubercle undoubtedly is possible under favorable circumstances, but just what constitute these favoring circumstances no one knows, since they occur in cases which do not terminate fatally. To be able to describe them would be to detail minutely the changes which permit of recovery after non-traumatic tuberculous infection, which clinical fact is amply demonstrated by the experience of the profession. Absorption is probably largely a matter of phagocytosis.

Encapsulation.

—Encapsulation has already been spoken of, the capsule being formed by the condensation of the original cells of the tuberculous agglomeration, the infectious organisms being thereby imprisoned as long that they are practically starved and finally die. The tubercle bacilli, however, may long lie latent in such a cellular prison, and should anything occur to break the prison wall they may escape and still prove actively infectious. In this way are to be accounted for the fresh eruptions from old miliary or other deposits.

Caseation.

—Caseation comprises a series of changes in the chemical constitution of the cells by which an albuminoid mass much resembling casein in composition and appearance is produced. The English equivalent cheesy well describes many of these masses, which both cut and appear very much like domestic cheese. They have a yellowish color, and are met with in masses in size from a pin’s head up to a robin’s egg. These are the yellow tubercles of the older writers, and such a cheesy tumor has been called tyroma.

Calcification.

—Calcification refers to a peculiar deposition of calcium salts within the interior of these nodules, the first precipitation occurring usually in the centre of the giant cell, which is itself the topographical centre of the miliary tubercle. It may spread from this until a mass easily recognizable by the naked eye and detectable by the finger is produced. Such calcareous particles are frequently found in sputa, and are always an index of the tuberculous character of the case. They differ markedly from the yellow calcareous nodules found in the pus of actinomycosis, the circumstances under which they are likely to be confused being met in pulmonary disease.

Suppuration, as indicated, is the result of a mixed or secondary infection with pyogenic organisms. In the previous chapter tubercle bacilli were grouped as among the facultative pyogenic bacteria, yet pus is not formed in this disease except in consequence of coincident activity of other bacterial organisms. Suppuration of tuberculous foci is of importance to the surgeon, because thereby is produced a distinct class of so-called abscesses—namely, the cold or congestion abscesses. These are of the chronic type, and are generally free from the ordinary signs of abscess formation. They are invariably the result of local infection, sometimes perhaps by the tubercle bacilli alone, but frequently by the combined action of these with pyogenic forms. For their formation a previous tuberculous lesion is essential. Wherever old tuberculous lesions are encountered cold abscesses also may form. No tissue or organ is exempt: they are found in the brain, in the bones, viscera, joints, skin—in fact, in all parts of the body.

Cold abscesses have not only a significance of their own, but for the most part an identity. Their distinguishing feature is a limiting membrane, which forms whenever sufficient time has elapsed. Much has been written about it, and much error has been perpetuated with regard to it. This is the membrane formerly considered and called pyogenic, under the misapprehension that by it the pus or contents of the abscess were produced. I desire to emphasize in every possible way that this is a mistake. This membrane does not act to produce pus, but is rather the result of condensation of cells around the margin of the tuberculous lesion, forming, as it were, a sanitary cordon, for the absolute and definite purpose of protection against further ravages. I would suggest that the term pyogenic membrane be abolished, there being no such membrane under any circumstances, and that, this be known as that which in effect it is—namely, a pyophylactic membrane. It is a protection against pus, and were it not for its presence there would be no limit to the spread of tuberculous invasion. A lesion thus surrounded is shut off from most possibilities of harm, rarely encroaches, except by the most gradual processes, and, on the contrary, often contracts and reduces its dimensions, the watery portion of its contents being gradually absorbed and the more solid and cellular portions becoming condensed into matter which undergoes caseous degeneration, so that eventually recovery may ensue as the consequence of a metamorphosis of an original cold abscess into a caseous nodule surrounded by the old pyophylactic membrane, which is now serving as a capsule.

The contents of the cold abscess are, in some instances at least, of acute origin, and consequently may have been originally pus or its near ally. On the other hand, in cases which have occurred very slowly this material is not real pus, but is a semifluid debris having certain properties which remind one of pus. It has been my effort hitherto to devise for this material a name which should distinguish it from pus and indicate what it really is. Inasmuch as most of it has been of a puruloid character, at least at one time, I have suggested that it be called archepyon (i. e., originally pus or puruloid). As this flows from such a cold abscess, it is more or less watery and contains caseous, sometimes calcareous, nodules in masses of considerable size, and not infrequently sloughs of tissue and old shreds of white fibrous tissue which resist decomposition for a long time. This material has been thus imprisoned, sometimes for months or even years, and consequently has lost most of its resemblance to what it was originally. The organisms which first produced it have long since died, and it is practically sterile. If any organisms survive, they are the tubercle bacilli, which are more resistant and tenacious of life than the ordinary pyogenic organisms. This is why most culture experiments fail, and why even inoculation with the contents of an old cold abscess is often without effect even on most susceptible animals. Nevertheless the bacilli which the semifluid contents do not contain may yet linger in the meshes of the pyophylactic membrane; and here lurks the greatest danger in dealing with these lesions.

In old cases the pyophylactic membrane is very tough and very adherent by its outer surface. It can sometimes be peeled off in strips of considerable extent, at other times cannot even be separated, or sometimes is so placed as to render it impossible to follow it to its termination. There must be complete extirpation of this membrane, or at least destruction; and when its removal is impracticable, failure to remove it should be atoned for by some powerful caustic, such as zinc chloride, nitric acid, caustic pyrozone or the actual cautery, which should be made to follow it to its ultimate ramification. The membrane and the tissues underlying, when thus cauterized, will separate as sloughs, and these will be replaced by presumably healthy granulations, which should be encouraged until the original cavity is filled or the surface healed.

Acute abscesses, as indicated in the previous chapter, have no real limiting membrane, although there is more or less condensation of tissues about the focus of infection. A typical membrane is distinctive of tuberculous abscesses, and is to be regarded always as their natural protection and a barrier against their further encroachment—a membrane whose inner surface may harbor active organisms which cannot escape through its outer texture. Consequently, to simply incise it or inefficiently scrape it is to do a worse than useless thing; and one should never attack it unless he is prepared to extirpate it or destroy its integrity, and in this way dispose of it.

Cold abscesses when near the surface cause a bluish or dusky discoloration of the overlying skin, while the superficial and subcutaneous veins of this region are usually enlarged. Fluctuation is also a prominent phenomena in connection with them when they can be palpated. Deep collections of this kind may be mistaken for cysts or tumors, in which case the aspirator needle may be used to facilitate diagnosis. They vary in size from the smallest possible collection of fluid to abscesses which may contain a gallon or more of puruloid material or archepyon. They are known often as gravitation abscesses, because by the weight of the contained fluid they tend to elongate or spread themselves in the direction in which gravity would naturally carry a collection of fluid. Thus cold abscesses originating from tuberculous disease of the lower spine frequently work their way along the psoas muscle and present below Poupart’s ligament as psoas abscesses, or elsewhere about the thigh, while those which come from similar disease of the uppermost cervical vertebrae may present behind the pharynx, as the so-called retropharyngeal abscesses, and those from the dorsal spine present not infrequently as lumbar abscesses. These are but two or three familiar examples of what may occur in any part of the body.

Treatment.

—Aside from the treatment of cold abscesses, already indicated by radical measures, other means have been suggested, and particularly for the treatment of those in which such extreme measures are impracticable or impossible. It is sometimes efficacious to simply tap or remove by aspiration the contents of such a cavity. It may never refill, or but slowly, and after repeated tapping alone a very small percentage of such cases will subside into inactivity and the lesion be subdued, if not absolutely cured. Treatment by injection of emulsions of iodoform has found favor with many surgeons. I have never been able to secure the good results reported by others, and consequently have abandoned it; yet it deserves mention here because of the repute it has enjoyed.

This is based upon the alleged specific properties of iodoform as being peculiarly fatal to tubercle bacilli, presumably by liberation of free iodine. A cavity to be thus treated should be first emptied as completely as possible, after which may be thrown into it a glycerin emulsion or an ethereal solution, or a suspension in sterilized oil of 5 to 10 per cent. of iodoform. From 25 to 200 Cc. of some such preparation is introduced, while the walls of the abscess are more or less manipulated in the endeavor to completely disseminate the mixture. The cannula through which it has been introduced is then withdrawn; and this can usually be done with but little unpleasant iodoform effect. This is due to the pyophylactic membrane, which limits the activity of the drug as it has done that of the previous contents of the abscess. Such cavities have also been treated by washing out through a trocar with an injection of various antiseptic or stimulating solutions, among which may be mentioned hydrogen peroxide, weak iodine solutions, etc. My own advice is to treat all tuberculous lesions radically when such measures are not contra-indicated by their multiplicity or by too great depression of the patient, and so long as lesions are accessible to ordinary operative procedures. This same advice pertains also to those which have already spontaneously evacuated themselves, or where the overlying skin is threatening to break and permit escape of contents. Almost any case where this is imminent is one in which the surgeon, as such, ought to interfere. On the other hand, in deep collections and in debilitated individuals the treatment by injection may be tried.

The best way to treat accessible tuberculous lesions is by extirpation, as this hastens convalescence and leads to more permanent results.

The other and essential characteristic of tuberculous disease is the infectious granuloma to which it gives rise. This is a term first applied by Virchow to new formations of granulation tissue which are the result of the presence of invading and specific irritants. This tissue varies little in type from that already described under Ulcers, and is common to the neoplasms which are found in tuberculosis, syphilis, leprosy, glanders, and other local infections. So little does the tissue type vary in these different instances that it is difficult to distinguish by microscopic sections of the unstained tissues, or at least those unstained for bacteria, to which class of lesions they belong.

PLATE VII

Lupus of Skin. (Gaylord.)

a, fresh tubercles containing numerous plasma cells; b, mature tubercle with giant cells. Below are accumulations of plasma cells about the vessels. Low power.
Unna’s polychrome methylene blue.

This tissue may be met with in any of the tissues of the body, but is less seen upon the serous membranes of the cranial and peritoneal cavities, whereas in the joint cavities it is common. It is provoked, as just stated, by the presence of tubercle, and has the power of penetration into and substitution for almost all the other tissues of the body. Thus in a primary tuberculous focus within the bone a granuloma will form and extend its limits, while the surrounding bony tissue melts away before it; and it is by the growth of this tissue in a particular direction that tuberculous products from within the bone cavity are finally carried to the surface. When this material has escaped from bone, or from tissues without the bone, toward the surface its presence is marked by induration, by livid discoloration of a limited area of skin, with elevation of the surface, which finally breaks down and shows discolored, bleeding, and pouting granulations, which in the absence of restraint now proliferate more rapidly, and often to the point where they loose their former blood supply, and consequently necrose upon the surface. This is the fungous granulation tissue, especially of the German writers, and may be met with upon the surface, or is frequently seen in opening into joint cavities and other tissues infected by tubercle. The appearances of this fungous tissue are modified somewhat by environment and pressure: in joints flat and radiating masses of it will be found, extending along the synovial surfaces and into the articular crevices. This fungous tissue may grow in any direction, but apparently advances in the direction of least resistance. It leads to complete perforations of the flat bones, like those of the skull, while tuberculous masses from the dura may cause multiple perforations, the granulation tissue finally escaping through the overlying skin. In tuberculosis of synovial sheaths and bursæ it extends along and may completely fill and even distend them. It will separate tissues which were united together, and it may lead to disintegration and disorganization of the firmest textures in the body. So long as it is not exposed to the air nor to pyogenic infection, it will preserve its characteristics for a considerable length of time. Immediately upon exposure it is likely to break down, and infection will travel speedily along it into the deeper cavity whence it has sprung. A mass of this tissue contained within the normal tissues, condensed more or less by pressure, uninfected, and not freely supplied with blood, is entitled to the name of tuberculous gumma, whose tendency, however, is too often to break down and suppurate. Such gummas may be found in any part of the body, and differ only in unessential respects from the diffuse and more or less infiltrated masses of granulation tissue which occupy serous cavities or which extend in various directions.

The lesions of surgical tuberculosis, except those already spoken of as constituting cold abscess, are so essentially connected with the presence of granulation tissue, just described, or of this form of the infectious granulomas, that no student can appreciate the subject until he is familiar with this tissue in its various phases and in various locations. Of such great importance is it that this be realized that some of the local manifestations of this new tissue must here be considered, although they may be rehearsed in other form in succeeding chapters.

In the skin and subcutaneous tissues and in and under mucous membranes this granulation tissue may be studied at places where it is free from most mechanical restraints to growth, and where, in other respects, its appearances are typical. The most characteristic manifestations in the skin occur as lupus, a disease considered cancerous or of uncertain etiology. Lupus is always a cutaneous manifestation of this protean disease. (See Plate VII.)

In its incipient stages lupus consists of multiple minute nodules of granulation tissue just beneath the surface, containing all the elements of true miliary tubercle, with infiltration of the surrounding skin, even into the subcutaneous fat. The most common location of these lesions is on exposed surfaces. Bacilli are not numerous in them, yet may be demonstrated. The tendency is more or less rapidly to break down, the result being a tuberculous ulcer, which, as it extends, manifests usually a disposition to cicatrize in the centre while enlarging around its periphery. The dermatologists describe several different forms of lupus under the names hypertrophicus, vulgaris, maculosus, etc., all of which are essentially the same in character, the differences being largely constituted by the rapidity or slowness with which the granuloma of the skin breaks down. From the surface these growths may extend and involve parts at considerable depth, even the periosteum. This name should also include the lesions described as scrofuloderma or scrofulous ulcers of the skin, they being all of the same character.

A variety known as anatomical tubercle has been described by some writers, found especially upon the hands of those who frequent dissecting-rooms or handle dead bodies, and is supposed to be the result of local inoculation. It appears usually as a warty growth, which ulcerates and becomes covered with a scab—is usually indolent in character, but is followed by lymphatic involvement, and in rare instances by death from tuberculous disease.

Fig. 20

Tuberculosis of cervical lymph nodes.

In the lymphatic structures and lymph nodes tuberculosis is a most frequent affection. In these localities it may occasionally be primary, but is almost always a secondary lesion. It is in separating from the lymph stream the tubercle bacilli, which would otherwise be passed into the general circulation, that the lymph nodes, acting as filters, render us the greatest possible service. These filters themselves, however, almost always become infected, and, enlarging, they assume the appearances known to the laity as scrofula, which have been generally referred to as scrofulous glands. These lesions abound rather about the axilla and the cervical and bronchial nodes than about the lower extremities. Nevertheless, the retroperitoneal, mesenteric, and inguinal nodes are occasionally infected. In these nodes will be found giant cells surrounded with epithelioid cells, containing bacilli and undergoing cheesy degeneration or suppuration. Infection often proceeds from centre to periphery, and then to the surrounding tissues, the filter, as such, having become so choked that nothing seems to pass it. By virtue of this surrounding infiltration (which used to be known as peri-adenitis, when lymph nodes were spoken of as lymph glands) generalized infection is in some measure prevented, while the natural barriers are altered and natural distinctions between tissues are lost. This makes complete extirpation of these tuberculous foci often very difficult, while the adhesions which they contract, for instance in the neck, are often to the large vessels and nerve sheaths, by all of which their operative treatment is naturally complicated. When infection from the superficial nodes extends toward the surface it is easily recognized by the dusky hue of the overlying skin, the hardness, infiltration, and, later, the fixation, of these masses, accompanied usually by evidences of suppuration.

In and on the serous membranes we find tuberculous lesions, either primary or metastatic, usually miliary in type. In the pleural cavity they produce effusion (hydrothorax), which may necessitate repeated paracentesis, or by a mixed or secondary infection may cause empyema, for which much more radical and even extensive operations are demanded. (See Thoracoplasty.)

In the case of the peritoneum we find (a) miliary tuberculosis, (b) a slower non-exudative form with firm, sometimes pigmented nodules, and (c) a form characterized by small gummas which become caseous, coalesce, and ulcerate, binding together intestinal coils and producing extensive and irregular adhesions, with seropurulent exudation, often enclosed in walled-off sacs. In all of these cases surgical intervention should be considered, while in the more acute miliary forms abdominal section, with flushing, has in many instances afforded relief.

Tuberculous meningitis, cerebral or spinal, is in surgical cases practically always of miliary type, accompanied by the inevitable increase of fluid, and, in the cerebrospinal canal, of consequent tension. Inasmuch as the latter constitutes the most formidable feature of these cases, its possible relief by puncture may be considered. And so lumbar puncture (q. v.) may be practised, and even tapping the cerebral ventricles after making the small trephine opening has been done a few times, though not with encouraging success. (See Hydrocephalus.) Too often tuberculous meningitis is the terminal infection which ends many a case of local tuberculous disease in other parts of the body.

In general the more acute and miliary the lesions presented in tuberculous disease of serous membranes the greater the tendency to profuse watery (serous) exudate, whose volume may demand operative measures for relief.

In the bones we often find indications of tuberculous disease. It is not much more than sixty years since Nélaton called attention to the frequency of these intra-osseous lesions, and demonstrated the essentially tuberculous character of much that had hitherto been overlooked or considered under that vague term scrofula. All those forms of bone disease comprehended under the names Pott’s disease, spina ventosa, tumor albus, etc., are now known to be distinctly tuberculous lesions. In many instances these follow the slight circulatory disturbances brought about by contusions sprains, etc. This is especially the case in those who are predisposed to this disease.

Fig. 21

Tuberculous spondylitis (caries): a, osteogenesis and osteosclerosis; c, cavity formed by degeneration of tuberculous focus. (Krause.)

Tuberculosis of bone always assumes the phase of miliary lesions, followed by the formation of a granuloma, which may gradually encroach upon surrounding tissues or may assume a more fulminating type and spread rapidly. Apparently because of the circulatory conditions these lesions generally occur near the epiphyseal lines of the long bones, apparently seeking the ends of the bones, as pulmonary lesions seek the terminations of the lungs. These lesions may be solitary or multiple. Beginning always minutely, they spread so as to produce foci perhaps two inches in diameter. As the result of the formation of granulation tissue, the surrounding bone melts away and disappears, the result being a great weakening of its structure and expansion of its dimensions in order to make room for the growing mass within. The tendency of this granulation tissue thus imprisoned is always to escape in the direction of least resistance. This carries it sometimes into the joint, sometimes out through epiphyseal junctions, and sometimes through channels in the bone made by its own pressure, with external escape and appearance of the dusky distinctive tissue, felt beneath and then upon the skin. Where bone is so weakened in one direction it is usually strengthened by compensatory deposition of calcium salts at other points, and the result frequently is a striking combination of osteoporosis in the immediate presence of the disease, with osteosclerosis, sometimes to a remarkable degree, even to eburnation, of an adjoining portion. When this mass undergoes caseous degeneration the progress of the disease is much slower and the pain less. When it undergoes suppuration there are more evidences of inflammation, with more pain and systemic disturbance, as well as local swelling, tenderness, etc. The surrounding musculature is rarely involved, although the periosteum is nearly always so. In fact, it is stated that in an inflamed and suppurating bone lesion, if the muscles are extensively invaded, it may be regarded as of syphilitic rather than of tuberculous origin. The pyophylactic membrane already alluded to is seen in almost every instance of tuberculous disease. The spina ventosa of some writers refers to the expansion of the shaft and medullary cavity of a long bone whose interior is occupied by a mass of tuberculous gumma, which is perforated at one point, and through which opening it escapes as does lava from a crater, to involve the structures on the outer side. The appearance of this granulation tissue in joints as fungous tissue has already been mentioned. In a general way it preserves its fungoid characteristics until attacked by pyogenic or saprogenic organisms, when it quickly breaks down, forming an ulcer if upon the surface, or a cold abscess if not externally open. Tuberculous disease of the bone is most common in the young, and in them the majority of tuberculous joints are those whose bony structures have been first involved. In other words, the majority of cases of tuberculous pyarthrosis are due to primary bone disease. As the result of the tuberculous infection the bones become distorted, which is best illustrated in Pott’s disease of the spine; while, as the result of the constant irritation, joint ends become displaced by chronic muscle spasm, and joint contours entirely altered by expansion of the affected bone and thickening and infiltration of the overlying soft parts.

I have often, for the sake of illustration to medical students, drawn a certain analogy (following Savory) of the gross resemblances between lungs and bones in their behavior when involved in tuberculous disease. In either case the structure is in a measure spongy and contains cavities and networks of tissue; in each case the structures are invested by a resisting membrane—in the one instance pleura, in the other periosteum. Again, each is closely related to a serous cavity—the lungs to the pleural cavity, the bones to the serous cavities of the joints. Tuberculous disease manifests a predilection for the extremities of both organs. Perforation into the adjoining serous cavity is frequent, and previous to perforation collections of serous fluid are frequently noted—in one instance pleurisy, in the other hydrarthrosis. Moreover, these fluids may frequently become contaminated, and then become purulent, constituting empyema or pyarthrosis as the condition may be. One sees, too, in each place the same striking combinations of weakening of tissue and strengthening in order to atone for the undermining of the disease. These are not all of the similarities that might be adduced, but are perhaps sufficient for the purpose of showing that tuberculous disease is essentially one and the same thing, no matter what tissue is invaded.

In the tendon sheaths and bursæ we frequently find manifestations of tuberculosis. When seen early these are always in the direction either of miliary affection, or, most commonly, of tuberculous gumma, while when seen late the disease has usually advanced to the point of suppuration, and we now have cold abscess of the affected part.

In many joints and tendon sheaths, particularly the latter, we find certain detached, usually colorless, firmly resistant masses, of smooth and polished surface, lying in a collection of fluid, in size from a minute particle up to that of a melon-seed. These have been known at various times as rice grains, melon-seed bodies, corpora oryzoidea, etc., and for a long time their explanation was a mystery. It is now well established that in the majority of instances these are the result of fungous granulations which have become detached in small pieces, which then, in the absence of infection, have shrunken and become rounded and polished by attrition. The bursal enlargement and distention with fluid in which they are usually found is commonly spoken of as hygroma of that particular bursa. Tuberculosis of these bursæ, however, does not always result so harmlessly as the formation of these bodies, but, on the contrary, tuberculous infiltration may extend beyond the serous limits to the surrounding soft parts, with a tendency finally to external escape, just as in the case of bone lesions. These constitute affections of the soft parts which are more or less destructive, and are difficult, often impossible, to deal with, because of the mutilation which a thorough extirpation of the disease would necessitate.

In the testicles and ovaries, particularly in the former, tuberculous disease is frequently met with. In the testicles it begins usually in the epididymis, forming a somewhat dense nodule and a distinct tumor, easily observed from the outside, although its minute character may be still concealed. The tendency here is almost invariably to progressive infiltration and breaking down, either into a caseous mass or, more commonly, into puruloid material, while sometimes acute infection supervenes.

It is not always easy to distinguish between syphilis and tuberculosis of the testicle, though the latter is usually characterized by the same tendency to effusion into the adjoining serous cavity, i. e., that of the tunica vaginalis, as is manifested in disease of the lungs or bones. When the disease is extensive the overlying skin is involved, and frequently the surgeon is called to deal with cases of perforation and escape of fungoid tissue on the outside.

In the kidneys, in the ureters, as also in the bladder, tuberculous lesions are noted, the miliary form being particularly frequent in the former. Tuberculous disease of the kidney leads sooner or later to caseation and a condition of pyonephrosis or its equivalent, which calls practically always for extirpation of the affected organ. Tubercle bacilli are sometimes recognized in the urine, but only when the lesion has an opportunity of discharging into one of the urinary passages.

In the peritoneum tubercle appears usually in the miliary form, leading sometimes to such extensive involvement of and interference with visceral functions as to produce anasarca or more general disturbance prior to death. Acute miliary disease here is as rapid and as essentially fatal as the same affection of the dura or pia, while the more chronic forms are followed by degenerations that may involve the intestines either in agglutinated masses or in ulcerations and possible perforations. The indication in all tuberculous lesions of serous membranes is for exposure by operation, disinfection of the surface, and evacuation of retained fluids. Recovery from tuberculous peritonitis, even of acute type, after abdominal section, is now definitely established as a possibility. The same would probably be true of tuberculous meningitis were we permitted to expose the membranes and attack them or drain them in the same way.

Although a few distinct organs or tissues have here been specifically considered in their relations to tuberculous disease, there is no organ or tissue in the body which is exempt from its ravages and in which evidences of tuberculous disease may not be found. Even the mammary gland occasionally presents tumors composed of tuberculous granuloma which more or less simulate malignant disease, while calling for the same radical treatment (Fig. 22).

Fig. 22

Gross appearance in tuberculosis of the mamma. (Dubar.)

Paths of Infection.

—The tuberculous virus may enter the body through various channels. Probably in the majority of instances it gains entrance through the respiratory tract, less often by the alimentary canal, and occasionally by air contact of open wounds or direct infection by local agencies. It is now well established that tuberculous disease is easily inherited, although a predisposition to its ravages is transmitted from parent to children.

In what this predisposition consists is not always easy to say. As the tubercle bacillus grows in the tissues, it is by preference an anaërobe, and it seems to be lowered in activity or banished by access of oxygen. It has been shown that in those individuals in whose pallid skin, long bones, flabby muscles, and pale conjunctivæ we recognize a predisposition to this disease, the heart is disproportionately small as compared with the weight and size of the lungs. This means a relatively feeble pumping power, and is perhaps the best explanation for what is accepted as a fact. The mucous membranes of the nose and throat are usually the first lodging places for germs carried by the air, they finding here the warmth and moisture necessary for their detention, development, and growth. As long as these membranes are unbroken and healthy, infection is rarely possible; but let tubercle bacilli become caught in the crypts of the tonsils or in adenoid tissue in the nasopharynx, and the other disturbance, set up by irritant organisms of various species, will usually bring about conditions favoring their growth and incorporation into the living tissues. This lymphadenoid tissue is often the port of entry for these organisms. The explanation for local and surgical tuberculosis in bones and other accessible tissues probably is connected with causes determining at these points an area of least resistance, in which the germs find tissues more susceptible than elsewhere, and in which they may live and thrive.

Not the least interesting and important of the considerations regarding tuberculous disease is the possibility of an acute outbreak of tuberculosis after long latent or chronic manifestations of the disease. This means, in effect, the onset of general miliary tuberculosis which soon terminates fatally, and death is not the infrequent result of such extremely rapid outbreaks from tuberculous disease of joints, bones, ovaries, etc. For the disease when it has assumed this extremely rapid type there is, so far as known, no relief.

Diagnosis.

—So far as the general recognition of tuberculous disease is concerned, it is not often difficult. It is accompanied usually by more or less marked cachexia (at least this is the case when infection is serious and widespread), one of whose principal characteristics is the so-called hectic (habitual) fever of old writers. This was a fever of a remittent type, accompanied also by more or less colliquative night sweats, with dryness of the skin during the daytime, and flushing of the face. Hectic fever, as a matter of fact, often accompanies tuberculous disease, but is seldom encountered until pyogenic infection has occurred and suppuration is taking or has taken place. There is now much reason to consider hectic fever as an auto-intoxication from absorption of morbid products. In advanced cases we may find evidence of amyloid changes, although these are seldom recognized prior to autopsy. It is seldom difficult to recognize tuberculous disease except when at a considerable depth. Here, as long as there is no suppuration, there is little tendency to leukocytosis, by which diagnosis as between sarcoma and tuberculous infection may perhaps be made. Sometimes when in doubt the exploring trocar or an exploratory incision may be resorted to, it being always best to be prepared at the same time to proceed with whatever further operative procedure the findings may indicate.

Treatment.

—It is well to emphasize, first of all, that tuberculous disease when circumscribed and accessible is a distinctly curable affection. If this is accepted, it puts a much more hopeful aspect upon the condition than it formerly bore. It moreover justifies operations of a more radical nature than were formerly practised. Treatment should be divided into the hygienic and constitutional and the local and operative.

Of all the natural remedies, oxygen undoubtedly ranks first. This means the best of ventilation, an outdoor life if possible, and preferably in localities and at altitudes free from dust and well supplied with ozone. When this is impossible inhalations of dilute oxygen are capable of doing much good. The two canons of successful treatment of pulmonary tuberculosis are equally of value in surgical tuberculosis, viz., abundance of oxygen and hypernutrition. The diet should be rich and nutritious, at the same time capable of complete digestion. The emunctories should be stimulated and elimination favored in every possible way. Undoubtedly the old standard remedies—cod-liver oil, compound syrup of hypophosphites, etc.—are beneficial, and much good may be accomplished by their proper use.

Certain remedies have been at various times supposed to be endowed with specific properties, and for many years clinicians have endeavored to find that substance with which the system could be safely saturated and prove inimical to the parasite causing this disease. Such agent has not yet been discovered; nevertheless, much has been done in this direction. Of the remedies highly spoken of for this purpose, creosote and guaiacol are considered the best. These are somewhat difficult of administration, but if the latter is given in the form of the carbonate, generally known as benzosol, it comes the nearest to the ideal for which we are striving. Benzosol should be given to the adult in doses of at least a gram a day, perhaps more. It is better tolerated and less offensive than the guaiacol from which it is made. I have never seen anything but benefit result from its use, and yet would not extol it as a positive cure. Nevertheless in conjunction with other local and constitutional measures its administration may be followed by complete recovery.

Of the various local measures, physiological rest should be placed first, and can be achieved in some places better than in others. The various forms of apparatus resorted to by orthopedists are simply mechanical measures in furtherance of this purpose. Some surgeons have faith in iodoform, used locally in solution or suspension in some menstruum like glycerin, oil, etc. The benefit which has been claimed in some cases is not duplicated in the experience of all surgeons; nevertheless, it has undoubtedly been of service. A recent and most promising method of treating tuberculous disease of the extremities has been suggested by Bier, and consists in the establishment of a permanent hyperemia by the application of a rubber tourniquet on the proximal side of the lesion. (See chapter on the Joints.)

It would appear that the access of more blood which is thus permitted is inimical, presumably by the presence of the oxygen which it brings, to the development of the disease germ. The method depends for its rationale upon the fact that the congested lung does not become tuberculous. Lannelongue has suggested what he calls the sclerogenic treatment of tuberculous lesions, by injection of a very dilute solution of zinc chloride, which serves as an irritant and produces a tissue sclerosis that serves the purpose of a prophylactic membrane, while at the same time the solution is fatal to those germs with which it comes in contact. This treatment is painful and has not proved acceptable.

The astute surgeon, who gains the confidence of his patients and retains it, will not hesitate to remove by a suitable operation the tuberculous focus which he feels confident that he can reach and extirpate. The resulting tissue defects may be in many instances atoned for by plastic operations. At other times this procedure means excision of some joint, which leaves usually a much better functionating member than would the disease if permitted to go on to spontaneous recovery—i. e., ankylosis—and at the same time removes a focus of disease which is a menace if left to the future welfare of the patient. It may mean at other times amputation, but the artificial limbmaker now supplies a member vastly more useful than a natural one crippled by this infectious disease. In a general way, then, time may be saved and recovery ensured by early and judicious operation, while later in the course of this protean malady it may be absolutely necessitated in the endeavor to save life.

After operations where clean extirpation and reunion of the parts with primary healing is impossible a local dressing of balsam of Peru containing 10 per cent. of guaiacol is recommended. Gauze saturated with this dressing and packed into the cavity best accomplishes the purposes of a surgical dressing for such cases.

The superficial and ulcerative (skin) lesions due to tuberculosis often yield very readily to exposure to the Röntgen rays and the ultraviolet rays. Recrudescences appear not infrequently, and the treatment should be administered at intervals long after the apparent subsidence of the lesion.

Deep pain of tuberculous lesions, especially in bone, is often relieved by ignipuncture, meaning thereby a perforation into the depth even of the bone-marrow by the actual cautery (Paquelin’s), which may be thrust directly through the skin or which may be used after exposing the bone by incision. The use of the actual cautery is indicated in eradicating and destroying tuberculous tissue when a neat dissection or extirpation is impossible.

Tuberculin.

—Finally the treatment of tuberculosis cannot be dismissed without a reference to the glycerin extract made from a filtered culture of the tubercle bacillus, containing the peculiar toxalbumin first prepared by Koch, forever associated with his name, and first given to the world in 1890, when its announcement created a furore and aroused hopes that have never been completely realized. Yet in spite of disappointments which have often followed its use, it is a remedy of great value when judiciously used in selected cases. The diagnostic value of the material should also not be forgotten, as by its use one may possibly decide in doubtful cases as between tuberculous or some other disease. The best preparation for use today is that made by Koch’s new process, by which the possibility of the presence of microörganisms is eliminated. It contains those constituents of the bacilli which are insoluble in glycerin, and which have distinct immunizing power. On the market it is known as tuberculin rest, indicated simply as T. R. The initial dose is ¹⁄₅₀₀ Mg., to be increased with each injection. Its effect, e. g., on lupus, is very marked.

CHAPTER X. SYPHILIS. — Manner of Contagion. — Nature of the Virus. — Evolution of the Disease. — The Lesions and Secretions which Convey Infection. — Location of Primary Lesions. — Symptoms of the Ulcer. — The Mixed Chancre. — Pathology of the Chancre. — CONSTITUTIONAL SYPHILIS. — TERTIARY OR CONSTITUTIONAL SYPHILIS. — SYPHILIS IN CHILDREN. — TREATMENT OF SYPHILIS.

The younger generation, when studying the subject of syphilis, should be referred back one hundred years or more to the time when the opinions held by John Hunter generally prevailed—when venereal diseases were grouped under one heading, and considered to be but three manifestations of the same morbid condition. It took years for the profession to break away from this mistaken teaching, and a generation had passed before gonorrhea was separated from the others. This left chancroid and syphilis still more or less confused in the minds of many, and until the middle of the previous century they were considered as different types of the same disease by some of the most experienced observers. Thus it happened that those who made a special study of this subject were grouped into two classes, the unicists and the dualists, according as they held to the unity or duality of syphilis and chancroid. It was a question of importance, and differences of opinions led to bitter antagonisms. Its importance inhered in this: either all venereal sores were to be subjected to constitutional treatment, or else differences in treatment were to be made according to the local or constitutional nature of the malady. Men sacrificed their own health, even their own lives, in their willingness to make experiments upon themselves, and auto-inoculability was proved by one observer through some 1700 inoculations produced upon his own body. Such devotion to medical science has been rarely eclipsed. In the latter half of the eighteenth century came clearer distinctions, and toward its close there were none who ranked as authorities who held to the old view of the unity of these diseases.

Syphilis is a disease of ancient if not of respectable origin. We read much of the possibility of so-called pre-Columbian syphilis, implying by that term that the Spaniards who came over to this country found it here and carried it with them back to Europe. This is probably the case, and yet the disease antedates the Christian era, as may be established by familiarity with ancient literature, whether Arabian, Egyptian, or Hebraic. No one can read the Psalms of David, for instance, without finding therein intrinsic evidence that the writer thereof, whoever he may have been, suffered from this disease. Of its antiquity, however, as well as of its universal distribution, we need not speak. History has shown that whenever it has appeared in a community previously unaffected by it, it has assumed malignant and epidemic features, and has spread rapidly while claiming many victims; on the other hand, in those communities where it has long been domesticated, it assumes usually a milder type, as though a racial immunity were being gradually established.

Syphilis is an infectious chronic disease, acquired either by inheritance or by contagion, mediate or immediate, with a certain period of incubation, characterized by an initial lesion at the site of infection, which is followed in time by a series of systemic disturbances, usually quite characteristic, in a commonly determinate order. A large proportion of these consist of neoplastic lesions of the general type of the infectious granulomas. In the majority of instances it is of distinctly venereal origin, although not always. It is known among the common people as pox, while a frequent synonym for it in foreign literature is lues venerea, or often lues alone, the adjective being luetic.

Syphilis is always transmitted as such and is not interchangeable with leprosy, tuberculosis, or anything else, although it is not unfrequently complicated with them as well as with cancer. It has certain resemblances to the exanthemas in its periods of incubation, and in the fact that one attack is supposed to confer immunity, as well as that many of the typical symptoms of syphilis pertain to the skin and mucous membrane; further resemblances may also be found in each case.

Within certain limits the specific infection of syphilis, or, as it is frequently spoken of, the specific disease, passes through a somewhat regular program in which periods of activity and latency seem to alternate. The first visible lesion is at the point of entrance of the virus, in acquired cases, after a certain period of incubation, and is known always as the chancre. Of course, in inherited syphilis no chancre or primary sore is found. Then occurs a second period of incubation, during which there is a still more widespread general infection of the body, in which at first the lymphatic system seems to suffer most. This is characterized by a certain degree of fever, progressive anemia, malaise, tenderness and pain in bones and joints, all of which indicate a progressive toxemia.

—The manner of contagion in acquired cases is naturally most often that of the sexual act, although contagion may come from many sources, including unclean utensils, pipes, etc., as well as the instruments of the dentist or the surgeon. Some abrasion of the infected surface is almost invariably presupposed, since it is not established that the virus of syphilis will enter an unbroken surface, though it may lurk thereon; but the abrasion may be trifling and occur in such situation, especially on the female genitalia, as to be undiscoverable or unnoticed. It is then possible that patients may speak truthfully when denying the existence in the past of any venereal sores. The transmission of infection from parent to offspring in the uterus will be discussed later.

—That syphilis is a disease of parasitic character, i. e., contagious, there can, of course, be no question. The nature of the contagium vivum which produces these changes, long unknown, is now believed to be revealed in the spirochæta pallida recently described by Schaudinn and others; an organism 4 to 10 μ in length, ¹⁄₂ μ in width, possessing several curves like those of a corkscrew, with sharpened poles, mobile, its motions consisting of rotations and bendings. It has been demonstrated that primary lesions contain the organism, either constantly or in the majority of cases, while in skin and nearly all other lesions it can be also shown (Fig. 23).

Fig. 23

Spirochæta pallida (syphilis) in adrenal of child with congenital syphilis. (Gaylord.)

—Ever since the days of Ricord’s writings on the subject it has been customary to group the manifestations of syphilis into three groups or stages: the primary, the secondary, and the tertiary. Less stress is laid upon these stages than previously, yet it is convenient to retain them for descriptive purposes. It should be emphasized, however, that between them there are no arbitrary limits of time or tissue. Primary syphilis under this classification includes the first period of incubation and the symptoms and appearances of the initial lesions. Secondary syphilis may be made to include the earlier constitutional symptoms which involve or at least become apparent upon the more superficial portions of the body, i. e., skin, mucous membrane, lymphatics, etc. Later comes the so-called tertiary period, in which the body surfaces are not necessarily spared, but in which also deep lesions of the viscera, the bones, the brain, etc., are noted. Between the first and the second stages comes the so-called second period of incubation. The second and third stages are characterized by frequent neoplastic formations, which assume the type of the infectious granulomas and are commonly spoken of as gummas; these lesions are destructive in their tendency, and will so prove unless dissipated or aborted by suitable treatment.

In the first and second stages of the disease it can be conveyed by inheritance and inoculation; in the later stage such an occurrence is exceptional.

That syphilis is, per se, an infection is proved by the constitutional symptoms which accompany its earlier manifestations; the fever, usually mild, though sometimes well marked, which comes early in the course of the disease, the general lymphatic involvement, the malaise and depression, all indicate the systemic disturbances of a true toxemia.

The periods of quiescence between successive outbreaks of the disease are, moreover, characteristic, although they sometimes lull the patient and his physician into an inactive state, during which medication is too often suspended, so that when fresh disturbance arises vigorous treatment must be renewed.

The infection of syphilis occurs on the instant of inoculation, as in the case of tetanus. This is important, as upon it depends the question of early local treatment. While excision of the primary sore, or even of an area which might have become infected during exposure, and before the actual formation of the chancre, has been often practised and urged by some, experience has shown that it has little to commend it, since the general experience is that it does not prevent the development of the disease.

In its tendency syphilis is constantly progressive and destructive, although it often behaves in a capricious manner, sometimes when under efficient treatment and generally when treatment is inefficient. It is usually more virulent in the dissipated and those who are weakened by inheritance or poor constitutions, or by other disease. One reads in literature on the subject about the malignancy of some cases and the benignancy of others. Some cases seem to have a malignant aspect, while others run an unusually mild course, so much so as to raise the question whether the patient had syphilis. As far as the nature of the parasitic cause is understood, this would depend on differences in the make-up of the individual rather than in the actual virulence of the germ. In the extremes of life individuals are more susceptible. When implanted upon a tuberculous constitution it sometimes renders the tuberculous lesions more active; whether it acts as a mixed infection is not definitely known. Tuberculous lymph nodes frequently break down during the course of secondary syphilis, and consumptive patients grow rapidly worse. Syphilis, like alcohol, tends to play havoc with the bloodvessel walls, and their combined effects in this direction are greatly to be deprecated and should be prevented.

—As far as acquired syphilis is concerned absolute contact is necessary between the infecting material and the infected area, while upon the latter must exist some abrasion of the surface. Chancres and the early eruptions or mixed lesions have been proved to be absolutely virulent. The genitalia of both sexes are frequently the site of wart-like lesions referred to as condylomas, which are usually kept more or less moistened by the secretion of the parts, and are fruitful sources of contagion. The discharging lesion of those suffering from syphilitic disease should be regarded as capable of transmitting it, while during the primary and secondary stages the blood and lymph should be regarded as probable sources of danger.

Inoculation with the blood of patients during these stages has been known to be successful. How long the blood retains its power of infection is uncertain; it is usually regarded as free from it when the disease is latent.

The natural and physiological secretions of various organs, e. g., saliva, milk, perspiration, tears, and urine, are not generally believed to be capable of transmitting the disease. The semen of syphilitic men may reproduce the disease by heredity but not by direct inoculation. It is possible under these circumstances for the father to transmit the disease to the ovum without previously infecting the mother; such infection of the ovum by diseased spermatozoa is quite different from the infection of the ovum by the mother who has acquired the disease, the father having escaped it.

In a general way it may be held that secretions of organs, or even of lesions, which are non-specific, are not contagious except as they happen to be mixed with blood or with disintegrated portions of actual syphilitic lesions; thus, for instance, vaccinal lymph might be safely taken from a syphilitic subject if there were absolutely no admixture of blood. But the difficulty of securing pure lymph is such as to make its use inadvisable because of its danger.

Suppuration frequently complicates syphilitic lesions. This is to be regarded as in the nature of a secondary and pyogenic infection. It has not been established that the germ of syphilis is by itself a pyogenic organism.

Gonorrhea or chancroid is often simultaneously contracted with syphilis, with resulting clinical complications that are perplexing as well as difficult to treat. The contagion of chancroid acts promptly, as will be stated in the chapter on Chancroid; and so it may happen that the sore which begins as a chancroid is gradually converted into a true chancre, the change taking place so gradually that it is difficult to state when it begins or is completed. In this way result the so-called mixed sores, which may give rise to so much doubt that the surgeon feels it wise to wait for some secondary manifestations before deciding that syphilis has been acquired. Confusion is often created by preliminary treatment which the local lesion has received previous to its examination by the surgeon. Patients, especially in the lower walks of life, frequently go to a druggist or to someone who will cauterize the sore and thus mask its characteristics to a degree which makes prompt diagnosis impossible. Again, patients are often uncertain regarding the matter of time, which is of great importance; thus the sore which appears within a few days after exposure may be chancroidal, while one which comes on twenty or thirty days afterward may be syphilitic. These periods, however, afford little help when there have been repeated exposures, by which confusion may be caused; but an accurate and complete personal history will be helpful toward a correct diagnosis.

—Owing to the greater delicacy of the mucous membranes they are more frequently the site of primary lesions than the skin: 85 to 90 per cent. of all primary sores occur about the genitalia; in men, especially on the inner side of the prepuce, the glands, and the sulcus behind it; externally, chancre may occur upon any part of the surrounding skin; in women, the tissues about the vulva are most frequently its seat. Occasionally it is found within the vagina, but rarely upon the os. The so-called extragenital chancres are met with anywhere, especially on the most exposed parts, as the lips, tongue, tonsils, eyelids, and nipples. Syphilis is occasionally conveyed to a wet-nurse by the infected mouth of an infant suffering from hereditary disease; even multiple chancres sometimes occurring. Conversely, children have been infected by wet-nurses with syphilitic lesions about the nipple. The disease has been conveyed by bites, as upon the face and fingers. Surgeons and obstetricians are peculiarly exposed, as are also nurses, to this disease, especially occurring upon the fingers and hands. Infants have been known to be inoculated during parturition. These are all examples of direct or immediate contagion. On the other hand, the disease may be positively conveyed by utensils in common use between different individuals, as table-ware or tobacco-pipes; by tools of trade which are passed from one person to another, as, for instance, the blowpipe in glass factories; and by cigars as they are made in some places, the wrapper being moistened from the mouth of the cigarmaker. These are examples of its indirect transmission. Physicians are familiar as well with instances where the disease has been conveyed by instruments, either surgical or those of the dentist. So possible is this last form of contagion that dentists are trained to sterilize their instruments as carefully as does the surgeon.

Possibility of conveying syphilis by vaccinal lymph has been alluded to as occurring only in those instances where the blood of the syphilitic patient is mingled with the lymph. The production of vaccinal virus is now, however, so well regulated that it is rare that the surgeon employs humanized lymph. Some cases considered vaccinal have been due to the use of infected instruments; hence the necessity for extreme caution in this regard. When the disease is acquired in a non-venereal manner it is called syphilis insontium, or syphilis of the innocent; this, however, is an unfortunate expression, as it tends to cast reflections upon other cases which may be, in effect, just as innocent.

—In all probability the initial sore and the ensuing lymphatic involvement are due to the parasite and to its toxic products. These latter are quickly taken into the general circulation and are held to confer the immunity which syphilitics enjoy before the outbreak of the general eruption. Anemia, malaise, and other like symptoms are evidences of a progressive intoxication or toxemia, while the earlier eruptions, which tend to evince the contagious element in a rather virulent form, may be due to the germs alone, or combined with their toxins. On this hypothesis can be explained the partial or complete immunity evinced by mothers who bear syphilitic children, the infection coming from the father.

From the first evidence of infection the whole syphilitic process gives evidence of its infectious character. The bloodvessel walls undergo a thickening of their coats and more or less obliteration of their lumen, and this, of course, causes a disturbance in the nutrition of the parts supplied by them. This vascular change can be recognized even in the minute vessels of the initial lesion, and thereafter pertains to most if not all specific manifestations of the disease.

Our knowledge of the nature of this disease would be more complete were it possible to convey it to animals, but these are practically exempt from it, for the few and rare instances where, it is said, the disease has been inoculated upon the higher quadrumana furnish insufficient data. In this respect the disease is like the exanthemas, of whose parasitic origin there can be no question.

The First Period of Incubation and the Chancre.—The time which elapses between the exposure and the first appearance of the initial lesion is known as the first period of incubation. This varies, within wide limits, from ten days to forty or fifty; some writers have made it even seventy days. The average period varies from three to four weeks. There is often uncertainty as to when the induration began, and patients, women especially, may easily make a mistake of several days in fixing this date.

Every case of acquired syphilis begins with an initial sore, though this may be so located or so complicated with some other lesion as to be overlooked. The character of the induration varies somewhat with the location, i. e., whether upon the skin or mucous membrane. The amount of moisture or maceration to which it is exposed will also influence its appearance. It may be minute, so as to almost elude observation even on visible parts, or it may spread and involve an area 1 Cm. in diameter. The lesion is usually solitary, but when several abraded spots are infected at the same time there may be multiple sores. When a surgeon sees a lesion of this character it has usually changed its original appearance—perhaps by some previous treatment, perhaps by maceration. There is one invariable feature upon varying expressions of which diagnosis is based, and that is induration. The instances in which this fails are very rare; on the other hand, it is possible that it may be the result of treatment already undergone, and for this reason the recent history of the case should be obtained; in other words, the typical chancroid is always indurated, but an indurated sore does not of itself necessarily indicate syphilis if it can be satisfactorily accounted for in other ways. The presence of an active primary lesion seems to confer immunity to subsequent infection for a period co-equal with the active manifestations of the disease, although even in this respect exceptions are occasionally to be noted.

The induration of syphilis develops beyond and beneath the limits of the superficial lesion, and gives the sensation, when grasped between the fingers, of a piece of firm material embedded in the skin or membrane. It is firm, slightly elastic, with usually well-defined boundaries, which accounts for the expression, parchment induration. Ordinarily no pain or other sensations accompany its formation or attract attention; hence the frequency with which it escapes observation for some time and the uncertainty which the patient feels regarding the dates. The surface of the induration usually becomes moist or abraded and frequently ulcerated; but these surface lesions tend eventually to heal, even if let alone, except in those parts, e. g., the lips, where they are constantly bathed by discharge.

The characteristic induration disappears slowly in a few weeks or months, leaving ordinarily no trace of its existence, although sometimes a small scar, occasionally pigmented, is left to mark its site.

There are two or three classical varieties of chancre which deserve more minute description. As ordinarily seen upon the genitalia, a chancre may assume the following types:

• A. Dry, scaly papule.
• B. Superficial erosion.
• C. Hunterian, or ulcerating chancre.

A. Dry Papule.

—The dry papule commences as a small rounded area of redness, becoming infiltrated and rising above the surface, gradually developing into a nodule the size of a pea or larger, over which the superficial skin seems to be thickened. Should the summit of this nodule become abraded there will escape a serous fluid, which dries and forms a thin scab. This papule may disappear more slowly than it came, or may become more infiltrated, while its surface breaks down into an ulcer, whose area will be dropped a little below that of the surrounding tissue. In this case the induration is produced almost entirely by new round-cell infiltration, as in the other varieties; when it ulcerates these cells are the ones mainly to suffer, so that there is not much destruction of the original elements, and but little scar remains.

B. Superficial Erosion.

—The superficial erosion is the most common of the primitive sores, but is not often seen so early as to have its first appearance noted. It begins as a well-defined, dark-red area, which loses its epithelium and exposes a raw surface, with a trifling depression whose edges are usually on a level with the surrounding skin, while in the previous case the edges are generally characterized by an elevated margin. The base of this sore is also indurated, and partakes usually of the parchment-like character already described.

C. Hunterian Chancre.

—The Hunterian chancre, so named after John Hunter’s description of it, is the most distinct and typical of these primary lesions. It begins as a papule, with some erosion, increasing slowly in size, sharply outlined, with a somewhat flat top. As it grows larger it increases in firmness until its base is extremely dense. In color it is greenish or bluish red, and this color appearance is more distinctive than in the other forms. In from one to three weeks its surface epithelium is usually loosened by maceration, and serous discharge is the consequence, or else it becomes covered with a grayish exudate, which, by its location, is rarely allowed to form a scab. The centre of the ulcer becomes deeper, its edges more elevated, and in typical cases a minute crater is formed by a characteristic destructive process. While the Hunterian chancre tends in ordinary cases to slowly disappear of itself, this involution can be materially hastened by local and constitutional treatment, and usually heals, when properly treated, with but slight local evidence of its previous existence.

—Chancroid will now be described, and its consideration will include the statement that it may be followed by true syphilitic chancre. Such a lesion is known as mixed chancre or mixed sore, and indicates a simultaneous infection by two distinct infecting agencies; it may easily cause confusion, for if seen early it will lack the characteristic induration of syphilis. This latter will only appear about the time that the chancroidal ulcers should be healed, if promptly and properly treated. Supposing this treatment to consist at least in part of caustics, the surgeon may be in doubt as to whether the induration is due to this agency or to developing syphilis. It seems justifiable to imagine causes of this kind while awaiting the further developments of the case, and to postpone vigorous antisyphilitic remedies until the diagnosis is established. It is a serious thing to condemn to a long course of mercurials a patient who perhaps does not need such drastic drugs. Instances arise where the situation is to be carefully considered in view of these possibilities. Should the healing and apparently healthy ulcer, however, take on an indurated base and develop the typical scleroses of chancre, it may be supposed that all doubt has been removed. The possibility of syphilitic infection being implanted upon a chancroidal base by subsequent exposure should also be taken into consideration. This will require an accurate history and a faithful narration of the same by the patient.

There are, also, the extragenital chancres, which may be met with upon the hands, upon the breasts, in the oropharynx, as well as about the eyelids. Chancres on those surfaces of the body where tissues are loose may attain considerable size and ulcerate early, the discharge drying into scabs or crusts, which mask the underlying ulcer. Around the margins of the nails these lesions show but slight induration. Sometimes suppuration and granulation are profuse. When appearing upon the tonsils there is nearly always ulceration, with considerable swelling and often a false membrane. A patient with this lesion will complain of sore throat, and involvement of the surrounding lymphatics is usually extensive.

When chancre appears upon the lips there is usually extensive induration; the lesion attains considerable size, with protrusion, unless recognized and treated, and ulceration takes place early and deeply. It may be confused here with epithelioma. The latter occurs during the later period of life, is slower in its evolution, and its involvement of the neighboring lymph nodes. The local changes which often precede cancer, e. g., hyperkeratosis and papilloma, will be lacking in chancre of the lip.

Sometimes at the site of the original chancre, which may have healed, there will be found one of the later lesions of the disease, which may be mistaken for another primary sore occupying the site of the first one. It may be distinguished by its central ulceration, its tendency to extend, and by the absence of the lymphatic involvement which is met with in the early stages of the disease.

—The chancre should be regarded as the first neoplastic evidence of a disease which is throughout characterized by its tendency toward new-cell formation. In the developed chancre there is a well-defined cell proliferation in the skin or mucous membrane, whose bloodvessels show the same character of change already mentioned, since in the walls, both of the minute arteries and veins, are found many new cells, some of which were originally leukocytes, but most of which are products of cell division, as shown by their numerous mitoses. All the coats of the vessels are involved and even the perivascular spaces are involved and obliterated. Essentially, then, the chancre consists of a local infiltration of the superficial tissues by cells, most of which are of the round type; the whole constitutes what may be spoken of as the initial sclerosis, which remains or disappears as such unless infected secondarily. This sclerosis should be carefully sought in every suspected region when the patient is first examined. It may range in bulk from a millet-seed to that of a good-sized grape; it is usually movable upon the tissues beneath; it may ulcerate deeply, and, should it persist for a long time, it may seem unusually active just before the outbreak of the so-called secondary symptoms.

But little can be predicted with regard to the future course of the disease from the size, number, or appearance of the primary sores. The nature of the tissues upon which the virus has been implanted is a more important feature in the evolution of the disease than anything pertaining to its primary lesions, so far as appearances go. In patients of depraved habits or vitiated constitutions the chancre may often become gangrenous or phagedenic.

Lymphatic Involvement.

—Soon after the appearance of the primary sore, or coincident with it, the enlargement of the adjoining lymphvessels and nodes begins. This is noted first in those which are in closest communication with the site of the chancre, usually in the groin. Occasionally thickened lymphvessels may be felt as cords extending along the dorsum of the penis. There may be enough involvement of the perivascular spaces to produce this appearance and sensation even around the bloodvessels. This lymphatic involvement is exceedingly significant, and yet may be found to some degree after chancroid and even after herpes of the genitals. It is, of course, an expression of a travelling infection—in the first case produced by the syphilitic virus; in the second, by the chancroidal virus; and in the third, by ordinary pyogenic organisms which enter through the pathway afforded by the herpes.

The involved lymph nodes of syphilis suppurate much less often than do those of chancroid, and suppurating bubo is, therefore, not common in syphilis. The term bubo generally means an involvement of the lymphatics in the groin, although, strictly speaking, it implies a similar condition in any part of the body. Syphilitic bubo, therefore, is to be distinguished from chancroidal as well as from non-specific bubo. These lymphatic lesions are sometimes spoken of as constituting the characteristic adenopathy of the disease, but this is an unfortunate expression, as it implies glandular involvement, and the term lymph gland should never be used, since the structures are not glandular in any respect. The enlargement and persistence of these lymph nodes constitute peculiar features of the disease, and may be noted long after the subsidence of active manifestations.

Treatment.

—With the earliest possible recognition of a syphilitic chancre or sore there is need for active and prolonged constitutional treatment, in addition to whatever may be required locally. If the diagnosis can be made, constitutional treatment should commence at once; only in cases of doubt is it advisable to wait. The local treatment is a matter of ordinarily small importance; the sores tend to heal spontaneously and quickly when the system is brought under the influence of mercurials. There are few authorities who recommend excision of the primary lesion or believe it is possible to abort syphilis by anything that can be done to the chancre. It is advisable to make mild antiseptic applications only. A chancre, however, in a location which makes it difficult to keep the parts clean, should be exposed to treatment by a minor operation, as an incision of the prepuce, circumcision, or a dilatation or incision of the hymen. Aside from such operation the indication is for surgical cleanliness; soap and water followed by hydrogen peroxide, which may be continued as an application, or dusting with calomel, will usually prove sufficient. Various antiseptic solutions may be used. Dry applications, however, are the most convenient and usually the most serviceable; iodoform should be avoided on account of its penetrating odor; and pure, dry calomel will sometimes prove a mild caustic, and is best reduced with one to three parts by weight of bismuth subnitrate. The stronger applications, especially caustic, are only employed when there is unhealthy ulceration. If the sore is gangrenous it should be cocainized, then the surface thoroughly treated with some powerful caustic like nitric acid, and thereafter kept moist with aqueous antiseptic solutions. When the surface is practically healthy, dry preparations or unguents may be employed, preferably the mercurial ointments. There is greater difficulty in preserving cleanliness about the female genitalia, and here the use of antiseptic cotton or gauze will probably be necessary in addition to the other precautions. Surfaces should be kept apart by their aid, and it is well to use frequent antiseptic douches or occasionally to insert a suppository containing an antiseptic drug. Of the various preparations used those containing mercury in some form are doubly serviceable. The inguinal lymphatics should be kept anointed with a mercurial ointment, which should be thoroughly rubbed in, and the parts afterward protected with oiled silk.

While these local measures are being employed vigorous general treatment should be promptly instituted. This will be discussed when dealing with treatment of the constitutional features of the disease.

There are locations in which chancre gives rise to considerable distress, as, for instance, upon the lip and tonsils. Great improvement and relief of pain in these lesions is afforded by proper use of auxiliary drugs.

In regard to local precautions, the patient should be impressed with the virulent and infectious character of the discharge from every primary lesion, and given minute and cautious directions so that its transmission to others can be prevented. This will mean the use of separate utensils, as well as soap, towels, etc., possibly the temporary isolation of the patient.

Between the time of appearance of the primary sore and the development of widespread constitutional symptoms there intervenes a period of latency, the second period of incubation. This is more variable in duration than the first. The shortest time on record is about two weeks, and the longest about two hundred days, the average time being six or seven weeks. The secondary symptoms indicate complete generalization of the syphilitic poison, and follow the early manifestations in almost every case; nevertheless, there are instances in which they are either wanting or are so trifling as to escape observation. A careful examination during the second period will usually show, however, that the lymph nodes throughout the body are gradually becoming enlarged, especially those in the neck, along the border of the sternomastoid, the occipital nodes, those in the axilla and groin, and particularly one or two small ones above the inner condyle of the humerus, known as the supracondyloid or epitrochlear nodes. When these latter become involved without evident and local cause, syphilis is always to be suspected or even diagnosticated. This node is to be found by bending the patient’s elbow and feeling for it on the inner side, above the condyle, in the interval between the biceps and the triceps. The other lymph nodes of the body might also be found involved if they could be as easily palpated. This lymphatic involvement is quite independent of skin or other lesions, and does not yield as readily to mercurial treatment. The enlargements are usually movable, distinct in outline, and never suppurate unless locally and secondarily infected. In tuberculous patients, however, they may break down. This generalized involvement of the lymphatics is also of importance in diagnosticating old syphilitic infections.

During the second period of incubation there is generally a certain degree of malaise and progressive anemia. Examination of the blood will show diminution of hemoglobin, and a relative if not actual leukocytosis, due to reduction in the number of the red corpuscles. Occasionally the anemic features become pronounced; the patient may complain of weakness, lassitude, sleeplessness, failure of appetite, and of pain and discomfort in the bones and joints, more pronounced at night, and often regarded by patients as “rheumatic.” The painful joints may also show a slight swelling due to increase of the joint serum.

Sometimes intermittent fever accompanies these cases, especially during the early eruptive period. The rise of temperature is noted mainly in the evening, when it may reach 104° or even 105° F. It does not last long, and often precedes the appearance of a well-marked and characteristic eruption. It is a peculiar feature of the syphilitic poison that it seems to attack points of least resistance in each patient, as is the case with that of influenza. In one patient fibrous tissues will suffer most; in another, joints; in others there will be headache or expressions of perverted nerve activity, as vertigo, convulsions, disturbances of sensation, temporary paralysis; again there occur disturbances like mild pleurisy, splenic enlargement, or jaundice. Occasionally there will be a typhoidal condition, during which the kidneys are seriously compromised. Morbid conditions are intensified by an attack of syphilis. During rheumatism and the various forms of neuritis, and during almost all affections of the central nervous system, symptoms are, under these circumstances, frequently aggravated. In malarial countries it is said that latent syphilis sometimes becomes active when malaria is present. Lesions of the bones and joints are occasionally influenced, while some claim that fractures occur more readily in syphilitic subjects, and it is generally conceded that delayed union of fractures is often due to this cause. I have seen fracture, apparently spontaneous, of both tibiæ, one after the other, in a patient with syphilitic disease of the cord and bones. I have also seen exuberant callus form around a fracture in a syphilitic subject, as it never does under ordinary circumstances. Injury seems sometimes to localize the manifestations of the disease; thus chronic irritation at the site of old syphilitic lesions frequently becomes a point of development for epithelioma, or some other expression of malignant growth. This is seen particularly in cancer of the tongue, which sometimes follows the change in the epithelium known as leukoplakia.

The influence of an attack of erysipelas upon certain specific lesions is remarkable. In many instances eruptions and ulcerations have been known to subside, and gummas and exostoses to disappear, after an attack of erysipelas involving their site, but these lesions are likely to reappear after the disappearance of the acute infectious process. The temporary effect of the toxins of erysipelas upon syphilitic lesions is similar to their influence upon some malignant growths.

Syphilis of the Skin.

—Passing now to the lesions of early constitutional syphilis as manifested in particular regions or organs of the body, we take, first, the skin. When syphilis seems to have ended its existence during the primary stage (Fordyce) no further disturbances are expected, and only by waiting can the termination of the disease be determined.

The malignancy of the disease may be estimated by noting the rapidity with which the destructive lesions appear; thus gummas which appear early in the skin or mucous membranes, or elsewhere, indicate a serious type of the disease. So also does profound cachexia, including in this term more than mere anemia. The devastations of the disease in Europe during the fifteenth century show that it presented at that time a severe type.

The eruptions of syphilis have been grouped under distinctive terms, and are usually referred to as syphilides or syphilodermas. It has been already stated that among the new formations of syphilis are those known as syphilodermas; any of the former which are distinctly due to syphilis may be syphilomas. Thus, we may have syphiloma in the skin, in the bones, in the viscera, etc. It has been customary to speak of the syphilides as simulating the non-specific eruptions and identify them by placing before them the adjective syphilitic. Thus writers formerly described syphilitic psoriasis, syphilitic erythema, etc.; but these terms have been abandoned, because it is recognized that the skin lesions of syphilis while imitating most of the features of the non-specific diseases are yet distinctly different from them. We speak, therefore, now of a macular, vesicular, papular, squamous syphilide, etc., implying thereby that it is vesicular, scaly, or otherwise, as the case may be, and at the same time that it is a cutaneous expression of syphilis.

PLATE VIII

Grouped Miliary Papular Syphilide.

PLATE IX

Mixed Papular and Papulopustular Syphilide.

PLATE X

Tuberculous Ulcerating Syphilide, showing Lesions in Different Stages.

The syphilodermas have certain peculiarities which are striking and distinctive; they are symmetrically distributed; their color is characteristic, and is due to the disease of the bloodvessel walls, which has been referred to, by which stasis is favored and exudation encouraged. The pigmentation is often striking, and, whatever it may be at first, it assumes a tint described by the terms “raw ham” or “coppery.” Dark pigmentation may take the place of the lighter colored, as the sole evidence of the existence of the previous lesion. Occasionally, however, the normal pigment of the skin disappears and a bleached-out area marks the site of the previous lesion. This is often irregular in shape and considerable in size. Such a spot is spoken of as leukoderma. Again, the syphilodermas are generally polymorphous, and seem to be capable of imitating almost every known non-specific skin affection; so close is the resemblance that it often requires careful study of the case to permit of diagnosis. The absence of itching is also a feature of most of these cases.

The early syphilides are superficial, distributed generally and symmetrically, and disappear spontaneously.

When skin lesions are clustered, as in the macular and papular forms, they usually group themselves symmetrically and in more or less circular outline. When, however, they are too regularly arranged, it may be taken as evidence of their older and more relapsing character.

The later skin lesions of syphilis differ in several respects from the earlier. They are less regularly grouped; they involve a greater depth of tissue; they tend to ulcerate and to leave permanent scars; and they have around them a more infiltrated area, probably because they are deeper. They are, however, not so infectious as the earlier lesions, and it is rare that they are of serious menace to others. (See Plates VIII, IX, X.)

Fordyce and others have pointed out that the prompt and specific influence of mercury and even of iodine upon these eruptions is an instance of the selective action of certain drugs, and nothing could be more conspicuous in demonstrating it.

Certain types of syphilide are common in the earlier stages and others in the later; there may be a well-defined limit between the two, since in not a few instances all types seem to be combined.

The first eruption of so-called secondary syphilis assumes the erythematous or macular type, and has been referred to as roseola syphilitica. It appears as a generalized eruption, in spots varying from 0.5 to 1 Cm. in size, which are of a vivid color and scarcely elevated above the surface. It commences usually upon the abdomen, proceeds to the chest, and then to the extremities. It does not often appear upon the face. Two or three weeks may be consumed in its generalization over the entire body. If let alone it has a duration of a few days to several weeks, and may then fade away, leaving nothing to indicate its presence save a slight pigmentation.

Of more pronounced character is the papular eruption, which commences as a small papule, and is described as lenticulopapular and miliary papular. At first these are generalized, then become circumscribed, and exhibit transition forms from the early to the later type of lesions. The papules vary in size from that of a millet-seed to that of a split pea; even this type may disappear without ulceration or suppuration.

Lichen planus may be mistaken for papular syphilide, but may be distinguished from it by intense itching and by lack of the pigment changes which characterize the syphilide.

The squamous syphilide is sometimes a continuance of the papular, and sometimes it begins as such. It is characterized by a variety of scaly macules and papules, which strikingly resemble the lesions of psoriasis. The latter are seldom seen on the palms and soles, while the squamous syphilide is very frequently seen in these locations. Moreover, along with the squamous lesions are frequently associated other skin lesions, which give the case a complex type, resembling at one point one of the non-specific affections, and others at other points. Such changes are mainly expressions of various stages in the involution or degeneration of the papule, but they may give the case a variegated appearance, in which pigmentation may be prominent.

Some years ago Biett described a form of syphilide which he claimed was unmistakable and indicative. Since he described the lesion it has been known as Biett’s collarette. It appears in from ten to twenty weeks after the secondary symptoms are fully declared, is superficial, usually situated upon the trunk and extremities, but never upon the palms or soles. It consists of a flat papule almost level with the skin, 1 to 2 Cm. in diameter, rounded in contour, while around it there is seen a zone of white epidermal scales pretty sharply defined and giving it the name of collarette. The area within is dry and painless, and the ring itself narrow. There is little or no itching. It may be followed by some other skin lesion. The lesion is often so mild as to pass unnoticed.

At other times pustulocrustaceous syphilides will appear above the level of the skin, surrounded by a series of narrow concentric rings, not scaly, but composed of a number of small pustules, the first ring being perhaps an inch from the centre of the inner lesion. This is seen more often in males than in females, and it seems as though the smaller pustules were the result of an auto-infection of ordinary pyogenic character. In the presence of either of these lesions a positive diagnosis of syphilis can be made.

The pustular syphilide may give rise to large or small pustules, which soon become superficial ulcers, often irregular in shape, with an unhealthy floor which may be livid or gangrenous, or may resemble a diphtheritic lesion, while from its surface exudes a mixture of blood, debris, and pus, which dries into dark-colored crusts and constitutes the lesion known as ecthyma. These lesions are often deceptive, since while scabbing seems to be occurring over the surface the ulceration may be extending beneath. This is an intermediate or earlier tertiary rather than a secondary lesion.

Another type of pustular syphilide is that known as rupia, where the ulcers are larger and are covered with concentric layers of crust resembling an oyster-shell. These lesions begin as papules and undergo changes which make them bullæ or pustules and then open ulcers. The peculiar scabs are somewhat conical in shape when not disturbed, and are greenish or brownish in color. If they are dislodged, irregular, indolent, and often sensitive ulcerated areas will be found beneath them. Even when these ulcers heal they are irregular in outline and show a white scar often surrounded by an areola of pigment. This rupia is the most visible lesion of syphilis, as no other skin disease assumes any such type.

In the last-described and ulcerative forms of syphilide there is a possibility of septic infection, or at least of septic intoxication by absorption; hence the need for care in this direction. In fact, into the treatment of every pustular indication of syphilis the elements of local protection and local antisepsis should enter.

The Mucous Membranes.

—Here the manifestations of syphilis are of great importance because of their extreme infectiousness. The earlier manifestations are seen mainly about the mouth. When an eruption appears upon the skin a condition corresponding to it may often be recognized in the pharynx and upon the uvula and soft palate. This will be accompanied by discomfort, and the patient complains of “soreness of the throat.” These throat lesions are chronic, liable to recur, and disappear slowly, unless the patient is vigorously treated; they sometimes cause dryness of the fauces, followed by a free flow of mucus. The dusky discoloration of the rash is quite distinctive.

The congested areas have a dusky hue on the skin and are spoken of as “coppery” or “raw-ham” in tint. They are usually well outlined; should the disease progress they become eroded. “Syphilitic sore throat,” as this condition is often called, may be aggravated by the use of tobacco and by unclean mouths. The involvement of the cervical lymphatics will be proportionate to the vividness of the lesion.

There is no distinctive time limit between the so-called secondary and the tertiary symptoms of syphilis. Generally the lesions disappear with but little treatment; in many instances they will fade away without any. In most cases, however, the patient, even under poor management, takes enough medicine to disperse the lesions more quickly than they would spontaneously subside. If he discontinues medicine for several weeks, sometimes many months will elapse before there are any active manifestations of the disease. During this period, however, the lymphatic enlargements will not decrease perceptibly, and there may be evidence of advance in this direction. The so-called tertiary symptoms appear usually without fever or other symptoms, and not often in less than five or six months after the commencement of the disease. On the other hand, their advent may be delayed for years, even when the early treatment of the case has been but partially effective.

No organ or tissue in the body is exempt from the ravages of tertiary syphilis. Even the finger-nails and the hair may suffer, while the teeth are affected in the hereditary manifestations. Affections of the skin occur, according to Haslund, in about 12 per cent. of the cases.

The mucous membranes are liable to exhibit those lesions above described, known as mucous patches, usually regarded as late secondary symptoms. The description applies equally well to the tertiary lesions. They occur about the oropharynx, upon the tongue, the lips, the nostrils, and the eyelids. They are frequently found also about the rectum, anus, and genitalia of either sex. In general they present about the same appearance. They commence usually with a slight elevation of the surface and at several points, sometimes simultaneously and successively. These surfaces ulcerate superficially, and thus are produced irregular but rounded patches, with uneven edges, of grayish-yellow surface, which ordinarily are not sensitive, but occasionally extremely so. They may disappear under local treatment, but in that case tend to recur at frequent intervals. If unnoticed or not properly cared for the ulcers may become deeper and assume an unhealthy appearance. In the mucus-lined cavities affected the condition of these ulcers will depend upon the personal habits of the patient. In mouths where tartar has accumulated upon the teeth, or where the toothbrush is seldom used, the patches may become large and foul.

These lesions are extremely infectious and the disease may be conveyed by kissing, by the common use of small domestic utensils, by the pipe, by dentists’ instruments, etc. Patches occurring at the junction of the skin and mucous membrane may extend over onto the latter and become deep, specific ulcers. Lesions of this character need judicious local as well as constitutional treatment. They will often disappear under the latter alone, but it should be combined with local measures. These consist in cleanliness and the use of various antiseptic solutions or applications. An antiseptic mouth wash, as diluted hydrogen dioxide, or of water given a mahogany color by tincture of iodine, should be frequently used. There should be an application of a 5 per cent. solution of silver nitrate, or some other astringent, stimulating, or mild caustic.

Fig. 24

Grouped papulopustular syphilide and numerous pigmented spots from former lesions. (Fordyce.)

The Skin.

—The late syphilides of syphilis belong to the gummatous or tuberculous types (i. e., tuberculous in the anatomical sense, or nodular). The latter may occupy the entire thickness of the skin or lie even deeper. Such lesions may begin as papules and develop into distinct and circumscribed nodules, while these may coalesce into considerable masses. These tend to break down and leave scars after they have disappeared. There is little difference, microscopically, between the nodule and the gumma. Clinically, the tuberculous lesions spread usually in a serpiginous manner, producing a more or less curvilinear outline. (See Figs. 24 to 27.) These ulcerations undermine the tissues to a greater or less extent, and pus and debris will be formed in consequence. In this way they imitate considerably the lesions of lupus, and it may require a careful study of the case and of its history to make a diagnosis. Some of these lesions are extremely slow in their course and long in duration. When scars form they are usually white and smooth, with irregular borders, but sometimes are surrounded by pigment that makes them characteristic. The extent of the scar is no criterion as to the size of the originating lesion, the former being always smaller than the latter.

Fig. 25

Ulcers resulting from deep ecthymatous syphilide. (Fordyce.)

The Gumma of Syphilis.

—This is as characteristic of late syphilis as is the condyloma of the earlier stage. By this term is meant a new formation which may vary in size from a millet-seed to a large mass. Sometimes it is diffuse, or it may be circumscribed. It seems to originate from connective tissue, and may be met in all parts of the body. Microscopically it consists of a delicate stroma filled with small, round cells, the mass being furnished usually with bloodvessels, also of new formation. Such a gumma may pass through various stages of integration and disintegration. The cells sometimes undergo fatty changes by which the entire mass is softened, and its interior contains a puruloid material resembling pus. The gumma, as it increases, will replace other tissues and cause them to disappear, and thus it happens that when it disappears the region previously occupied by it seems to have diminished in size. Sometimes, however, cicatricial tissue takes its place and not only distorts an organ or part but impairs its function. Thus softening and melting may occur at one time and a dense scar or mass at another.

The degree of infectiousness of gummatous and other late syphilitic ulcerations is uncertain. The later they occur, the less infectious. It would be safe, however, to assume that they are all dangerous.

The Gummatous Syphilide.

—This begins, as a rule, as a subcutaneous gumma which quickly proceeds to and involves the skin. At first it appears as an induration, developing into a distinct tumor, becoming more indurated and firmly implanted as it grows, the overlying skin becoming reddened and swollen. After a time there occurs softening in the interior of the mass, and upon incision there will escape not pus but viscid, puruloid fluid, yellowish gray in color, which may contain corpuscles resembling those of pus. It is the content of such a tumor as this which has given it its peculiar name, gumma. Should proper treatment be rapidly pushed, it is possible for a softened gumma to disappear by absorption, but if ulceration or evacuation has taken place, there remains usually a permanent disfigurement at the site of the mass; like tuberculous gummas these growths may undergo caseous or even calcareous degeneration.

A gumma of the skin will open at one or several points, and, becoming thus secondarily infected, may give exit to sloughing tissue and foul discharge. If the skin directly overlies the bone, then the tumor may involve the latter as well; and when it ulcerates, the bone will be exposed. In the healing process, however brought about, deformity from cicatricial contraction may cause much disfigurement. When a gumma appears beneath the true skin and then disappears it may leave areas of depression, with more or less adherent, bleached-out scars, perhaps with a pigmented margin. The appearance of such scars is suggestive of the disease even without a definite history.

The gummas form the most important features of syphilis, at least from a surgical standpoint, since they frequently appear in the depths as well as on the surface of the body, without any other symptoms, and they often cause no little perplexity in diagnosis. Syphilomas, tuberculous gummas, phlegmons, innocent and benign tumors, as occurring especially in and upon the bone, in the muscles, tongue, the breast, the testicle, and elsewhere, may be difficult of diagnosis. Of course, a history of syphilis is a great help. Doubt frequently arises when such a history cannot be obtained. Scarcely any other disease will produce multiple lesions such as are seen in syphilis, and when multiple they are usually distributed, with some appearance of symmetry. Ulcers formed by their breaking down are often extremely sensitive, but do not bleed easily, nor show a tendency to exuberant granulation. In cases of doubt the most successful test is perhaps the therapeutic, and consists in giving mercurial or mixed treatment to the point of toleration and noting its effect.

Fig. 26

Tuberculous serpiginous syphilide resembling lupus vulgaris. (Fordyce.)

Fig. 27

An ulcerating gumma of the leg. (Fordyce.)

 

In many patients, especially of the hospital class, scars, which are strongly suggestive, will be visible upon the legs. It does not follow, however, that an old scar upon the legs, even if surrounded by a pigmented area, is necessarily of syphilitic origin. Old ulcers of the limbs are frequently seen in connection with varicose veins, and may show exceedingly chronic tendencies; moreover, it is possible for chronic and non-specific ulcers to occur in old syphilitic subjects when the course of the local lesions may be influenced by the old affection, although they are not specific ulcers. Benefit, however, will in such cases accrue by the reasonable administration of antispecific treatment, but it should be combined with suitable local measures.

The Vascular System.

—The lesions which are encountered in the bloodvessel walls in chancre and early syphilis have been described. The heart and vessels are liable to suffer, as they contain connective tissue. Gummas have been noted in the heart, while the poison also may produce thickening of the valves, and disease of the coronary arteries, the endocardium and the myocardial structure.

The arteries often suffer from arteriosclerosis, which is either diffuse or nodular. Endarteritis is a common manifestation of syphilis and leads frequently to the formation of aneurysm. Sometimes this appears as a single and large lesion; at other times hundreds of small aneurysms will form in the arterial system of the brain, so that the arteries are studded with them. The explanation of aneurysm under these circumstances is that the arterial walls, being weakened, dilate under the influence of blood pressure. Thus the arteries, from the largest to the smallest, also may suffer. The veins likewise are subject to syphilitic phlebitis, which is frequent in the superficial veins of the extremities.

Bones and Joints.

—Syphilitic manifestations in bones are frequent, but are not so common in the joints. While early syphilitic periostitis is not infrequent the actual lesions of the bone are mostly expressions of late syphilis. Nearly all of them are painful. The pain is worse at night, and is called the osteocopic pain of syphilis. At first these bone lesions are hyperplastic, because of the connective tissue in the bone. Periostitis is a common manifestation, and here, again, the neoplastic tendency of the disease is manifested, in that the periosteum is thickened as well as the bone beneath, and swellings called nodes are thus formed. Nodes are met with more often on the tibia and the sternum than elsewhere, but are frequent upon the skull and clavicles. No bone is exempt from these lesions. They often form at points where there has been previous injury. These swellings are ill-defined, and usually quite tender, while the skin over them is easily movable unless secondary infection has occurred and suppuration is present. The nocturnal pains in these lesions, of which patients often complain, are sometimes excruciating. Should suppuration occur, with subsequent formation of ulcer, there may be necrosis of the exposed bone. Another bone lesion of syphilis assumes the type of ostitis. Physiologically this consists essentially of gummatous involvement of the connective tissue, which may be either localized or diffuse. When this undergoes retrocession there occurs a rarefaction of the bone, by which it is weakened and easily broken, so easily in fact that we have to deal sometimes with what is referred to as spontaneous fracture. There is frequently a thickening and condensation of the entire bone, with some distortion, so that the actual weight of the bone may be nearly doubled. Dactylitis is the name given to syphilitic ostitis of the phalanges, which increase in size and become tender and useless, while the skin becomes glazed. Occasionally the disturbance appears to involve the extra-osseous tissues rather than the bones themselves. Bones which are spongy are liable to this disease. Some of the bones in the face are peculiarly susceptible; hence the loss of the bridge of the nose, or of a portion of the hard palate, by the ulcerative processes so common in this disease.

The joints are subject to changes somewhat similar to those occurring in tuberculous disease. There may be either a gummatous synovitis or an arthritis, or else destruction of articular surfaces. These joint lesions of syphilis are all slow in their course, and sometimes difficult of distinction from tuberculous and other lesions. They have so much in common with the joint expressions of tabes that some writers believe that tabes is necessarily an expression of syphilis of the cord.

As long as no active destruction has occurred within a bone or joint these cases are usually amenable to treatment, but for the actual destructions caused here or elsewhere by syphilis there is no repair possible, and the harm once done cannot be undone. Plastic operations and injections of paraffin may have to be practised for cosmetic purposes and relief of disfigurement.

Muscles and Tendons.

—It is the connective tissue of muscles which suffers most in the luetic affection of these structures. It may be met with as a diffuse process or as a gumma. In the former cases the muscle becomes irregular in shape and size, and in the latter distinct tumors are formed. As such growths advance and contract adhesions to surrounding structures, there is interference with muscle play.

Syphilitic myositis causes little pain, and patients with gummas in muscles are often not seen until ulceration has begun.

The dense fibrous structure of tendons and aponeuroses is frequently involved in late syphilis, causing pain and disability. Little is discovered on physical examination, but considerable loss of function may result. Points of tenderness sometimes are noted along junctions with the adjoining periosteum. Such a tendoperiostitis may be painful, and even crippling.

Bursæ.

—Bursæ are prone to be involved in syphilis, especially those in front of the patella. A gumma frequently develops at this point, where it constitutes a painless, somewhat tender enlargement, which may be dense or elastic. After it has become adherent to the skin it is usually infected, and a chronic ulcer results at this point, which may often manifest gangrenous tendencies. This constitutes one form of so-called housemaid’s knee.

The Eye.

—Of the manifestations of syphilis in particular organs the eye sometimes suffers severely. Iritis is the most common and serious manifestations of constitutional syphilis. It has been estimated that nearly 60 per cent. of all cases of iritis are due to this cause. It may occur in two months after the primary sore; it is usually acute, and rarely begins in both eyes at the same time, but may involve one after the other. The ciliary body is frequently associated in the lesion, and iridocyclitis occurs. It commences with congestion of the conjunctiva, photophobia, and lacrymation. The pain is not always severe. Inspection of the iris will show beads of lymph, a small pupil, with loss of contractility, or the dull iris may appear infiltrated and inflexible. The pain in some cases is extreme. Where treatment has been only partially effective relapses are common. The greatest danger to be feared is formation of adhesions between the anterior surface of the lens and the margin of the pupil, i. e., anterior synechiæ. These are detrimental, and serve as the cause of many irritations.

The treatment of these affections is constitutional; locally solutions of atropine of sufficient strength to ensure dilatation of the pupil should be used, not only to relieve the pain, but to carry the margin of the pupil from the central portion of the lens and prevent adhesions. The patients should be kept in the dark because of their photophobia. Atropine may be substituted by duboisine if the former tends to produce congestion. Leeches applied to the temples will also give relief from pain.

The cornea is often affected by a deposit on its posterior surface of particles of debris, which give it a punctate appearance known as keratitis punctata. It also becomes the seat of opacities which materially interfere with vision, and prove only partially amenable to treatment. Lesions of the cornea are frequent in hereditary syphilis.

Retinitis and choroiditis, of either acute or chronic type, are the most common syphilitic lesions of the fundus. They are usually associated and involve both eyes. They come on so insidiously that they are often far advanced when first discovered. The lesions consist of patches of exudation and areas of atrophy, accompanied by some haziness in the vitreous. Vision is affected in proportion to the area involved.

The movements of the eyes are interfered with by lesions which pertain, however, rather to the brain and the ocular nerves than to the eye itself. The sixth nerve, lying on the floor of the skull, is affected by syphilitic disease at the base of the bone. As a result of these nerve lesions paralysis is often seen, or at least disturbances of motility from which diplopia results. Ptosis occurs from affection of the third nerve. In lesions situated below the aqueduct of Sylvius, the paralytic condition which Hutchinson has spoken of as ophthalmoplegia is likely to appear. Optic neuritis is also a late manifestation of syphilis, and may be either chronic and mild, with a small disturbance of vision, or acute, with rapid loss of eyesight.

The Ear.

—The ear may suffer in various ways. The external ear may participate in affections of the adjoining skin. The middle ear may be affected as a result of extension of trouble from the nasopharynx, while in the late stages of the disease patients may suffer from labyrinthine disease, with partial or almost total deafness.

The Nose.

—The lesions of syphilis in the nose are numerous and offensive. Ulceration is frequent and followed by perforation through the septum or into the mouth. When the vomer is involved the bridge of the nose falls in. In neglected cases the whole substance of the nose may be involved and subsequently lost. The bone is often exfoliated. These ulcerations of the mucous membrane and periosteum give rise to a characteristic condition known as ozena, with its characteristic discharge.

The Oropharynx.

—The tongue may be the site of intermediate and late syphilitic lesions. Men suffer more than women, apparently because of their use of tobacco. Mucous patches, deep ulcers, and even gummas, single or multiple, are seen here. Gummas in the tongue are inclined to undergo superficial ulcerative infection and become abscesses. In these lesions there will be notable involvement of the adjoining lymphatics. The appearance of smooth, bluish-gray patches upon the mucous membrane of the tongue and cheeks is known as leukoplakia or leukokeratosis. These lesions do not respond readily to treatment; they give rise to little or no complaint, and are often followed by malignant disease.

It is difficult to distinguish between gumma of the tongue and epithelioma. Usually the latter is a single lesion; the former often multiple. In epithelioma the ulcer is superficially painful, with more elevated and indurated edges, while the pain is sometimes intense and radiates toward the ears.

Interstitial glossitis is a late manifestation of a sclerosis beginning in the connective tissue and involving the muscle fibers, leading to enlargement of the tongue and later to atrophy and inflexibility.

The Larynx.

—Syphilis of the larynx appears either as one or more ulcers, as gumma, or as chondritis or perichondritis, often with necrosis of cartilage. When ulcers form they are deep and destructive, involving even the intrinsic muscles of the larynx, and causing harshness or loss of voice, with dyspnea. Subsequently they lead to cicatrization, often leaving a stricture which may call for tracheotomy. The epiglottis is also liable to ulceration and gummatous lesions.

In these cases, aside from the general treatment, there is need also for local applications of combined antiseptic and anodyne character. Cocaine or one of its less toxic substitutes may be used in spray or by insufflation, in connection with an antiseptic powder, morphine or heroine. Edema of the glottis may be subdued by the local use of adrenalin.

The Alimentary Tract.

—Between the mouth and the rectum the intestinal canal is rarely involved in syphilitic disease. In the rectum, however, ulcers, as well as gummatous infiltrations, are frequently encountered. If the ulcers are low, within two inches of the anus, they will cause great pain. Higher up the rectum is not so well supplied with sensory nerves. Ulceration may involve the entire circumference of the anus.

In the rectum chronic ulcers are liable to be followed by stricture, which will call for surgical relief. (See chapter on the Rectum.)

In the colon chronic ulcers have been so serious as to lead to dysentery, followed by stricture formation. It has been suggested to make an artificial anus at the cecum and allow the large intestine to rest, treating it at the same time with irrigation through the opening.

The Viscera.

—Of the solid viscera the liver is more commonly affected than the spleen or kidneys. Chronic interstitial hepatitis may lead to cirrhosis, the new tissue being less distinctly distributed than when due to alcohol, the liver consequently becoming irregular, with a deep separation between its lobes. The pain is sometimes intense.

On the other hand isolated gummas, or confluent masses of smaller gummas, may be found beneath the capsule or in the substance of the liver. From one or both of these cases combined this viscus may attain an enormous size, with acute pain. Under these conditions there may occur albuminuria and evidences of amyloid disease.

Likewise in the spleen there may be diffuse or localized trouble. Here the lesions cause but slight distress.

The mercurials are of greater importance than the iodides in treatment of these lesions. The kidneys suffer less often than the spleen. Syphilitic patients do not lose their liability to renal disorders, but there seems to be but small, direct connection between syphilis and the common changes in these organs.

The Genitalia.

—In both sexes the genitalia are subject to gummatous involvement during the later stages; in the male more frequently in the corpora cavernosa and testicle. In the latter a chronic induration, with some enlargement of the epididymis, is one of the manifestations of constitutional disease. Most of the enlargements of the testicle are slow and painless, and occasionally some fluid will collect. The prostate and the seminal vesicles are rarely involved in syphilis, but frequently in a tuberculous process. This is an important diagnostic point.

In the ovaries there may occur a diffuse cirrhotic process.

The Nervous System.

—Here the manifestations of syphilis are often serious and widespread. They are produced by the same new tissue to which we have so often alluded, with its tendency at first to degeneration and later to sclerosis. They are always insidious. Gummatous thickening may occur at any point, springing often from the pia of the brain and cord. The arterial walls are frequently so affected, and at many points, that multiple minute aneurysms are produced, any one of which may give way and produce the fatal results of a cerebral hemorrhage. In diffuse gumma of the membranes or cortex the process is slow, and likely to involve areas which may be recognized by cerebral localization. Many cases presenting the features of brain tumor will yield to antisyphilitic treatment, and thus show themselves to be syphilomas.

In the spinal canal implication of the membranes is more likely to occur than in the vessels. In the cord these sclerotic changes are also quite common and produce symptoms strongly suggestive of tabes; in fact, there are those who hold that tabes is of specific origin.

In the motor and sensory nerves much connective tissue is present, and consequently these nerves are not exempt from sclerotic changes with pressure symptoms, which will give the clinical picture of a neuritis.

Syphilis appears in young children under the following circumstances:

A. The disease may have been transmitted from the father to the ovum, at the time of conception, by infected spermatozoa.

B. From the mother, who may have acquired it before impregnation or during the early part of her pregnancy. In the latter case the infecting influence is transmitted through the placental circulation.

C. From the mother at the time of its birth, from a recently infected puerperal tract.

D. From some possible extrinsic source, a short time after its birth, as, e. g., through the umbilicus.

The later the mother acquires the disease after conception, the less likelihood that the child will be infected. If infection takes place from the placenta, then it also will be found to be diseased.

Profeta’s “Law.”

—Profeta first made the statement that the child of an infected mother who acquired the disease late in her pregnancy may not only be born healthy, but may be immune to subsequent infection, as are other healthy children of syphilitic parents. But, on the other hand, such a child may be anemic, puny, with small resisting power, or it may develop a late hereditary syphilis. When the ovum is infected by the father the healthy mother may escape, or she may acquire the disease through the placenta in her own uterus, or she may suffer from a mitigated form of syphilis whose principal features will appear as late manifestations of the disease.

Colles’ “Law.”

—Colles, in 1837, made the statement that such a mother may remain healthy with an acquired immunity to subsequent infection. The statements above made have often been alluded to as Profeta’s and Colles’ “laws.” These should, however, be regarded simply as statements of what usually occurs, and too much dependence should not be placed upon them. In fact, the immunity which the mother or the child may enjoy under conditions mentioned above is not likely to be permanent, though it may last for a varying period of time. There is no limit to the time when a parent may transmit syphilis to the child. The five-year limit given for the father is often overstepped, and the longer the man waits before marrying after acquiring the disease, and the more thoroughly he submits to judicious treatment, the less likely he is to convey it to offspring. This is the strongest kind of argument that can be used to delay marriage of syphilitics.

The indication of syphilis on the part of the mother is, in addition to those already given above, a tendency to miscarriage or abortion. The earlier she acquires the disease the earlier will the mishap occur. Should she escape the child may go on to full term, or it may die and be expelled as a dead fetus two or three months before the expiration of term. Should a child be born alive with hereditary syphilis, the evidences may appear at birth or within three months. Should a child apparently escape for six months it may grow up to be puny or develop some form of late hereditary disease, or it may possibly remain well. These children usually show developmental defect in some direction, and manifest a much weakened resisting power to other diseases; moreover, the spleen will usually be found enlarged.

Among the changes which may occur are the following: The skin becomes loose and resembles that of an old person. This is partly because it grows even faster than the tissues beneath it, so pronounced is the emaciation. Snuffles, or nasal catarrh, is one of the earliest features. This is due to specific swelling of portions of the Schneiderian membrane. Snuffles may occur in children without syphilis, but syphilis will nearly always produce snuffles, which may last for some time, and cause a widening at the root of the nose which will persist through life. Following the snuffles there usually appears a rash over the trunk and thighs and about the anus, accompanied by mucous patches. This will have the same bright, coppery tint as roseola syphilitica, already mentioned, which it much resembles. Sometimes it assumes the mixed type of eruption, while upon the palms and soles appears the so-called pemphigus syphiliticus. Should the child live nodular or gummatous syphilides may develop.

In the bone and cartilage characteristic changes are met at the lower end of the femur and at the costochondral junctions. This consists of an osteochondritis syphilitica. At the affected points enlargements take place, which may disappear under treatment or may go on to ulceration and necrosis. In the fingers and toes there are manifestations already described as syphilitic dactylitis.

The bones of the skull are likely to be involved in thickenings, especially about the anterior fontanelle, where they form the so-called Parrot’s nodes. These may disappear, with or without treatment, and the affected bone may undergo atrophy or may entirely disappear.

Among the viscera the spleen generally becomes affected first and then the liver. Syphilitic iritis may occur early, but is rather rare; ocular changes occur more often in the choroid. In the brain distinctive lesions may occur to such an extent as to lead to considerable thickening of the dura, with or without hydrocephalus, and subsequent imbecility or idiocy.

Deafness is not infrequent in hereditary syphilis. It may begin suddenly and at any age, even during infancy. It is produced by deep lesions which do not yield readily to treatment, and sometimes leads to deaf-mutism, especially when it occurs before the child has learned to talk.

Among the later manifestations of hereditary syphilis are opacities of the cornea from interstitial keratitis. This may occur in children who are apparently in good health and free from other signs of hereditary disease. The condition is rather obstinate, but it can be made to disappear under suitable treatment. Retinitis occurs frequently in young women, and is likely to lead to atrophy or detachment.

The Teeth.

—The permanent teeth often show peculiar changes that are distinctive, especially in those who have shown signs of corneal involvement, which, having been first described by Hutchinson, are frequently alluded to as Hutchinson’s teeth. When they first appear they are smaller than natural and irregular. Later they become notched. The crescentic notches show best upon the incisor teeth. Sometimes the canines are also affected, being narrow, rounded, and peg-like, with jagged edges. These teeth are usually so formed that they do not meet properly, and so small that they scarcely touch each other. The most characteristic changes are met with in the upper incisors, which may be affected when all the others are fairly normal. In such cases they will be found narrow and short, with a single broad notch at the edge, with perhaps a furrow passing from it upward and on both anterior and posterior aspects. Notching is usually symmetrical. No conclusions can be drawn from the teeth if they are normal, as they may be, but when they present the above-described features they prove a very important indication.

The relations between syphilis and rickets have attracted much attention, and there is little doubt but that rachitic changes are prone to occur in subjects with inherited syphilis. The two conditions are sometimes blended in various degrees and ways, and yet it is not safe to say that rickets is always an expression of inherited syphilis.

There is no question but that some of the above-described lesions constitute as disgusting and repelling diseased conditions as the physician or surgeon is ever called upon to treat. In spite of these circumstances, however, it is generally believed that syphilis is a most satisfactory disease to treat. This is because of the almost mathematical certainty with which results can be predicted and estimated. There is nothing more satisfactory in therapeutics than the rapidity with which many pronounced and serious manifestations of syphilis will disappear under the influence of proper treatment. These statements, however, should be modified to make room for exceptional cases, where the disease assumes a malignant type, owing probably to some defect in the patient’s constitution, or where patients show peculiar idiosyncrasies and susceptibilities to the influence of mercury and iodine. Such cases happen occasionally and prove difficult of solution, while they sorely try the surgeon’s ingenuity and resources.

In the majority of instances syphilis is a curable disease. A patient should be first impressed with the necessity of faithfully following the directions of his physician, and continuing under treatment for a period of at least three years after the disappearance of the last manifestation of the disease. The disease is curable, but only by the judicious combination of two principal remedies, i. e., mercury and iodine. Those rare instances in which cure seems to have followed lines of treatment which do not include the use of these two drugs are so exceptional and misleading that they should not be considered criteria. Mercury and iodine are powerful remedies, needing to be administered with caution and judgment. Unfortunately there is no arbitrary limit of time for any given case. The time stated above is that usually considered requisite. While syphilis may be curable in some cases in less than the stated time, it is better to give it longer treatment than is absolutely required rather than the reverse. The treatment entails no unpleasant consequences. Warnings as to the approach of toxic symptoms from the drugs can be easily recognized.

Of the two drugs the preparations of mercury are the more important. The surgeon may adopt as his motto, mercury, more mercury, and again mercury, and if he begins with this measure early in the disease he may be able to conduct it to a successful termination with but little resort to iodine. Iodine is effective rather in those cases where treatment has been begun relatively late, and where it seems necessary to make a double impression upon the disease.

When the nature of the primary lesion is positive treatment should begin with the first visit of the patient to the surgeon. When there is uncertainty regarding the character of the venereal sore, treatment may be postponed until the appearance of the first eruption. As soon as this has appeared the treatment should be hastened. It is necessary to begin with mercury. The patient’s mouth should be examined by a dentist and all tartar removed from the teeth, especially from the gingival borders, at which lines the gums are likely to become sore when mercury is too freely used. All diseased teeth should be extracted or filled, and the mouth and its contents should be put in normal condition. The dentist should be informed as to the reason for the visit. Smoking should be discontinued, especially when there are mucous patches, since it is apt to irritate and make subsequent lesions of the mucous membrane more likely to occur. The habits of the patient should be regulated as to alcohol and other indulgences, and he should be warned as to the infectious nature of the disease, in order that others may be protected. In many instances tonic, even roborant treatment may be advantageously combined with the antispecific. It will be found that the anemia so characteristic of well-marked secondary syphilis will improve materially under the influence of mercury alone.

Should the disease occur in a married person, or develop after marriage, caution should be given as to the danger to offspring, and to the other associate in the marriage relation, which might follow the occurrence of pregnancy.

Mercury may be given by the mouth, by inunction, by hypodermic injection, or by fumigation. The intent should be to get the patient under its influence as rapidly as is consistent with safety. The most effective of these methods to which patients will ordinarily submit is that by inunction. This consists essentially in the use of mercurial ointment (blue ointment), of which 15 Gm. may be used daily or nightly, which should be thoroughly rubbed into some area of the body; the areas selected being changed at perhaps three-day intervals, in order that irritation, which its prolonged use produces, may be avoided. It takes considerable effort to so completely rub this in as to make most of it disappear, and it can be done more easily upon those parts of the body which are free from hair. It can be best done by employing someone for the purpose, but patients can be easily taught to use it themselves. There are upon the market, ointments containing mercury made with other excipients than lard, which are less uncomfortable to the skin and seem to be absorbed better; among these is a preparation made with a petroleum compound called vasogen, which may be procured in different strengths; that containing 33 per cent. or 50 per cent. is the best.

Inunction should be practised at least once every twenty-four hours, until either the gums become tender or swollen, with an offensive odor of the breath, or until the skin is irritated. The mouth should be protected by use of an astringent antiseptic mouth-wash, such as the following: Carbolic acid 10 parts, oil of wintergreen 1 part, tincture of myrrh 50 parts. A little of this solution in a tablespoonful or more of water makes a serviceable wash, which should be used several times a day. There are sanitaria and springs, or health resorts, in this country where a specialty is made of this manner of treatment. At these resorts inunction is practised freely and thoroughly, but the benefit which is obtained comes rather from the attention which patients give to the treatment, and their abstention from business or dissipation, than from any inherent medicinal features either in the mineral water or climate.

Under the influence of mercurial ointment alone, if a patient is willing to persist in its use, many cases of syphilis may be conducted to a successful termination; but its use is disagreeable to some people, and it may be impossible to resort to it for any great length of time. It has its inconveniences and disadvantages, but it should be applied in at least the first stages of the disease.

When mercurial ointment is seen to have made a distinctive impression upon the constitution of the patient it may be discarded and the treatment changed to the internal administration of the drug.

Mercurials may be given internally in any one of several different preparations. Hutchinson has recommended gray powder, in doses of ¹⁄₄ to ¹⁄₃ Gm. three or four times a day. Corrosive sublimate is a reliable form in which to administer mercury in doses which can be tolerated, from 1 to 2 Mg., three or four times a day. The red iodide may be given in similar doses, or the green iodide may be administered in doses of 0.15 to 2 Cg. These preparations sometimes irritate the intestinal tract and produce a certain amount of colic or looseness of the bowel. For the latter some astringent may be combined with the mercury, while intestinal pain may be checked by the use of extract of conium.

The hypodermic use of mercury can be made effective, but there are but few preparations which can be used that do not cause pain and subsequent irritation. Perhaps that which gives least pain is the sozoiodolate of mercury. This is sparingly soluble in water, dissolving in about 500 parts by weight. As the dose is 9 or 10 Cg., the amount of water necessary for this solution is so bulky that the dose should be injected into the gluteal region. Corrosive sublimate is also used in 1 per cent. solution, made up in common salt solution of the usual strength of 9 to 1000. Of this 10 minims represent a suitable dose to commence with, which may be increased to 30 or 40 minims when necessary. This should be given in the same region, the needle being driven in its full length perpendicularly to the surface. When this is done an injection is made into the muscle, where it seems to be more effective than in the subcutaneous fat. When the dose is increased to more than 20 minims a 2 per cent. solution may be used and the amount of fluid correspondingly reduced.

Fumigation is a method now not often adopted, calomel being used for the purpose, an ordinary cabinet hot-air bath confining the vapor about the patient. One treatment a day by either of these methods is usually sufficient.

About the initial sore dry calomel, pure or reduced with bismuth subnitrate, may be used. The condylomas met with about the perineum will often shrink and disappear under the influence of this application. Mucous patches should be treated with absolute cleanliness; in the mouth a wash of diluted hydrogen dioxide may be used, and the patches touched with a strong nitrate of silver solution, pure carbolic acid, or camphophenol. This will not prevent contagion from such a source, but will reduce it to a minimum beneficial in every respect.

The various eruptions of syphilis will disappear gradually under the influence of a local application of one of the mercurial preparations, either the ordinary mercurial ointment or ammoniated mercury.

In cases of inherited syphilis, especially in young children, a reduced mercurial ointment, or the use of gray powder (mercury with chalk) will give the best results. The dose should be regulated by the age of the patient; for instance, of the latter 1 to 2 Cg. for an infant. The iodides have also proved successful.

Iodine and its preparations have by many authorities been held to be useful in the later and especially in the gummatous lesions of syphilis. There are patients who cannot take iodine to any extent without suffering from such disturbance of mucous membranes, especially in the nose and intestines, as to make it an exceedingly unpleasant remedy.

The iodides have not proved as successful as the mercurials; nevertheless, the combination is a popular one and sometimes of peculiar value. The potassium salt is the one generally used, as it is cheaper than the sodium compound. The latter, however, is less irritating and often more available. The lithium compound is ideal in some respects, but very expensive. The iodides may be given in large doses, to the extent of 30 Gm. or more (an ounce or more) in twenty-four hours. Large doses are sometimes necessary in the treatment of late syphilis of the nervous system. When it is necessary to put the patient rapidly under the influence of antispecific medication the combined use of these two drugs, as for example by mercurial inunction and the use of one of the iodides internally, will most speedily bring about the desired result. This result may be overreached, and sore mouth or other toxic manifestations may appear suddenly and unexpectedly.

The mercuric salts are soluble in solutions of the iodides, and what is known as mixed treatment is often employed. The salts may be combined in any desired preparation. Donovan’s solution is exceedingly valuable, the arsenic which it contains seeming to reinforce both the mercury and the iodine.

The iodides produce eruptions or rashes which strongly simulate both syphilitic and non-syphilitic skin diseases, and confusion may arise from their use. In those who are sensitive to the iodides, and in whom catarrh of the mucous membranes is easily produced, it is best to begin with small doses, increasing them as circumstances may warrant. Some patients cannot take iodine in any form. When iodides irritate the stomach they should be given in essence of pepsin.

Of the various vegetable remedies some are unreliable and of little value. Certain combinations can, however, be effected in some cases by which the value of the effective agents may be enhanced. Zittmann’s decoction or McDade’s formula will occasionally prove of service. In aggravated cases the former is believed to be the most effective of all methods of administering mercury. Tonics or any other medicines which may be called for in particular cases should be given judiciously. There is nothing in antisyphilitic treatment which precludes other treatment when needed.

CHAPTER XI. CHANCROID OR VENEREAL ULCER. — CHANCROIDAL BUBO.

Since the time of John Hunter and his pupils, who confused the three totally different and so-called venereal diseases, pathologists have drawn a distinct line between chancre, which is simply the initial sore of syphilis, and chancroid or venereal ulcer, which is a distinctly local lesion, often destructive, but never followed by constitutional disease, except of septicemic or pyemic type. It is usually found upon the genitals, about the foreskin, glans, and vulva, but may be met anywhere upon the body where infection has occurred. It is distinctly auto-inoculable, in which respect it differs from chancre.

Varying views have been held as to the minute agency concerned in the production of this lesion. The bacillus discovered and studied by Ducrey, in 1889, is now accepted as the exciting cause. This is 1.5 μ long and 1 μ thick, with rounded deep-staining ends and fainter-staining central portion, occurring with great constancy in chancroidal pus, less often in buboes than in ulcers, in and outside of the cells, and in chains. It is cultivated with difficulty, grows best on human blood, takes basic aniline stains, but is easily decolorized by alcohol or by Gram’s method. Characteristic ulcers can be produced by inoculating it, even in monkeys.

Chancroid begins, in twenty-four hours, as a red point or papule, which is quickly converted into a pustule and then into an ulcer. The borders of this ulcer enlarge, its depth increases, until after a few days it forms a more or less deep, often undermined excavation, irregular in contour, discharging grayish purulent material. In this respect it differs also from chancre, whose natural discharge is more like serum. In other words, chancroid is essentially destructive, chancre constructive, since the latter forms a new-growth which ordinarily has little or no discharge. When the necrosis of chancroid becomes extensive and tends to spread rapidly the ulcer is spoken of as phagedenic. This tendency to rapid local gangrene is the combined result, probably, of virulence of virus and lowered local or constitutional tissue resistance. It is consequently most often seen in alcoholics and prostitutes. In rare instances a surface larger than the hand may be rapidly destroyed, every particle of material sloughed being infectious.

In chancroids of the mild variety the discharge may dry upon their surfaces and scabs or crusts result, beneath which, when detached, the characteristic ulcer is present.

Under proper treatment this foul ulcer is soon converted into an ordinary granulating surface, which heals by cicatrization.

Infection, by propagation along the lymphatics, of the inguinal nodes is frequent, and, since the infection is almost always a mixed one, suppuration is frequent.

The pus of a suppurating chancroidal bubo is as infectious as the discharge from the original sore; hence the need of great caution. The edges of the local incision should be promptly cauterized so that they may not become linear chancroids. Phagedena shows itself here as well as about the genitals proper, and differs only in that it makes the case more serious. A chancroidal bubo may, however, subside without abscess formation. The signs of suppuration are those incident to pus formation anywhere near the surface. When pus is present its early evacuation is demanded.

Diagnosis.

—Chancroid is likely to be confounded with chancre and herpes preputialis. It has no period of incubation. Destruction commences after infection, so that within twenty-four hours macroscopic evidence may be observed, and within two or three days the sore has attained distinct size and shape.

Prognosis.

—Except in the most debilitated and dissipated, in whom phagedena may prove fatal, recovery always occurs, but often with the loss of tissue and disfiguring scars.

Treatment.

—In mild cases—i. e., those showing but little destructive tendency—cleanliness and the use of hydrogen peroxide, followed by local use of any of the ordinary antiseptic powders, or even of calomel, will usually prove sufficient. Sodium sozoiodolate makes an excellent application. It is odorless and non-toxic. At first its use may be preceded by morphine or cocaine, but after a few days it will prove a painless application. If the ulcer manifest any tendency to spread, it should be cleansed, cocainized, and then cauterized with nitric acid or the actual cautery, after which it should be so treated as to encourage granulation. This plan should be followed in phagedenic cases, which may call for general anesthesia, with the use of scissors and a sharp spoon, followed by cauterization of every particle of raw or diseased surface.

Widespread phagedena is more rare now than formerly. Cases which are extensive do best when submitted to continuous immersion of the hips in a sitz-bath as hot as can be tolerated. All aggravated cases call for invigorating and tonic measures, laxatives, improved nutrition, and stimulants.

Suppurating buboes should be incised, usually curetted, and thoroughly swabbed with pure carbolic acid, followed by pure alcohol to neutralize the acid, then packed lightly with antiseptic gauze, and allowed to close by granulation. Virulent cases will be accompanied by sloughing of so much tissue that it is best to remove all sloughs with scissors. Here even stronger caustics will be called for. Phimosis often complicates chancroid, and will necessitate circumcision or incision along the dorsum of the prepuce, with such attention to the parts thus exposed as their condition may require.

Mixed Chancre.

—Mixed chancre, or the combination of the two lesions, has been already discussed.

Extragenital Chancroid.

—Extragenital chancroid may occur upon any portion of the body, but is more rare than extragenital chancre. It is characterized by the same peculiarities as pertain to the venereal sores already described, and is amenable to similar treatment.

CHAPTER XII. GONORRHEA. — Diagnosis. — Course. — Complications. — Treatment. — CHRONIC GONORRHEA, OR GLEET. — GONORRHEA IN WOMEN.

Gonorrhea is an acute infectious process, involving especially the mucous membranes of the genito-urinary organs, but met with elsewhere about the body, in both superficial and deep tissues. The name itself is a misnomer, since it implies a flow of semen, whereas the discharge which issues from the male urethra is simply mucopus, and is the product of a severe inflammation of the mucous membrane. A less inaccurate name for it is blennorrhea, although this is usually limited rather to a discharge from the vagina, and indicates a whitish and copious fluid exudate, mingled with pus corpuscles and bacteria. It is stated that probably 80 per cent. of men have at some time contracted this disease. Neisser claims that it is a more common affection than measles.

True gonorrhea is the result of an infection by a specific organism universally recognized as the gonococcus of Neisser, though the discharge, when studied in the clinical laboratory, may give evidence of being the product of a mixed infection and contain the ordinary pyogenic or other organisms. The common name for the disease is clap.

The gonococcus is a diplococcus which seems to be injurious only to the tissues of the human being, as inoculations in animals have produced no definite or reliable result. Like syphilis, it is spread by direct or indirect contagion, and usually in the same way. It is generally found in the genito-urinary mucosa of both sexes, but it has been accidentally and even innocently conveyed by immediate and mediate transfer to the mucous membranes of the eye, the rectum, and even to the mouth, although here, as in the nose, the mucous membrane is but little susceptible to its activity. It is generally stated that 20 per cent. of the blindness occurring in the young is due to gonorrheal conjunctivitis. Those membranes covered with cylindrical epithelium are more liable to succumb to infection by this parasite than are those covered with squamous epithelium. The more the epithelial cells conform to the former type, the more difficult it is to get rid of the infection; hence the disease lingers in the cervical canal longer than in the vagina.

The disease always commences as a contagious catarrhal discharge from the mucous membrane. It may spread much farther than this, invading deeper tissues by continuity, or tissues at a distance by the lymph stream, or producing even metastatic expressions of infection in distant tissues and organs. Under these circumstances the serous membranes are likely to suffer, and the peritoneum, the endocardium, the pericardium, the pleuræ, the meninges, and particularly the serous linings of some of the joints, as the elbow and knee, show unmistakable evidences of infection; while through the medium of the venous and then the arterial systems typical representations of pyemia following gonorrhea may occur.

The disease as it usually appears is seriously and often obstinately complicated by the structure of the membranes which it involves. The mucous membranes throughout the body are more than mere mucous surfaces; they are dotted with openings for the escape of glandular secretions, and nowhere is this more conspicuous than in the urethra, where many minute follicles, so called, empty tiny drops of secretion into the mucous canal. Infection may easily travel along these routes and lurk within such minute recesses long after it has apparently disappeared from the surface; and so it often happens that in the male not only the urethral follicles but the ducts leading to Cowper’s glands and prostate become involved, while in the female the follicles around the meatus, the urethra, and the vulva rarely escape. The clinical importance of this statement is of interest, as by it may be explained many of those cases where an old infection seems to have been lighted up, or where the contagion has been conveyed to another after an attack which was supposed to have been entirely cured. Nothing seems to favor outbreaks of this kind as do alcoholic and sexual excesses.

The gonococcus may be scarcely regarded as an obligate pyogenic organism by itself, but the parts most often involved in this disease may be regarded as never free from the presence of other germs of greater or less activity, and by association, if not by actual symbiosis, such an intense reaction is provoked that the resulting products do not differ from true pus, save by the added presence of the specific organism most at fault. Under these circumstances abscesses may form in any tissue infected. Another expression of this fact would be the establishment of a pyarthrosis after involvement of one or more joints. Gonococci may be found in almost every abscess of truly gonorrheal origin; on the other hand, in some of the serous cavities it is possible, at least for a time, that gonococci may be present in the serous fluid without producing in it more than a disturbing effect, the fluid now appearing turbid rather than puruloid.

The amount of toxemia which may be produced by gonococci without reference to formation of pus has not yet been established. It is, moreover, a difficult thing to estimate in cases of mixed infection. Occasionally there are cases of metastasis and gonorrheal invasion which are free from evidences of suppuration, and yet there may be anemia and cachexia of profound type; these can only be explained on the theory of an intoxication.

Besides the serous tissues of the body the fibrous structures may suffer seriously, not only in an acute manner, but also in a chronic and obstinate form.

It has been the custom to speak of urethritis as a synonym for gonorrhea, and to divide it into the specific and non-specific forms, including under the former expression cases where the gonococcus can be demonstrated, and under the latter term those which do not seem to show it. There is no doubt but that urethritis may be set up by the introduction of a foreign body, such as a sound or catheter, as well as by some irritating discharge from the vagina, and also as the result of excess of uric acid in the system, perhaps even of alcohol. These, if occurring in a previously uninfected urethra, may be regarded as distinctly non-specific lesions. It is also supposed that under certain circumstances inflammation may be set up by other organisms than the gonococcus; nevertheless almost all cases of so-called clap are positively gonococcus infections, simple or mixed, and have but one origin.

—Diagnosis can be made positive only with the microscope. A recognition of the gonococci by staining them and then watching the effect of iodine in their decolorization will be of great importance and reliable. The affinity of these germs for basic aniline dyes, and the fact that they do not take the iodine stain of Gram, will serve to differentiate them from the numerous other organisms with which they may be found mixed. By staining a cover-glass preparation first with methyl blue or other basic color, then placing it in Gram’s solution, and finally in a solution of Bismarck brown, the true gonococci which have been made visible by the methyl blue will have disappeared under the influence of the iodine, while other bacteria will be stained by it. It has been mentioned that the germ is a diplococcus of rather ovoid form, met in clusters but not in chains, and in groups of four or multiples of four; it may be attached to epithelium and pus corpuscles, or found within them, and is rarely found free in fluid except when present in large numbers. These organisms are capable of cultivation, growing best upon a mixture of human serum and neutral agar, at a temperature of 36° C.

The urethra may be infected from without and from within, and this infection may be either of a truly specific type (gonococcus) or of the pyogenic type; as between these forms information may be gained by the history and the clinical course, but the minute diagnosis is only to be made with the microscope. This is of more than theoretical value, inasmuch as it substitutes a certainty for a working hypothesis. It is, moreover, sometimes of great value, as when the question of infection of one of the opposite sex comes up, or it may have at times even an important medicolegal value, as in cases of rape.

Infection from without, so far as the male urethra is concerned, is a question of the venereal origin of the disease. Infection from within, in the specific form, is a matter of recrudescence of a formerly active lesion supposed to have disappeared. Infection of non-specific type from without affects the introduction of germs either by venereal contact or by the medium of an unclean catheter, sound, or some other instrument, or from within by the extension forward of an inflammation higher up in the genito-urinary tract, such as may be due to stone in the bladder, cystitis, enlarged prostate, or uric acid or oxalic acid crystals. Urethritis, usually of mild type, is not infrequent in old men from either of these causes. It may also be produced by the infection of a too strong or irritant injection, whether used either for prophylaxis or for ordinary treatment.

Classifying them we may then have urethritis of the following four types:

• A. Gonorrheal of extrinsic origin.
• B. Gonorrheal of intrinsic origin (originally extrinsic).
• C. Non-specific urethritis of extrinsic origin.
• D. Non-specific urethritis of intrinsic origin.

A. The period of incubation is short, usually two to six days, and the resulting inflammation is severe; the consequences are often remote and sometimes disastrous. Gonococci will be found in the pus and epithelial debris.

B. This has been described as “bastard clap.” It is really an auto-infection, with an incubation period of a few hours, and is practically the reawakening of a quiescent stage of A. It is characterized by abundant purulent discharge; this latter is thin and mucilaginous, more like that of so-called gleet, with an abundance of pus threads, or “clap threads,” in the urine. In this form gonococci are also found, but less frequently.

C. Much like A in its clinical course, but less violent, and with less widespread reaction. Its period of incubation is rarely over thirty-six hours. This type is most common after alcoholic and sexual excesses; the latter especially with one already suffering from vaginal discharge, particularly so when near the time of menstruation. Here the microscope will show few if any true gonococci, but a profusion of pyogenic organisms.

D. This form of disease is of non-venereal origin, and is susceptible of easy explanation and of satisfactory treatment if the cause be properly treated. No case of urethral discharge which does not seem to fall easily into one of the above categories should be treated without a search of the anterior urethra, especially the fossa navicularis, for possible chancre or chancroid, as well as for stricture.

Among the laity the idea is prevalent that gonorrhea is a disease of more or less trifling import, while many of the profession regard it as rarely worthy of serious consideration. This is an unfortunate notion regarding this disease, and those who have had largest experience unite in expressing the opinion that gonorrhea reckons more victims in the death list than does syphilis—not because it is more common, but because of its complications and the ravages, especially in the kidneys, resulting therefrom. It has been shown that the specific organism producing it may linger for years in the follicles of the urethra, whence it may issue forth, unexpectedly, to produce vaginitis, perhaps in the most innocent of women, and thus bring on a train of pelvic disorders which may involve the ovaries, the tubes, and the peritoneum. Doubtless gonorrhea has made in this indirect way many more victims than syphilis.

Regarding gonorrhea thus seriously, it is well to treat it cautiously and to inculcate vigilance in the daily life and habits of the patient. There are no arbitrary limits during which danger exists and then passes; peril lurks about such a case for an almost indefinite time. There is danger not alone to the individual, but to all with whom he may have sexual or even other relations. This advice pertains not alone to the urethral discharge and the care of the urethra, but especially to the avoidance of all possible contamination of the conjunctiva. One of the saddest spectacles in the domain of medicine is to see one or both eyes of an innocent victim injured or ruined by gonorrheal infection.

There is no denying the clinical fact that individuals vary considerably in their susceptibility to this disease; moreover, individual susceptibility varies at different times. Alcoholic and sexual indulgence seem to materially lower this susceptibility. Thus from the same individual, and within twenty-four hours, one may acquire the disease while others escape. In some instances immunity seems to be afforded by repeated attacks; in other individuals repeated attacks seem only to enhance the liability to the disease. The gonococcus grows best in alkaline media. Prolonged sexual excitement diminishes the acidity of the urethral fluids, and this favors the growth and development of the germ. No credence should be given to popular notions concerning the possible avoidance of infection after exposure. Even a careful toilet is usually inefficient for this purpose, while the use of prophylactic injections is to be reprehended. They do more harm than good. If strong enough to be bactericidal, they should be extremely irritant; if weak enough to be tolerated, they will prove useless. The patient should also be warned concerning possible transfer of the disease without sexual contact, and all toilet utensils, towels, etc., should be kept by themselves, and all syringes and instruments used in the treatment of the case should be carefully sterilized.

—The period of incubation generally varies within wide limits, as mentioned above under classification of the various types; it may be as short as a few hours or may extend to ten days, or possibly even longer. Usually it is from two to five days. The early symptoms consist of discomfort along the course of the urethra, chemosis or edema, and swelling of the meatus. Within a short time after these symptoms the characteristic discharge appears. It may at first be viscid, but soon becomes purulent, and then more or less profuse, while urination gives rise to great discomfort. By the end of the first week the discharge is usually grayish in color, thick, continuous, and so profuse as to equal in volume 20 to 50 Cc. in twenty-four hours. The lesion is not confined to the urethra, and soon spreads to the peri-urethral tissues and thence to the lymphatics. A peri-urethritis with venous engorgement is added to the urethritis, and there is such an obstruction of the return circulation as to produce swelling and edema of the prepuce; this not only makes access to the urethra difficult, but conceals any excoriation and ulceration which may be going on beneath it. Sometimes this tumefaction proceeds to a degree where gangrene results.

All these local disturbances will be accompanied by more or less lymphatic involvement in the groins and in the perineum, with great soreness and tenderness throughout the entire genital tract. Chordee (painful erection) is a common and painful complication of this stage of the disease. Finally a well-marked degree of auto-intoxication, with its ordinary febrile and septic manifestations, may ensue. As the disease spreads farther back into the deep urethra there is irritability of the bladder, while in severe cases the frequent attempts at urination thus excited, with the accompanying pain during the act of expelling a few drops of urine, are distressing features of the disease. The pains are not limited to the organs involved, but are often referred to the back, to the perineum, and down the thighs. The symptoms above referred to belong to a well-marked case of acute specific type. There may be milder manifestations of each kind, and occasionally a case will run its course with but a minimum of the difficulties and discomforts above mentioned. Sometimes by the end of the third week, usually before, the disease will show a tendency to subside, even if inadequately treated. The inflammatory symptoms become less marked, the discharge thinner and less voluminous, until perhaps by the end of the seventh week there is noticed only a small amount when the patient rises in the morning. With all this apparent and spontaneous improvement there may be present, nevertheless, a serious and distressing amount of peri-urethral infiltration, which will soon be followed by cicatricial contraction and the formation of a stricture, the most frequent sequel of gonorrhea.

—Complications may occur along any portion of the genito-urinary tract. These will be considered in their anatomical order.

Balanitis.

—Balanitis signifies an inflammation of the mucosa covering the glans. When the mucous surface of the prepuce is also involved, as it usually is when the orifice is contracted, then the condition is known as balanoposthitis. In the absence of ordinary cleanliness of the parts this may go on to erosion or extensive ulceration. It is sometimes complicated with chancroid or chancre. When such a condition exists, and the glans cannot be sufficiently exposed for purposes of cleanliness, the dorsum of the prepuce should be slit up sufficiently to permit of complete exposure, while in some cases the edema and the infiltration will be such as to justify circumcision. When needed these operations should be practised even if raw surfaces are thereby left exposed to infection. Such possibility may be usually obviated by cauterizing a fresh surface, as soon as exposed, with pure carbolic acid or one of the stronger caustics, or operation may be made with the thermocautery.

Folliculitis.

—Folliculitis implies the extension of the infection to the follicles and lacunæ which abound within the urethral canal. As long as their orifices do not become occluded they easily discharge their contents into the urethra, but when so swollen as to become occluded they lead to the formation of abscesses, which, beginning in a minute way, may sometimes give relatively extensive disturbance. These discharge internally; sometimes they so present that they may be opened externally, as they should be under these circumstances. They form a communication between the urethra and the exterior, and in this manner the majority of the ordinary urinary fistulæ are produced. These often occur in the perineum, but sometimes even in the pendulous portion.

Peri-urethritis.

—Inflammation frequently extends beyond the anatomical confines of the urethra, and produces a degree of infiltration which is often well marked and disastrous. The site of such a lesion is marked by a nodule, more or less tender, which may subsequently break down into an abscess. The pus from these abscesses will usually escape into the urethra. Sometimes it burrows into the tissues of the corpus spongiosum, or travels even farther, and produces locally extensive destruction of tissue, with its possibility of urinary infiltration as a sequel, and all the septic disturbances which can be imagined as resulting therefrom. Thus fistulas often follow abscess formation, and these may be succeeded by phlebitis of the peri-urethral and prostatic plexuses, extensive destruction or multiple abscesses, or even gangrene and pyemia. Peri-urethritis is the essential factor in the production of strictures of the urethra, which constitute an exceedingly common condition.

While urethral stricture is a common result of gonorrhea it constitutes by itself a special lesion. (See chapter on the Genito-urinary Tract.) These peri-urethral infiltrations may occur in irregular patches, so variously placed as to encroach upon the urethra at different points without completely surrounding it, or they may form tubular lesions by which very serious annular constriction is produced. The degree of infiltration is, to some extent, a measure of the violence of the inflammation and of the virulence of the infection. This is true, however, only up to a certain point. One object of properly directed treatment should be to guard against the deep extension of a gonorrheal infection, in order to limit the tendency to the formation of stricture.

Between the folds of the triangular ligament are situated two racemose follicles known as Cowper’s glands. These occasionally become infected in the same way as the anterior follicles of the urethra and give rise to a painful swelling in the perineum, which gives most discomfort to the patient in the sitting posture. This condition is known as Cowperitis. It may proceed to abscess formation, in which case incision in the perineum should be made for its relief.

Prostatitis.

—The prostate consists of a collection of follicles embedded in a mass of involuntary muscle fiber. The largest of these follicles is known as the utricle, or, under the old anatomical name, uterus masculinus. These are liable to invasion when the infection has reached the deep urethra. The reaction which follows in this tissue after such invasion gives rise to prostatitis and causes much pain and general reaction. The prostate, being embedded within a fibrous capsule, cannot expand easily when it becomes inflamed, and the pressure thus made not only causes intense pain, but will also obstruct the urethra and occasion great difficulty in urination, sometimes retention of urine. In proportion to the other disturbance will be the general reaction, and fever may run high, with early expressions of septic intoxication or of septicemia. The prostate becomes tender, and pain is felt not only in the pelvic region, but in the back and in the thighs, as well as along the urethra. Prostatic abscess is a frequent sequel to this condition; it sometimes evacuates spontaneously into the urethra, or bursts through the capsule and burrows along the structures in the perineum and lower pelvis; occasionally it empties into the rectum. Intensity of symptoms should give rise to a suspicion of prostatic abscess, and a perineal incision should be made early and the abscess evacuated. Occasionally these abscesses present toward the rectum, when they should be tapped or incised through the bowel.

From the prostatic urethra inflammation may extend on one side or both along the vas deferens to the seminal vesicles. The production in this way of a vesiculitis is made known by the reference of pain to the rectum and by the appearance of blood, sometimes with pus, in the seminal discharge. By a digital examination of the rectum the enlarged and tender vesicles can be recognized above the prostate.

When the deep urethra has become seriously involved the condition of the patient is unpromising. Belfield calls attention to the triple function of the deep urethra, in that the impulse to urinate originates therein, that it is a sphincter for the bladder, and that it is intimately concerned with the sexual act. When it is disturbed by gonorrheal infection all of these functions are disturbed, the most serious symptoms being increased desire to urinate, amounting to almost constant vesical tenesmus; marked difficulty in expulsion of urine, which may increase to complete retention, and frequent bloody emissions, with chordee. The pain, the heat, and the sense of tension in the perineum and in the parts around it are distressing, as well as pain during and after urination, which is usually referred to the end of the urethra. The last few drops of urine will often be bloody.

Cystitis.

—Cystitis is the not infrequent result of the further migration of the infectious process from the deep urethra to the bladder. The process is usually acute and serves to further complicate the case and to harass the patient. Except in the nature of the exciting causes cystitis differs but little from the other varieties to be considered in their appropriate place (q. v.). Cystitis of gonorrheal origin is likely to travel along the ureters and lead to involvement of the kidneys. Ascending infection is most commonly of gonorrheal origin. In proportion to the extent and rapidity with which the disease travels upward the case is marked by expressions of septic intoxication and infection, such as chills, fever, pain in the loins, along the ureters, and in the testicles. The kidneys may become enlarged. A more minute appreciation of the condition of affairs can be obtained by microscopic examination of the urine. In proportion as the kidney is involved, there is a preponderance of albumin, i. e., more than pus alone would produce. One of the numerous ways in which gonorrhea kills its victims is by the production of a pyelonephritis of the type known as “surgical kidney.”

Lymphangitis.

—No such invasion of mucous membrane by septic organisms can take place without active participation of the lymphatics in the region involved. In cases of gonorrheal or even non-gonorrheal urethritis, not merely enlargement of the lymph nodes in the groin may occur, but an active lymphangitis, manifested as a tender, sensitive cord beneath the skin, especially along the dorsum of the penis. The lymph nodes thus become involved and sometimes suppurate, and these abscesses are referred to as suppurating gonorrheal buboes. The suppurative feature is probably caused by contamination with the ordinary pyogenic organisms.

The Testicles.

—Gonorrheal infection seems often to extend along the vas and thus invades the epididymis, where evidences of activity are more frequent than in the vas itself. Epididymitis complicates cases of clap usually after the second week. It is characterized by pain, tenderness, and swelling of the epididymis, which occupies the same position relative to the testis proper that the heel does to the rest of the foot when a person stands in the ordinary military position, i. e., to the rear and inner side. The swelling becomes pronounced, and it is not unusual for a certain degree of swelling to be manifested in the testis proper, with the accumulation of a small amount of fluid in the sac of the tunica vaginalis, thus constituting a mild degree of acute hydrocele. While the inflammation is confined to the epididymis the pain is not intense, but of a dull, heavy character; but when the testis proper is involved there is a true orchitis, the inflammation being confined within the inelastic sclerotic tunic, and the pain then may be severe. Considerable fever accompanies many of these cases, with occasionally some edema of the scrotum and congestion of the testicular coverings. The weight of such a “swelled testicle,” as this condition is called by the laity, is irksome, and occasionally causes extreme discomfort. Under these circumstances physiological rest, i. e., in bed, and the use of a suitable suspensory apparatus are essential.

While resolution of this swelling ordinarily begins early and proceeds satisfactorily, the latter portion of the process is often slow and tedious, and the epididymis thus once involved will for months contain nodules and irregularities of contour. Usually the affection is limited to one side; but both testicles may be involved. If the infection be violent and the treatment inefficient abscesses may result.

This condition calls for early and effective treatment. If seen at the very outset, progress of the lesion may be checked by embedding the affected part in cold, wet compresses, and keeping them cold with ice. Relief later is more likely to be afforded by hot applications, and a hot poultice containing a small amount of fine-cut tobacco has been popular as a local application—the tobacco apparently being anodyne in its effect, although perhaps no more so than belladonna leaves. This may be regarded as a good emergency dressing when it affords the only means of treatment. The greatest relief will be obtained by the application of guaiacol, diluted with three volumes of olive oil or castor oil, well applied over the scrotum, and covered with oiled silk or rubber tissue. This application should be made twice a day. Later, in the more chronic and less painful stages, a reduced mercurial ointment containing a little guaiacol or ichthyol may be used to advantage, resolution being thereby assisted. In quite tedious cases the flying application of the actual cautery is serviceable. Internally tincture of pulsatilla has proved beneficial. It should be given in 1 Cc. doses every two hours. While the benefits accruing from its use are questionable, it has helped to allay fever and subdue pain.

Much has been said about the sterility which results from epididymitis, especially when both sides have been involved. It is easy to understand how the vas may become occluded in many cases, either temporarily or permanently, and yet within my own observation men have suffered from the double lesion and yet begotten children.

Gonococcus Septicemia and Pyemia. Postgonorrheal Arthritis (Gonorrheal Rheumatism).

—Considering the extent of the mucous tract involved, the open port of entry for germs, and the virulence of these organisms in many cases, it is remarkable that there are not more conspicuous illustrations of septic absorption in cases of gonorrheal urethritis. That these do occur and have a widespread, sometimes disastrous, effect has long been recognized. The severe forms are usually the more acute, and if they assume the septicemic type, go on to abscess formation, and in parts which are not always accessible. In rare instances septic disturbance assumes the pyemic type. The writer believes that he was the first to report a case of typical pyemia following gonorrhea, and to recognize it as such.

Aside from these acute manifestations, more chronic and mild affections, especially of the serous membranes, are well known. The most common of these exhibitions occur in the joints, mostly in the knee. A gonococcus peritonitis, pericarditis, or endocarditis are, however, well known. Because of the similarity of the discomfort and the disability resulting from the joint complications of clap to the ordinary joint manifestations of rheumatism, these lesions have long been popularly called gonorrheal rheumatism. The name, however, should be discarded as being incorrect, and for it the best substitute would be postgonorrheal arthritis.

These lesions may be sudden in their onset or may come slowly. They may occur at any time during the acute stage or after its apparent subsidence. The first manifestations involve the serous membranes proper; the fibrous tissues participate sooner or later, and the infiltration resulting from the inflammation thus set up will often permanently compromise their integrity and cause an impairment of their function for the rest of the patient’s life. They are usually confined to one of the larger joints, but may involve several, either simultaneously or consecutively. In acute cases the swelling is somewhat pronounced and the pain and soreness intense. The local symptoms simulate those of acute articular rheumatism. In the fluid drawn from these joints the gonococcus can be occasionally demonstrated. The course of the disease is usually slow, and convalescence may be protracted. Nor is the disability acute only and temporary, but it is often made permanent by the formation of adhesions resulting from the condensation of exudates. Partial or complete ankylosis may result, with considerable deformity. The muscle spasm provoked by the acute joint inflammation will occasion the same distortions and subluxations as are produced by tuberculous and other forms of arthritis, and operations varying in severity from forced motion to joint exsection may later be necessary. (See pp. 392 and 393.)

The writer has seen cases of postgonorrheal toxemia of extremely chronic and even fatal type, where the joints were conspicuously involved and where they did not constitute the most serious features of the disease. These cases proved most intractable to treatment and illustrate the possible complications of gonorrhea.

In addition to the joints various bursæ and tendon sheaths may suffer in the same way as do the joint membranes. Such lesions are seen about the hands and feet, especially about the tendo Achillis, and are also seen in the muscles of the neck and of the orbit.

The treatment of these gonorrheal complications should be effected largely by improving elimination and getting rid of the general toxemia; thus hot-air baths, diuretics, and cathartics are advisable. These eliminants, with free massage, are useful in dislodging the toxic products.

—The treatment of gonorrhea is directed not alone toward the mere alleviation of symptoms, but to the destruction of the invading germs. The patient should abstain from much exercise, and in cases of severity should be kept in bed, avoid alcohol and tobacco, and eat sparingly of meats and of richly seasoned foods. He should wear a “gonorrhea bag,” or large condom, and there should be no obstruction to the outflow of pus. His hands should be washed immediately after contact with the parts involved, and all dressings and linen which may have been contaminated should be promptly burned.

The actual treatment of gonorrhea should be both internal and local. Internal treatment should consist (1) of the administration of laxatives; (2) of such amount of alkali as may be necessary to overcome hyperacidity of the urine and mitigate the distress caused during its passage; (3) of remedies which, being eliminated by the kidneys, serve to medicate the urine and give it the effect of a retrojection; (4) of such anodynes and sedatives as may be necessary to give comfort, allay distress, and produce sleep or relieve and prevent chordee.

Of the drugs which are supposed to be eliminated by the kidneys, the balsams have sustained a high reputation. Among these is cubebs, of which 2 or 3 Gm. may be taken every two or three hours, as this remedy favorably influences the amount of discharge, though sometimes disturbing the stomach. Of the oleoresin of copaiba a ¹⁄₂ Gm. capsule, taken several times a day, is more pleasantly borne by the stomach, and with nearly as good effect as cubebs. Copaiba is known to produce a vivid scarlatiniform rash. The oil of sandal-wood, or santal oil, is the most efficient of these remedies, and may be given in the same dose as copaiba. That these drugs are eliminated by the kidneys is shown by the odor which they impart to the urine. It must be said, however, that these remedies are of but trifling benefit until the bladder is involved; when this occurs, they may prove of great value.

The urine should be diluted that it may be less irritating, and also to overcome its acidity. Fluids should be administered in profusion and alkaline diuretics in considerable doses. Hyperacidity is readily controlled by the administration of liquor potassæ, or the common sodium bicarbonate.

Sedatives may be necessary even from the first. The stronger anodynes are rarely needed during the first day or two, but by the end of the first week vesical tenesmus and chordee may be so marked that remedies such as cannabis indica, lactucarium, chloral, and the bromides may prove insufficient, and an opiate should then be administered. When required, morphine or heroine subcutaneously and in doses sufficient to promptly bring about the effect desired are preferable.

The local treatment of urethritis is directed to the alleviation of discomfort and distress and the cure of the local disease. Much has been said about abortive treatment. There is no such thing as aborting the disease. Much may, however, be done in the way of mitigating and shortening its course, and mild cases, especially of the non-specific form, may be considerably relieved within a few days.

The local treatment is carried out by injections into the urethra, which must be made with a syringe, preferably of hard rubber, with a blunt tip and without a nozzle, or by a douche bag connected with a soft catheter, all of which should be kept constantly sterilized. During the first days of an attack, when only the anterior part of the urethra is affected, treatment can be made more readily and effectively with a small “P” syringe, and at this time only 15 to 20 Cc. of fluid will be required, which should be held in the urethra for some time. When irrigation is decided upon a douche should be employed. Accurate directions should be given the patient as to how to make the injections, and he should be cautioned to first empty the bladder before using the syringe. The patient’s comfort may be increased by injections of water up to a temperature of 115° F. Antiseptics, i. e., potassium permanganate, boric acid, or one of the new preparations of the silver salts, may be added to the water. The parts may be advantageously immersed in hot water at intervals during the day, and for fifteen or twenty minutes at a time. There are many ways of conducting local treatment in these cases. Those mentioned below have given the best results in the practice of the writer.

A very satisfactory method would be to commence the local treatment with the use of hot water, as above, every two to six hours, and to follow it with a small injection of an emulsion of bismuth subnitrate, with sufficient cocaine and a little morphine to blunt sensibility and diminish tenderness and pain. The following formula, which may be varied, will accomplish this purpose: Morphine sulphate 0.3, cocaine muriate 2, bismuth subnitrate 20, cherry-laurel water 150, mucilage of acacia 50.

The injection should be retained for a few moments and no effort made to expel it. The bismuth salt is not only antiseptic, but is soothing, slightly astringent, and non-irritating.

Belfield has recommended the use of the yellow hydrastia muriate in connection with protargol. His formula is as follows: Yellow hydrastia muriate 2.50, protargol 1.50, glycerin 15, water 500. After using this for a few days the proportion of protargol may be doubled. Of this preparation 15 to 20 Cc. should be injected several times a day. The silver salts are the least irritating of all the stronger and more reliable antiseptics, and drug manufacturers are putting upon the market at frequent intervals new preparations for which much is claimed. Among the latest of these is argyrol, a combination of silver with albumen (vitellin), in such form as to make it antiseptic and non-irritating. In solution it is of a dark mahogany color and stains whatever it comes in contact with; these stains, however, are readily washed out. Argyrol in solutions of 2 to 5 per cent. strength has proved reliable, and if such a solution be retained in the urethra for five minutes at a time a pronounced effect may be made upon the disease. It is my custom to alternate the use of the bismuth formula with a solution of argyrol as above, and in this way give the greatest relief in the shortest time. It has been demonstrated that under the influence of this preparation all gonococci which are reached by it are destroyed; therefore the earlier it is employed the better. Before using either of these formulas the anterior urethra should be washed with hot water or with hot normal salt solution. No harm need be feared should either of the above injections reach the deep urethra, and the effort should be to make them reach at least as deeply as the disease has gone.

When the discharge has reached what Finger has called “the mucous terminal stage,” then the argyrol may be used two or three times a day only, and one of the following solutions substituted for it part of the time: Zinc sulphate 0.75, bismuth subnitrate 8, colorless liquor hydrastis 15, cherry-laurel water 60. Of this solution 10 Cc. may be used three or four times a day.

Belfield strongly recommends the use at this time of a solution of muriate of berberine, in strength of ¹⁄₂ to 1 per cent., or the yellow hydrastia muriate in about the same strength. He also recommends zinc chloride 0.25, zinc iodide 0.50, water 500. Either of the above salts may be added to this.

When nothing remains of the discharge but the so-called “morning” or “military drop,” and the urine is almost clear, argyrol solution at night and one of the above formulas once or twice through the day will be sufficient. This, in brief, is a description of how a case of urethritis may be satisfactorily treated.

The systematic use of potassium permanganate solutions was introduced by Janet, and has been enthusiastically described and prescribed by Valentine. The treatment is more complicated and less satisfactory than that advised above.

With deep extension of the disease and its added symptoms of tenesmus, pain local and referred, etc., the limit of the injection should be extended and the entire urethra should now be treated. The bladder being empty, the patient should make a strong effort to empty it again at the moment when fluid is being injected into the urethra; the compressor muscle being thus relaxed, the fluid passes into the deep urethra. It will take a little practice to enable him to do this, but when once learned the procedure is simple, and those who cannot accomplish it in the standing position will succeed if they lie down before making the attempt. In this way the entire urethra may be traversed.

In the treatment of deep urethritis it is not necessary to change the formulas or drugs above advised.

Under this line of treatment it may be possible to cure the majority of cases of gonorrhea in from two to five or six weeks. This by no means indicates that the lesion is actually cured, for trifling evidences, such as adhesion of the lips of the meatus, with the retention of a drop or so of mucopus, and the presence in the urine of the so-called “clap threads,” i. e., threads of flocculent material that consist of mucus and epithelial debris loaded with bacteria, will for a long time be noted. These appearances indicate that there are still areas along the urinary tract which are infected, and are sources of possible danger.

The vesiculitis which often follows deep urethritis, as shown by the enlargement of the vesicles, detected by rectal examination, requires physiological rest, hot sitz baths, hot enemas, and opiates, the latter usually by suppository. After a short time the vesicles should be “milked” with a finger in the rectum, gentle pressure being made toward the prostate in the direction of their outlet. This will frequently cause an outflow into the urethra of pus and debris and give great relief. Should the infection persist and the above manipulation prove insufficient, the vesicles may be opened through the rectum, washed out, and packed with gauze.

Gleet is the name given to gonorrhea which persists, being only partly influenced by treatment, and which has extended over an arbitrary period placed usually at six weeks to two months. Strictly speaking the term gleet should be restricted to cases where there is a mucopurulent discharge from the meatus, often complicated by formation of strictures in the anterior urethra; on the other hand, a chronic gonorrhea may for a long time persist in the deep urethra and the glands and ducts adjoining, whence will issue a discharge which appears anteriorly, but, nevertheless, comes from the depths of the genito-urinary tract.

It is possible to have a chronic gonorrhea with little or no true gleet, the infection being latent, but nevertheless persisting. In gleet the discharge varies from a thin watery flow to one which is profuse and purulent, most noticeable in the morning on rising, when the meatus may be occluded by adhesion of the surfaces and there appears the so-called “morning drop.” Careful investigation of the urethra will generally disclose at least some constriction, with tender areas along the anterior urethra. To successfully treat the disease these areas and constrictions should be determined and suitably medicated. For this purpose two instruments especially are necessary—the bulbous bougie, for which a sound of the same size is an unsatisfactory substitute, and the endoscope, through which the lesions may be not only viewed but suitably treated.

The peculiar discharge comes from a lesion of one of the following varieties—either from isolated areas of inflamed mucous membrane with underlying exudate, from follicles and vesicles which fail to completely empty themselves, or from preëxisting strictures. The endoscope will easily reveal the first and second of these; the bulbous bougie the first and third, while further examination by the rectum may be necessary to decide in regard to the seminal vesicles.

Fig. 28

Bulbous sound.

The bulbous bougie is an instrument of great importance in urethral work. It should be carefully sterilized before introduction, and the urethra should be cleansed before its use. The instrument should be gently passed into the urethra; its course will be obstructed by any constriction which will give rise to stricture of smaller caliber than the bougie itself, while the discomfort or pain which it will excite as it passes over a tender or ulcerated area will be significant. The urethra is most distensible at its bulbous portion, while its caliber varies in different individuals, ranging ordinarily from 30 to 35 of the French scale, while the urethral diameter is about four-tenths of the circumference of the penis. We owe more to the studies of Otis in this matter than to any other investigator. He also showed that the size of the meatal opening is not a criterion as to the size of the urethra; that the contracted meatus often produced a certain degree of reflex and spasmodic stricture behind it, and that when the meatus is too small to permit the introduction of such an instrument as the urethra should take it should be enlarged, the operation for its enlargement being known as meatotomy, which may be easily effected with a blunt bistoury under the local use of cocaine. The meatus having been enlarged to suitable size, any consistent and organic constriction which then prevents the passage of the bougie should be considered a stricture and treated accordingly. Such a constriction may be of recent origin, when it will be found easily dilatable, or it may be old, resillient, and tough. Otis also devised an instrument known as the urethrometer, which is of value in the accurate estimation but not necessary in the treatment of many cases.

Fig. 29

Urethrometer.

These instruments may be passed down to the bulbous portion of the urethra; beyond this further investigation should be made with the ordinary sounds. By their use much may be determined in regard to prostatic tenderness, and the combined use of the sound in the deep urethra with the finger in the rectum will give more accurate information regarding the size of the prostate than can easily be obtained in any other way. Much reaction, however, may occur from the use of the sounds in this way, and it is a good rule never to introduce an instrument into the deep urethra without having ample reason therefor, and then doing it under antiseptic precautions; while, as a formal measure after it, the patient should be placed at absolute rest. This serious reaction, which occasionally follows instrumentation of the deep urethral passage, is commonly known as urethral fever. It is characterized by chills, elevation of temperature, and often by local indications, the constitutional features being sometimes pronounced, and in rare cases terminating fatally. Such serious symptoms are difficult to explain. Doubtless the use of the instrument opens up paths of fresh infection, and absorption rapidly follows, which may be limited to the surrounding tissues or cause widespread trouble. This may ensue after every precaution has been adopted, although doubtless many of these cases have been the result of carelessness and failure in antisepsis. Much may be done in the way of prevention when this condition is feared, for these cases are rarely so urgent but that the urine can be medicated and its quality improved, while a part of the procedure may consist in having the patient empty the bladder and then carefully washing it, or filling it with an antiseptic solution, which may be expelled before any instrument is used except the catheter, through which it may be necessary to introduce the bladder wash. The administration of 2 or 3 Gm. doses of urotropin, with or without quinine, previous to the exploration, may also be of great service. The surgeon perhaps does not always take these precautions, but he should when the history of the case shows that patients have already suffered in this way. In the presence of such a history the urethra should be explored with great caution.

When the rectal examination is made the intent should be to discover any enlargement, irregularity, or undue sensitiveness of the prostate, and then to pass the finger still farther and ascertain if there is involvement of the seminal vesicles. At the same time a species of manipulation described as “milking” may be conducted, by which the contents of the vesicles as well as of the prostatic utricle may be incited by gentle pressure, directed from above downward, to empty into the deep urethra, whence they may be promptly expelled or may be carried out by the urinary stream, or removed through the endoscope. The discharge of pus or catarrhal debris in any visible amount is suggestive, and indicates that these passages have participated in the infectious process. This act may be repeated at three or four day intervals; it should be so gently done as not to cause much pain, and will be found of great value in cases calling for it.

Treatment.

—The treatment of gleet is essentially treatment of the causes which produce it, and these should be carefully determined. In the urethra, as in all other tubular channels of the body, an abnormal constriction is accompanied by an area of excitement behind it, from which will issue more than the normal mucous discharge. We see this in stricture of the esophagus, intestine, or any of the ducts. This discharge is not to be subdued by mere applications nor by astringent and antiseptic injections, but the stricture itself, being the most important factor, must be suitably managed. In recent cases its gradual distention by the use of conical sounds will usually suffice.

In long-existing strictures more radical measures should be adopted, and they should be divided with one of the numerous urethrotomes in general use. Mere division, however, is not sufficient, but the patient should be impressed with the fact that cicatricial tissue tends invariably to contract, and that persistent dilatation is to be practised lest the stricture recur. The old saying used to be, “Once a stricture, always a stricture.” If this is to be disproved, it can only be by the frequent and long-continued use of sounds. Ignorance or indifference impel many a patient to return for further treatment, sometimes in a condition worse than at first, while occasionally the penalty paid for carelessness is life itself.

No routine in the treatment of gleet will give satisfactory results beyond this fact, that patients should be instructed to regulate their lives by absolute rules as regards indulgence of every description, and avoidance of intestinal inactivity and constipation. The urine will be found concentrated and irritating in many of these cases, and this should be overcome by the free use of water and diluent drinks. Hyperacidity should be corrected by suitable alkaline medication, and remedies administered, already mentioned, which are supposed to medicate the urine. Capsules may be procured containing salol, oleoresin of cubebs, balsam of copaiba, and pepsin, and except in cases where there is already great irritation of the urinary tract, these serve their purpose admirably.

When the anterior urethra alone seems to be involved, one of the milder injections already mentioned in describing the treatment of acute cases may be employed. When the deep urethra appears to be the site of continued irritation, it should then be treated extensively with deep irrigations and injections of suitable medicaments. The deep irrigations can be practised with or without the use of a catheter. The deep urethra may be flushed through a smaller catheter than the urethra will comfortably take, allowing the fluid to return through the urethral channel outside of the catheter itself. When this practice is adopted, hot water which has been made antiseptic should be used, preferably with one of the silver salts. The nitrate may be used in proportion of 1 to 500, and the citrate or lactate in strength of 1 to 300 or 1 to 400. Protargol is effective in 1 per cent. solution, or argyrol in 1 to 3 per cent. strength.

In the employment of irrigation in these cases a shield should be used, by which the end of the penis may be covered and all danger of spattering avoided. The simplest expedient for this purpose is one-half of an old atomizer bulb, which may be punctured and slipped over the catheter or irrigator tube.

Apart from mere irrigation it is well to deposit within the depths of the urethra, in the membranous portion, by means of a deep urethral syringe, a drop or two of a fresh solution of silver nitrate in distilled water, in strength of ¹⁄₂ to 1 per cent. This should be deposited behind the “cut-off” muscle, where it will cause a burning sensation for a short time. The strength of the solution is to be regulated by this complaint, as no benefit is derived from using it too strong.

Of all the medication that has been suggested, nothing gives better results for this purpose than this silver nitrate.

For ordinary urethral injections, besides those already mentioned, formalin may be used, but in weak solution (1 to 2000, or stronger if the patient can tolerate it); while picric acid has been recommended by Belfield and others in strength of 1 to 1000 or 1 to 2000.

Some surgeons believe that patients can learn to flush the deep urethra, or even the bladder itself, without the use of the catheter or internal tubing of any kind. The procedure may have to be learned in the sitz bath, the pelvis being immersed in warm water; the nozzle of the irrigator tube is inserted into the urethra and the patient is told to make an effort as if to void his urine. This will so relax the “cut-off” muscle as to permit the passage of fluid into the bladder, and this, which is most desirable in many cases of cystitis, where the bladder washing is an essential feature of the case, is to be avoided when the gonorrheal infection has travelled backward beyond the prostate; no attempt should be made to pass the solution into the bladder, but simply to wash out the urethra. The better plan is to teach the patient the proper use of a small soft catheter, which may also be used in the sitz bath, inserted to the proper extent.

Recent strictures should be treated by sounds after the urethra has been thoroughly cleansed. For this purpose a conical cylindrical sound should be selected, whose urethral end will comfortably enter the stricture. Gentle force should then be brought to bear to pass it beyond the stricture. If gradual dilatation be aimed at, it is well not to go beyond the point of drawing a drop or two of blood; even this may be avoided. On the other hand, should it be decided to use sufficient force, the dilatation should be done thoroughly and at one sitting, in order to avoid repetition of the irritation. The instrument generally in use in this country for this purpose is the Otis dilating urethrotome, by which the degree of dilatation and the size of the cicatricial ring can be estimated and the extent of the division and the effect gained also regulated. (See Operative Surgery of the Urethral Canal.)

The divulsion of strictures, formerly in vogue, is now abandoned for the more accurate division performed by this instrument. The strictures having been thus divided, sounds should be passed at intervals of from three to five days, by which the urethra is distended to its full caliber and the divided surfaces not allowed to contract. This is an important part of the treatment, and gives opportunity for widest discretion in their employment. Ordinarily they should not be carried farther back than the lesion calls for, as the deep urethra is best let alone. On the other hand, there are many cases where the stimulus of the cold metal passing the entire length of the urethra and the effect which it seems to have in expressing from the various follicles any retained contents seem beneficial. It has been stated that instrumentation sometimes leads to epididymitis or “swelled testicle;” should this take place in a case undergoing treatment for gleet it may necessitate a temporary cessation of the mechanical treatment. It is not good surgery to introduce any instrument into the urethra when one or both testicles present this complication.

In the local treatment of these lesions, cocaine or one of its substitutes should be employed. It is questionable whether the full benefit of applications is obtained when the surfaces are so anesthetized; on the other hand, the treatment can be made more endurable by its use.

This is true, also, of the use of the endoscope, and applications which may be made through it to inflamed or hypersensitive patches. When these are recognized or exposed, they are best treated by a probang moistened with silver nitrate solution, in 5 to 10 per cent. strength, or by the solid stick or crystal of copper sulphate, pure or mitigated, as used by the oculists.

One of the most important features in the consideration of gonorrhea is to determine, if possible, when a given case has ceased to be dangerous to others. In theory the danger passes with the disappearance of the gonococci, but it is so difficult to determine when this has occurred that it is almost impossible to fix a time limit in any given case. An excellent method of determining the matter in a reasonably accurate way is by having the patient void urine in two different glasses; a small quantity in the first, which will contain, then, the washings of the urethra. In this glass will be found those chains of gonococci clustering around masses of epithelial cells or debris which have been especially described as “clap threads” (tripper-faden of the Germans), upon which, by careful examination, gonococci can often be recognized. As long as these threads are in evidence it may be held that the infection still persists, and might be either brought into activity again by excitement or convey the disease in the sexual act.

Gonococci have been found in clap threads years after the last known infection, and this will illustrate why they are such a source of danger, and how an innocent woman has been made to suffer when it was supposed that all danger of infection had passed away.

This naturally assumes the type of a specific vaginitis, usually with active participation of the mucous membrane of the vulva and of the vulvovaginal glands, the urethra and bladder being sometimes secondarily involved, while the role of the lymphatics is about as described in the male. In the young, especially in young girls upon whom rape has been attempted, the mucosa is extremely susceptible. In adults, particularly in those who have borne children, the vaginal walls offer more resistance. The nature of the parts permits of more violent chemosis of the mucous membrane, while in serious cases there will be well-marked edema of the labia. The urethral orifice is usually inflamed and chemotic, even though the infection travel no farther in this direction.

It has been stated that 80 per cent. of deaths from pelvic disease in women are due directly or indirectly to gonorrhea, as well as one-half of the cases of involuntary sterility.

As in the male, there may be different types of so-called gonorrheal infection of the vagina, varying from the pure gonococcus type to that in which the preponderating bacteria are of the ordinary pyogenic varieties. The detection of gonococci in the discharges sometimes assumes medicolegal importance, and upon it has depended the guilt or innocence of more than one individual.

The intensity of the vaginitis will vary with that of the infection. In the worst cases the discharge is profuse and acrid. It may amount to 50 Cc. or even 100 Cc. in twenty-four hours. The burning pain will be extreme, while backache and pelvic soreness will be bitterly complained of. In mild cases the disease assumes the clinical form of a low-grade vaginitis with abnormal discharge, such as may be characterized as a severe case of “whites.”

In these cases of either type the question is, whether infection has already travelled upward beyond the vagina into the uterine cavity or through it into the tubes.

Gonorrhea is the most common, and some believe almost the sole, cause of pyosalpinx with its attendant complications and dangers. Even when not severe, vaginitis may permit of such extension, and so not only induce sterility, but compromise the physical welfare of the patient; while in acute cases the activity is so great that it occasionally terminates in peritonitis, primarily of gonorrheal origin. When both tubes have become involved, the patient is almost invariably sterile.

In nearly all of these cases strings of mucopus will be found hanging out, or beads of it presenting at the external os, and when examined this exudation will afford a fair test as to the character and degree of the infection. Here, as in the male, there are so many follicles difficult of access, and so many recesses in which germs may lurk, that a complete disinfection of the parts is almost impossible. For this reason, then, latent gonorrhea is a frequent outcome of the disease when once it has existed, and a possible and more or less constant source of danger to others.

Treatment.

—A case of acute gonorrheal vaginitis with its accompaniments will present a difficult problem. The discharge is so great that the danger to others, and especially to the eyes, is pronounced, while the exquisite tenderness of the parts makes radical treatment difficult. The treatment should consist of antiseptic douches, which in serious cases should be made as nearly continuous as possible. The water used for the purpose should be as warm as the patient can tolerate, and contain an antiseptic, of which corrosive sublimate, in strength of 1 to 2000, silver nitrate in the same strength, or formalin in double this strength, are the most serviceable. The irrigating tube should be carried to the upper end of the vagina and the stream made to flow outward. In milder cases a douche at intervals through the day may suffice. The vaginal surface should later be exposed through a speculum and the entire mucous surface treated with nitrate of silver solution in from 6 to 10 per cent. strength. Should the surface be tender, this will be painful, and might justify the use of an anesthetic, especially of nitrous oxide.

If the disease extend upward and there is an endometritis or a salpingitis, external applications of ice may be used to lull the pain; but probably hot poultices or some application of external heat might afford greater comfort to the patient. Byford has used succinic dioxide in the treatment of specific vaginitis with great satisfaction. It is sold in the open market under the trade name “Alphozone.”

The edema of the vulva will subside with the general improvement of the case. Abscesses in the vulvovaginal glands are not uncommon. These are easily recognized, are often painful, and should be incised early or as soon as recognized, cleaned out thoroughly, the interior of the cavity cauterized to prevent the result of fresh infection, and then packed and left to heal by granulation.

Urethritis and cystitis may be treated as when they occur in the male. There is the same liability in women as in men to lymphatic involvement, with the consequent bubo, which may perhaps suppurate. They are less liable to the widespread manifestations of postgonorrheal infections of the joints, etc., although they are even more liable to infection of the endocardium, and, as will be readily understood, more so to infection of the peritoneum. It will then be seen that the treatment of the disease is essentially the same in either sex, certain differences in method rather than in principle having to be made in accordance with anatomical requirements.

As to the rectal mucous membrane participating in gonorrheal infection, under ordinary circumstances it would escape. In the treatment of any of these cases by the sitz bath, the question might arise whether there would be danger of extending the contagion in this direction. It does not appear that much fear need be felt, for two reasons: the grasp of the sphincter is usually sufficient to prevent entrance of fluid, and, furthermore, the rectal mucosa is itself extremely resistant to the gonococcus. Gonorrheal proctitis is an exceedingly uncommon infection, and one rarely seen, except in extreme cases of sexual perversion. It should be treated in about the same manner as gonorrheal vaginitis, i. e., by continuous irrigation with hot water, and stretching the sphincter in order to overcome the spasm into which it would be thrown by reflex activity.

Gonorrheal urethritis in women is best treated with local applications of argyrol or one of the other silver compounds. These can be made with a syringe or with a small swab. Cystitis is to be treated in the same manner as when it occurs in the male.

CHAPTER XIII. SCURVY AND RICKETS. — SCURVY. — RICKETS.

Scurvy is placed among the so-called surgical diseases, since it manifests many distinctly surgical features and is possibly of parasitic character, although this feature of its existence has not been incontrovertibly established. It is a starvation disease, its principal characteristic being that of malassimilation, accompanied by profound anemia. Well-marked cases are seen during long sieges, like that of Paris, in 1871, or during long imprisonment, as in Andersonville prison. It has certain points of resemblance to that condition of multiple neuritis met with in warm climates, and known usually as beriberi. The former is apparently due to the absence of a vegetable regimen, while beriberi is largely due to the absence of an animal regimen, nature having intended that man’s diet should be mixed, and having ordained that suffering and disease always follow confinement to one or the other.

Pathology.

—The pathology of scurvy is obscure. It has been shown that gastric digestion is seriously at fault, that there is much intestinal putrefaction, that the urine shows great absorption of toxins, that the hematopoietic function is incomplete: that scurvy is a toxemic or chronic ptomain poisoning, which may in part or at times be due to the use of tainted food. Morphological changes are, however, neither distinct nor pathognomonic. It has been described as a disease of diet and occupation rather than of race, age, sex, or season. The ease with which hemorrhagic effusions occur, the degeneration of muscles and other tissues, the frequent detachment of cartilages, can be accounted for by conditions thus summarized, for which, however, we have no minute explanation. Scurvy may so complicate various other diseases, and usually does when occurring in large bodies of men—as in armies, prisons, among convicts, etc.—that it is hard to dissociate morbid phenomena and assign to each its proper place.

Symptoms.

—The disease begins by a condition of generalized prostration, with an icteric tint of the skin, malaise, mental torpor, loss of appetite, insomnia, etc. The first recognizable or distinctive local appearances occur about the margins of the gums. Here, in the intervals between the teeth, the gums become livid, friable, and bleed easily, while the breath assumes a characteristic fetid odor. The skin becomes dry and brittle, and covered with minute prominences, which give it the popular name “goose-flesh.” These appearances are followed by local pains, diversified and sometimes excessive, and extravasations of blood in the skin and under the visible mucous membranes, causing small ecchymoses, which by themselves would be considered as simple purpura hæmorrhagica. These pass through the usual phases of extravasations, while it is made evident by pain, nodular masses, etc., and by postmortem examination, that similar hæmorrhages occur in the deeper tissues, especially in the muscles, even in the bones and epiphyses. So easily do hemorrhages occur in advanced stages that there is often external bleeding, particularly from the gums and mucous membranes, while from points thus involved pyogenic infection may proceed internally. Near the close the victim presents a picture apparently of an animated corpse, with surface discolored and mottled, often appearing bruised, with ulcerations where extravasations have failed to resolve, and where infection has occurred, possibly with epiphyses loosened, and necrosis of the bones of the extremities. In such cases death results from marasmus and sepsis.

Treatment.

—As long as the patient is not in the desperate condition just described the prognosis and outlook for treatment are promising, as all the milder manifestations of scurvy can be dispersed by suitable feeding and medication. Loss of teeth and cicatrices of ulcers leave permanent traces, but function can be restored. The purpura is but one expression of the scorbutic condition. Nearly all cases of scurvy will present purpuric manifestations, but all cases of purpura are not necessarily scorbutic. The course of treatment may be summed up in proper diet and in the administration of certain drugs. Proper diet should be prescribed at once, but administered, especially in severe cases, with extreme caution. The food selected should be given in small quantities, but frequently. It should consist in large measure of fresh fruits and vegetables, while cranberries and lime-juice figure largely among the former. Buttermilk is excellent, and cider may be allowed; also lemonade, with but little sugar.

PLATE XI

FIG. 1

Rickets. Rib. Very low power. (Gaylord and Aschoff.)

FIG. 2

Rickets. Flat Bone of Skull (Craniotabes). (Karg and Schmorl.)

For the local condition in the mouth an antiseptic mouth-wash containing a fair proportion of hydrogen dioxide is advisable. Alcoholic stimulants are called for, at least up to a certain point. Strychnine and cinchona preparations will give force to the heart’s action, and the horizontal position, for a time at least, will prevent sudden heart failure. Compound syrup of the hypophosphites, with meat preparations, will supply lacking material, while the hemorrhagic manifestations are best controlled by the fluid extract of ergot and aromatic sulphuric acid, separately or combined. Particular attention should be given to cleanliness and fresh air.

Infantile Scorbutus.

—Infantile scorbutus sometimes furnishes the surgeon with very young patients who are brought to him especially for disability of the limbs, with pain and fretfulness, leading to immobility, followed by enlargement of the lower ends of the femurs (due to subperiosteal hemorrhages) with fixation by muscle spasm; this may be followed by “spontaneous” fractures. The gums will show the same changes as are seen in adults, while subcutaneous hemorrhages and infiltrated muscles, with foul breath, ashen pallor, listlessness and apathy, and perhaps several swollen joints, will complete an unmistakable picture.

Fresh milk with orange-juice in small amounts between feedings, combined with more strictly surgical measures if needed, will secure good results in these little patients.

Rickets, or rachitis, is another of the diathetic conditions, in this instance not yet considered of parasitic origin, most commonly occurring in infancy and early childhood, although its resulting lesions may persist throughout life. It is characterized by nutritional disturbances and organic irregularities.

Pathology.

—Rickets is generally referred to as “fetal” or “congenital,” according to whether the infant presents characteristic markings at birth or whether they develop later. The most marked constitutional defect seems to be in the supply of calcium salts, which leads apparently to formation of bone which has not sufficient compact tissue to make it strong. Especially along the line of junction between bone and cartilage do we see the most marked expressions of rachitic lesions. Here the cartilage is evidently actively growing, while the bone formation proceeds with difficulty, and the proportion of vascular tissue is excessive. The result is prolongations of soft vascular into the cartilaginous tissue, by which the latter becomes more or less absorbed, and this essentially interferes with ossification. In severe cases it may be lacking. At epiphyseal lines one may see a layer of osteoid tissue which is not cartilage and will not become bone. Because of its yielding nature it warps under the mechanical strain to which the bones of the extremities in young children are constantly subjected.

The obscure but unmistakable relations existing between rickets and the status lymphaticus will be referred to in Chapter XIV.

The osseous lesions of rickets differ from those seen in osteomalacia, since in the latter the softened tissue is practically decalcified bone, while in the former case most of the affected tissue has never gone so far as genuine bone formation, but is arrested in its perverted state.

The result of rickety changes in the skeleton is a thickening of the shafts of the long bones, of the outer table of flat ones, of the epiphyseal extremities of shafts, and frequently a stunting of their development, so that they do not attain their normal length. The periosteum is also affected in rickets, with the result that when the changes occur, mostly subperiosteally, there are warpings and curvings of the bone shafts, while so long as the disturbance is epiphyseal more or less abrupt curvatures and angular deformities will be produced as the result of muscle action. So marked are the changes in some instances that it has been stated that bones may even lose three-fourths of their calcium salts. When rachitic bones are so soft as to be easily cut with a knife, marked deformities occur as the result of muscular activity. (See Plate XI.)

In the extremities we see bow-legs, knock-knees, clubbing of the ends of the long bones, bending of the neck of the femur, flat-foot, club-foot, etc.; while the clubbing of the bone ends also may be well marked in the bones of the upper extremity, where, however, marked deformity is less common, because the upper extremity does not bear the weight of the growing body. In the skull the bones remain soft and yielding to pressure, with a tendency to return to their original membranous condition, and this is the condition comprised under the term craniotabes rachitica. The fontanelles always remain open for an undue time; the sutures are broad and membranous. The bones of the face grow less rapidly, giving to the face a disproportionately small size; dentition is delayed and the teeth decay easily. The upper incisors often project far over the lower.

In the thorax there are enlargements of the sternal ends of the ribs, causing a row of nodules referred to as the rachitic rosary. The ribs tend to sink in, the sternum to be protruded forward, and the deformity known as pigeon-breast becomes often pronounced. Curvatures of the spinal column, especially kyphosis, are common, and distinct degrees of lateral curvature are frequently begun as rachitic deformities, to be magnified by perverted muscle action as the child grows older. In the pelvis the innominate bones approach each other, causing the pelvic cavity to become contracted, or the sacral promontory projects too far, or in various other ways the normal pelvic diameters are so far compromised that rachitic deformities of the pelvis constitute the most common and serious obstacles to normal labor in adult women, and are frequently the cause of major obstetric operations.

While the rachitic changes in the osseous system are the most distinctive and easily recognized, numerous other organs and tissues of the body are more or less seriously compromised. Ventricular dilatation, leading to chronic hydrocephalus, is one of the common results of rachitis of the skull, which may be followed by convulsions and terminate fatally. Porencephalon and cerebral sclerosis may also ensue. Disturbances of digestion are common in rickety children—the liver may decrease in size or become much enlarged; the spleen often enlarges, sometimes to enormous dimensions. In various other parts of the body there are the same expressions of malnutrition as are met with in tuberculous disease. Rickety children perspire easily, particularly at night, when the head will often be found bathed in perspiration. They are fretful and irritable, as a rule, and difficult to control. A child with protuberant belly, due to enlargement of liver and spleen, as well as to crowding of pelvic organs, with relaxation of abdominal walls, and a contracted and distorted thorax, the skull flattened on the top, clubbed bone ends, a history of resting badly at night and sweating profusely, constitute a clinical picture of rachitis so marked that it can be recognized at a glance. Between this picture in its worst forms and the slightest deviation from the ideal type there may be met all degrees in manifestations of rickets in the children of the rich or the poor, while in adults may often be seen evidences of that which prevailed during early childhood. In order that all these features may be made out the child should be stripped and examined from head to foot.

Laryngismus stridulus is a frequent accompaniment. It may be followed by general convulsions and tetany. (See Chapter XIV.) While rickets may be a very acute disease, it is as a rule chronic, and children dying essentially from this disease die rather from cerebral or other manifestations which may be regarded as in some degree accidental. Scurvy and other nutritive disturbances may be associated with rickets.

Treatment.

—The treatment for the condition consists mainly in proper nutrition. Mothers’ milk is certainly preferable to any other, and should be demanded. If feeding must be artificial, it should be in accordance with the best precepts of modern therapeutics. Cod-liver-oil emulsions are of advantage; compound syrup of the hypophosphites is a remedy of great virtue. Minute doses of phosphorus seem to be of value—1 Mg. pro die. It is a mistake to let rickety children begin to walk or even to creep too early. They should be kept upon the back in their cribs.

The modern opotherapy of rickets includes the employment of thyroid and pituitary extracts. The dose should be graduated to the age of the patient, based upon 30 Cg. for an adult, and given thrice daily. This will not preclude the necessity for a careful regulation of diet, etc., but will constitute a valuable adjunct in treatment.

The deformities due to rickets are so numerous as to constitute a large part of those to which special or orthopedic surgery is addressed. The mechanical and operative treatment of these cases will be referred to in their appropriate place.

CHAPTER XIV. THE STATUS LYMPHATICUS. — Diagnosis. — Treatment.

Under the term status lymphaticus has been described a condition which is of interest to the surgeon, as it includes not only minor complications, and even those which are serious, which follow surgical procedure, but it also has reference to the cases of sudden death during or after operation, some of which have been attributed to the anesthetic, while others have been considered absolutely unexplainable. The condition is so easily described or defined that it should be recognized during life, but it has often been discovered only after sudden death.

The essential feature of the condition is enlargement of the lymphatic tissue and apparatus, perhaps throughout the entire body, more frequently through its internal portions. It usually occurs in children. It is accompanied by much lowering of the power of resistance, and results in sudden death from cardiac failure, as the result of causes which seem disproportionately trivial; as, for instance, such deaths as occur not merely during anesthesia, but during bathing, convalescence from the exanthemas, etc. It stands in close relation to diphtheria, perhaps because of its peculiarly depressing toxins, and probably accounts for cases of sudden demise in that disease, even when mild.

The status lymphaticus is also designated by other names, as lymphatism, lymphatic constitution, and status thymicus, the latter because of the active participation of the thymus. Enlargement of this body has been noted at autopsy, but its relation to the other features of status lymphaticus were unknown until Rokitansky, in 1842, first recognized the condition in its entirety, but confused it with the tuberculosis of the lymphatics formerly called scrofula.

The death of a son of a German professor, a few years ago, shortly after an injection of antitoxin to protect him from diphtheria, and the subsequent discovery that the boy was the victim of this condition, caused a widespread interest in and a most careful study of the problems involved. They occur in the thymus more frequently than in any other organ of the body. Normally the thymus begins its involution within a few months after birth, and this process should be completed at puberty. In the status lymphaticus this involution does not occur, but enlargement persists or increases even into adult life, varying in different cases, the weight of the thymus varying from 20 to 135 grams.

While the thymus may for some purposes be grouped among the lymphatic tissues of the body, little is known as to its function. Its juice contains leukocytes, which find their way into the general circulation, and it is supposed to have an internal secretion correlated with that of other ductless glands.

Injections into dogs of thymus extract produce a fall in the blood pressure, with acceleration of the heart, and, in fatal doses, dyspnea and collapse. While enlargement of the thymus may cause death by pressure on important structures other than the trachea, it produces a type of asthma known as thymic asthma, in which death sometimes occurs unexpectedly and rapidly by strangulation.

An examination of the thymus rarely shows anything more abnormal than the enlargement of its natural structure, with perhaps acute hyperemia, while occasionally the cut surfaces will exude a milky fluid; there will be found, in addition to these changes in the thymus, a general hyperplasia of the lymphatic system, with enlargement of the superficial and deep nodes, especially the cervical and axillary, the inguinal and those in the abdomen. The spleen enlarges and the Malpighian bodies seem to be packed with lymphoid cells. There may be enlargement of the heart and increase in the thickness of the arterial walls. This is so marked that Virchow suggested the name lymphatic chlorotic constitution. It has been suggested that the narrowing of the aortic valve in these cases is due to this lymphoid infiltration.

The relations between rickets and the status lymphaticus are so frequent and so conspicuous as to make one suspect a more than casual connection between them. Nearly all cases of lymphatism show the ordinary clinical evidences of rickets. By some such relation may be explained the benefit which accrues in rickets from the administration of the extract of thymus, as well as of the thyroid and the pituitary body.

Enlargement of the lymphoid tissue in the wall of the alimentary canal also occurs, and in those rings of adenoid tissue which mark the site of the embryonic canals. This tissue may be seen around the origin of the appendix, while its most conspicuous illustrations are seen about the pharynx, where not only the faucial, but the lingual and the pharyngeal tonsils are enlarged. In many of these cases there are the so-called “adenoids” of the throat specialists, while, of still greater interest to the surgeon, the deaths that have occurred from the status lymphaticus have happened repeatedly in operations for these growths within the nasopharynx. Furthermore, the yellow marrow of the bones seems to be replaced by red marrow, but whether this is due to the anemia which always accompanies the condition is not known.

Kaposi some years ago described under the name lymphodermia perniciosa a rare condition characterized by a scaly and itching skin, exuding fluid, with later a diffuse and doughy condition of the affected parts, and then by nodules which sometimes ulcerate, lymph nodes and spleen being also enlarged, and the general health impaired. While some have held that this is a variety of mycosis fungoides, it is supposed that it is only another expression of lymphatism.

Another variety of this condition occurs in young people, in which coma comes on suddenly, followed by death in twelve to eighteen hours. Vomiting may occur during the coma, but it is convulsions and spasm of the glottis that cause the death of the patient.

Thymic asthma has been called laryngismus stridulus. Whether the latter can ever occur without the former is not definitely known, but doubtless the asthma is very frequently the cause of the obstruction and the difficulty in breathing.

Medicolegal questions arise in this connection which are of interest. Death occurs, except under anesthesia, after a series of convulsions, yet it may happen almost instantly. Some claim that death may take place as the result of pressure of an enlarged thymus upon the vessels, and especially upon the nerves, while others claim it to be due to a sudden arrest of heart action by reflex activity.

Convulsions of any character in adolescent individuals and young children should raise a suspicion of this condition, and, of greater importance for the surgeon, all possibility of existence of the condition should be eliminated before operation is undertaken. Deaths occurring during anesthesia are often attributable to the anesthetist; nevertheless there are instances where he is absolutely blameless, and where death may occur as by a flash of lightning.

It does not follow that chloroform is the agent at fault in these cases, and opinion seems to trend in the direction of ascribing the censure to the status itself rather than to the anesthetic used. Deaths may occur at any stage of anesthesia, or some minutes after the anesthetic has been stopped. It is significant that the most conspicuous illustrations of the relations between the condition and sudden death have occurred during operations upon the throat and nose. This seems to show the role played by the adenoid tissue.

Another interesting question is why individuals with well-marked status lymphaticus should live, apparently comfortable for years, and then suddenly succumb from apparently trifling causes.

The relations between the thymus and the thyroid are unmistakable, yet obscure. In perhaps one-half of the cases where the thymus is enlarged the thyroid is also increased in size. When one is removed the other seems to undergo more or less compensatory enlargement. This would seem to indicate a species of interchangeable function. Much less has been ascertained between the relations of either of these bodies and the pituitary, while nothing has as yet appeared concerning any sympathetic involvement of the coccygeal body or Luschka’s gland.

—Recognition of the status lymphaticus during life is somewhat difficult, nevertheless there are certain suggestive features which should arouse suspicion. Of these the close relation between the status lymphaticus and rickets, already alluded to, furnishes a hint, and, when recognized, a positive warning. Widespread enlargement of the lymph nodes may furnish another. Adenoid growths in the nasopharynx accompanied by enlargement of the spleen should be regarded as a suspicious combination; and when an area of dulness is discovered over the thymus, or when it can be detected by palpation, the diagnosis may be regarded as established. Moreover, children who are subject to this condition usually have a pasty complexion and an anxious facies. Besides showing evidences of rickets they are anemic, with liability to spasm of the glottis. The thyroid is often enlarged. In young adults the condition may simulate cretinism, in that they are retarded in growth and infantile in appearance, while sexual development is incomplete.

—In well-marked instances of status lymphaticus there should be ordinarily no operative intervention; yet when the nose and pharynx are obstructed it is advisable to give free channels for breathing purposes.

Assuming that the result of experimental injection of thymic juice shows it to have a depressing and pressure-lowering effect, an effort should be made to ward off danger by the use of adrenalin, which should be given previous to the commencement of the anesthesia. These are cases where it is best to treat the surfaces to be operated with a spray of mild cocaine solution, in order to deaden liability to those impressions which may produce secondary and reflex cardiac disturbances if conveyed to the brain. When operation is necessary for glottic spasm or laryngismus stridulus it may be commenced with a tracheotomy, with the use of a long trachea tube. When operation is required for the relief of thymic enlargement, a preliminary tracheotomy should be made, with the use of a long tube. The improvement which results after the completion of the surgical treatment, for instance after removing adenoids from the nasopharynx, is gratifying.

The most reliable measures have proved to be adrenalin and artificial respiration, used as described in the chapters on Blood Pressure and Shock and Anesthetics.

CHAPTER XV. SURGICAL ASPECTS AND SEQUELS OF OTHER INFECTIONS AND DISEASES. — DYSENTERY. — CHOLERA. — PNEUMONIA. — INFLUENZA, OR LA GRIPPE. — MEASLES AND SCARLATINA. — TYPHOID FEVER. — DIPHTHERIA. — MUMPS. — VARIOLA. — INFECTIOUS ENDOCARDITIS. — DENTAL CARIES. — SYPHILIS AND GONORRHEA. — THE PUERPERAL STATE.

As a result of the conditions which two centuries ago and more so distinctly separated the barber surgeon from the practitioner of medicine, there has been evolved an artificial separation of surgery from so-called internal medicine. The consequence has been a more or less deep-rooted feeling that medical cases were to be treated exclusively by non-operative measures, and that surgical cases could scarcely be expected to present any perplexities that were not to be solved by an operating surgeon. It has been no small part of the benefit resulting from modern teachings that these imaginary boundaries and limitations have been swept away; and one of the lessons which this text-book is intended to inculcate is that broad principles underlie disease conditions, and that their bearings must be appreciated thoroughly in order to practise either medicine or surgery successfully. In order better to inculcate this teaching a chapter with the above general heading has been inserted, in order to impress the statement that any of the so-called internal diseases may present at almost any time indications for distinctly surgical intervention.

Some of the surgical sequels of the exanthematous and continued fevers are well known and commonly recognized: for example, orchitis following mumps, suppurative inflammation of the middle ear after scarlatina, and bed-sores after typhus and typhoid. These are easily recognized. Moreover, scarlatiniform eruptions occasionally follow various operations and give rise to great perplexity.[4]

Joint complications in this disease have been recognized from the earliest times. One hundred and fifty years ago Strack expressed himself thus: “If the dysenteric poison affect only the chest, it causes asthma; if the limbs, it produces arthritis; if both, abscess.”

Joint pains and swellings, with other suppurations, have been noted in several of the epidemics of this disease which have ravaged various parts of the world at different times. Postdysenteric arthritis may assume noticeable and even pyemic aspects, and is occasionally fatal. The bones and joints may become involved in painful and even suppurative swellings, not alone during the active stage of the disease, but during the period of convalescence; while mildness of the primary attack does not necessarily provide immunity from later complications. Here thrombosis of large veins or thrombophlebitis are also observed. When the joints are involved it is usually in irregular order and not simultaneously. Joint lesion does not necessarily proceed to suppuration, but perhaps only to the point of edema and fluid exudation or hydrops. In the Cuban and South African campaigns, during which dysentery prevailed, joint complications were noted.

Cholera is usually too rapid and too violent in its course to be followed by secondary infections. Nevertheless, Poulet reports from Val-de-Grace several instances of articular and osseous lesions, some of these characterized by effusion of fluid which was sometimes very thick and resembled balsam, while at other times pus was present.

Pneumonia having now taken its place as a distinct germ disease, and the micrococcus of Fränkel and the capsule coccus of Friedländer being well established as the active agents in the two principal forms of this disease, pus may be found in other parts of the body. The most common surgical sequels of pneumonia occur as postpneumonic pyarthrosis, which has been wrongly considered a rheumatic affection. These lesions are of embolic or of metastatic origin.

This disease has assumed prominence in medical literature, and not a few instances have been reported of surgical sequels—abscesses, purulent ear disease, pyarthrosis, bone lesions, etc. Even necrosis has been repeatedly observed.

The infectious agent in these affections is not yet recognized and their surgical sequels should be regarded as due to secondary pyogenic infections.

Surgical tuberculosis appears often as a sequel of the exanthemas. In the lymphatics, periosteum, bones, and joint cavities, and in and about the eye and ear, manifestations of suppurative disease are often found. It is believed that these sequels are likely to appear when the eruption has been incomplete. Hyperplastic thickening of periosteum and neuralgic pains of the affected parts occur without suppuration, hence the rheumatic character which Bonnet and others have wrongly ascribed to these manifestations.

While the absence of pus takes these out of the category of pyogenic infections, it nevertheless leaves them still as surgical complications which have often to be dealt with by mechanical measures, such as orthopedic apparatus, etc.; while more or less formidable operations, as for relief of ankylosis, have to be performed. Postscarlatinal arthralgia may be explained as a local ischemia; so may acute swelling or chronic thickening. But pus is an expression of infection, and cannot be otherwise regarded. Retropharyngeal abscesses and a peculiar necrosis of the alveolar process of the jaws, described by Salter, are among the various serious surgical complications of scarlatina. Epiphyseal separations and purulent destruction of ribs have also been noted.

Although in elaborate treatises, as by Liebermeister and Murchison, there is no mention of bone and joint complications as sequels of typhoid, they have, nevertheless, been recognized by surgeons. Post-typhoid hip dislocations have been reported by several German surgeons. Boyer observed spontaneous dislocation of both thighs after what he called “essential fever,” and the general topic of spontaneous luxations subsequent to typhoid has been frequently discussed.

Those affections of joints formerly considered rheumatic occur much less often after typhoid than after dysentery. Nevertheless, post-typhoidal arthralgia and myodynia have been recognized by several French writers. Some with affected joints, supposed to be rheumatic, have later been discovered to be suffering from genuine typhoid fever, and it has been afterward recognized that the joint lesion was a bizarre expression of the typhoid poisoning. The works on general practice call attention to the frequent complications of the pleural and pericardial serous membranes in this disease. They say little, however, about the implications of the articular serous membranes, though one is as easy to explain as the other. Post-typhoidal polyarticular serous arthritis has been described by more than one writer. Multiple joint abscesses have been rarely seen. Pus has been known to collect not only in the joints, but also in the tendon sheaths and bursæ. The lymph nodes are also frequently affected, and cervical, axillary, and inguinal abscesses are not rare. Post-typhoidal pyarthrosis, as leading to spontaneous luxation, has had a medicolegal interest, for luxation has been known to occur while raising or lifting a patient, the question of violence being subsequently brought into court. When the joint disease assumes the mono-articular form it is likely to terminate in suppuration; when polyarticular, pyarthrosis is less common. In the pus from many of these abscesses typhoid bacilli may be recognized, but by no means in all. The writer has found them in a case of abscess in the abdominal wall occurring during convalescence from typhoid in a young woman. A non-suppurative but painful form of periostitis is occasionally observed. I have never seen more exquisite tenderness nor expressions of suffering than I met in a case of this kind in a boy in whom the bones of both lower extremities, of the pelvis, and the lower spine were involved. The slightest jar upon the floor would make him exclaim with pain, and to minister to his ordinary wants was a distressing task. He eventually recovered without any pus formation. Deep suppuration in bones occasionally occurs, and even necrosis with separation of sequestra.

Thrombosis and thrombophlebitis are also well-known sequels of typhoid, which may lead to unpleasant complications. Typhoid fever appears to bear a peculiar relation to the growth of bones, as it has been noticed that during its course, or during convalescence, they show an extraordinarily rapid growth in length, even to the extent of 1 Mm. a day. This is probably caused by the irritation of the typhoid toxin upon the osteogenic tissue, since hyperemic areas have been found in the bone-marrow of those dying of the disease, and bone pains are a frequent accompaniment of the disease. Typhoid bacilli have the power of remaining latent in the tissues for a long time after cessation of active symptoms, and have been found alive and capable of active growth seven months after cessation of the fever. Remembering the multiple ulcers of the lymphoid tissue which characterize the intestinal lesions of typhoid, it is difficult to explain pyogenic or other septic infection by absorption through these open ports of entry; and the typhoid bacilli themselves, entering the circulation through these paths, may be carried to all parts of the body, and have been found in the pia.

A large amount of interest has attached to the so-called “surgery of typhoid fever,” which, however, has been permitted to include only abdominal section for perforation of intestinal ulcers. The mortality due to this accident is nearly 70 per cent.—i. e., is formidable. It occurs generally during the third week. It is usually preceded by leukocytosis, and is followed by profound shock. Operation offers almost the only hope. It has been successful in about one out of five cases. (See Surgery of the Intestines.)

Post-typhoidal infections of the biliary and pancreatic ducts, with their resulting complications, play a conspicuous part in the etiology of biliary obstruction. They are regarded as among the most common causes of acute and chronic or latent disease in these passages.

This also belongs to the diseases frequently complicated by lesions, aside from those of laryngeal obstruction calling for surgical relief. Abscess occurs so frequently as to scarcely call for comment. Here, as in the cases of scarlatina, the location of the throat lesions and the absorbing powers of the lymphadenoid tissue so completely involved will readily account for all septic or pyogenic manifestations at a distance. Multiple abscesses have been found in the liver, the spleen, and lungs, in and around bones, betokening thereby a pyemic manifestation. Infectious nephritis is also common.

Mann, of Denver, has communicated to me personally cases of embolus of the femoral artery with resulting gangrene as sequels of diphtheria, as well as instances of true diphtheria of the penis, established by bacteriological diagnosis.

The infectious character of this disease is not questioned, although not definitely established. Orchitis, ovaritis, stomatitis, enlargement of the tonsils and spleen, and albuminuria are frequent accompaniments of the disease, while articular and peri-articular complications have been noted. Bursal abscesses and pyarthroses have also been reported. These surgical complications have been regarded as rheumatoid or rheumatic, their essential significance not being recognized until recently.

The writers of the earlier part of this century allude frequently to the rheumatoid complications of smallpox, among which pyarthrosis seemed the most common and most serious. The various arthropathies are the most interesting of the surgical complications of this disease. The joints become swollen, red, and painful, one joint after another being involved.

The individuality of this condition has been recognized only within the last thirty years. That it deserves the characterization of “malignant” often given to it is well known. It is an infectious disease with a special localization in the heart, the term cardiac typhus being very expressive. Although so apparently spontaneous, it is usually a secondary lesion, sometimes a primary infection. The arthritic manifestations often assume a pyemic character, and even at the beginning of the affection, as Trousseau pointed out, there are frequently severe joint pains.

Nearly one hundred species of microörganisms from the mouth have been studied and identified by W. D. Miller, who has clearly established that dental caries is due to the specific action of some of these parasites, which, gaining entrance into the dental tubules, determine fermentation and acid production, with erosion of the dental structure of the teeth and an increase in softening and destruction. In this way the teeth, as already indicated in Chapter IV, become paths of infection for germs which may travel but a short distance, causing only local disturbance, or which may be carried to other points about the head, producing disturbance in the antrum, in the neighboring bones, in the middle ear, and not infrequently in the brain. Abscess in the brain has been distinctly traced to caries of the teeth. Tuberculous infection is also common through this channel, and its most common expression is probably the invasion of the cervical lymphatics, superficial and deep, constituting those lymphatic tumors of the neck, formerly known as scrofulous, with their disastrous train of adhesions, suppuration, erosion, etc.

These are surgical affections whose secondary complications in the way of abscesses, infarcts, tumors, etc., have been dealt with in other parts of this work. It will be well to group all of these infections with anthrax, glanders, etc., into a class of infections which may be followed by tardy or late surgical sequels that may call for more or less radical operation. In the case of gonorrhea this is best seen, perhaps, in the so-called pus tubes of the female pelvis, which often require removal years after the date of the primary invasion.

Endocarditis and pyemia are occasionally of solely gonorrheal origin, as well as peritonitis by extension from infected pelvic viscera.

This is seldom followed by surgical sequels, save in the instance of mechanical lacerations demanding plastic repair, or of septic infections, which, when life is saved, sometimes lead to disastrous consequences. Puerperal septicemia is in no respect different, pathologically speaking, from septicemia due to any other presumably streptococcus invasion; and the predilection which streptococci manifest for serous membranes, and especially joints, is well known. Consequently after puerperal fever one may meet with articular or peri-articular abscesses, affections of tendon sheaths, lymphatics, etc., or the complication may assume a different type, the veins and their contents being mainly involved, with thrombosis, infarct, etc., for its immediate results.

There is probably no disease of known or suspected germ origin which may not be followed by disastrous or unexpected surgical complications, while even degenerative changes, for which as yet no theory of parasitism has been invoked, are followed by conditions which may call for serious surgical measures. In other words, the surgical complications of any so-called non-surgical disease may loom up at any moment in any case.

CHAPTER XVI. POISONING BY ANIMALS AND PLANTS. — SNAKE BITES. — POISONING BY LIZARDS. — POISONING BY SPIDERS AND SCORPIONS. — POISONING BY WASPS, HORNETS, AND BEES. — ARROW POISON. — IVY POISONING.

Certain poisons or deleterious substances are introduced in various ways into the human system from without, some of which produce only symptoms of moderate intensity, while others are fatal. It is authentically stated that in India many thousands of individuals lose their lives every year as the result of the bites of poisonous snakes. In 1903 there were officially reported 23,164 deaths from this cause. Nothing approaching such injuries in frequency or intensity can be found in any other part of the world. Animal poisons may be introduced by animals of many species. The poison of hydrophobia has been described. The bites of the mammalia may be serious and may be followed by septic symptoms, but are not ordinarily regarded as due to any special toxin secreted by the animal. A number of reptiles, however, possess special poison glands which are connected, in most of them, with a tooth on either side of the upper jaw which is canaliculated, and serves as a duct through which the poison is injected when the animal inflicts its bite.

The principal poisonous serpents in North America are the rattlesnakes—of which there are several species, usually placed at eighteen—the copperheads, the moccasins, and the vipers. Some of these have movable poison fangs, some fixed. In other parts of the world others equally or even more poisonous are known.

The poison gland is analogous to the parotid in location and structure. The duct which runs through it is so dilated as to contain a small amount of the peculiar poison. The amount of poison contained in these reservoirs varies from eight to twelve minims, and is secreted somewhat slowly. It seems to be, in some cases at least, a glucoside; in others, a toxalbumin. It is capable of being preserved either dry or in alcohol or in glycerin. The active poisonous principle seems to pertain to a globulin or to a peptone. Almost all of these venoms are innocuous if swallowed, and like septic infections seem inoculable only through the tissues and the circulating fluids. According to Mitchell, the venom of the rattlesnake renders the blood incoagulable, paralyzes the walls of the capillaries, and facilitates escape of leukocytes into the tissues, thus making actual hemorrhagic swelling occur; while the red corpuscles rapidly lose shape and fuse into irregular masses and their hemoglobin is dissolved or disappears. This poison seems to paralyze both the respiratory centre and the heart. Cobra poison, not containing globulin, at least to a great extent, does not produce the rapid changes of rattlesnake poison.

Symptoms.

—A snake bite is like a hypodermic injection of a deadly poison, and symptoms set in promptly. These are both local and general. There is more or less local pain, with swelling and discoloration, which are due to effusion of blood. They increase in intensity, and are followed by vesication and necrosis of tissues—that is, gangrene—if the patient survive for some time. Constitutional symptoms are not long delayed, and are characterized by severe prostration, including cold, clammy sweat; feeble and rapid pulse, irregular respiration, etc. When patients succumb they usually die in collapse. The pathological changes are not well-marked or characteristic.

Treatment.

—Treatment of snake bite must be prompt if it is to be successful. It should consist of incision and drainage of blood from the part, in order to prevent diffusion into the rest of the body by means of the returning blood and lymph. Bleeding should be facilitated by cups or by sucking the wound. An elastic tourniquet should be applied around the limb near the trunk, the site of the wound freely incised, and the blood worked both ways toward the wound by “stripping” the member. If there be any known antidote to snake poison it consists of potassium permanganate or calcium hypochlorite (chloride of lime), applied locally in solution, the former sufficiently strong to have a marked color and capable of producing local irritation (1 per cent.). With these local measures, constitutional stimulation should be indulged by means of volatile and other stimulants. There is a popular fallacy in favor of inducing alcoholic intoxication. To do this is a mistake. Nevertheless, alcohol may be given freely, dosage being limited not by amount but by effect. Strychnine, digitalis, atropine, etc., will often prove serviceable. The tourniquet should be gradually released after being in use for two or three hours, and an assistant ready to antidote the poison which may then enter the system with the necessary doses of stimulants above mentioned. One-half grain of strychnine may be administered in divided doses, it apparently being an antidote to the snake venom. There is much reason from recent experimentation to expect benefit from serum therapy—i. e., by injection of serum from immunized animals who have been fortified by increasing doses of the snake poison. Calmette advises the use of 20 Cc. of serum from a horse which has been immunized by cobra poison. He believes the active poison of all venomous serpents to be essentially identical. Good results have been reported even after an interval of an hour. In this country, however, such treatment will be called for so seldom that there is not the hopeful outlook for the serum therapy of snake bite that there is in India.

A large lizard found in the southwestern part of this country and in Northern Mexico, known as the Gila Monster (Heloderma suspectum), is credited with being a poisonous animal. The probability is that the bite is fatal to some of the lower animals and may produce more or less serious disturbances in man. Nevertheless there is little real evidence that this is to be considered in the same category with the venomous serpents above mentioned.

Certain species of spiders are venomous, the tarantula being the best known. Certain scorpions also inflict poisonous stings, and centipedes and other animals occasion at least serious local disturbance by bites or stings. These insects and animals seldom attack unless irritated or disturbed. Tarantula bites are occasionally inflicted in the Northern States by spiders which have concealed themselves in shipments of fruit, bunches of bananas being especially likely to be their hiding places. The injuries inflicted by these animal organisms cause local pain, considerable swelling, with remote effects on the nervous system, prostration, restlessness, etc. They are seldom fatal, but may cause annoyance and serious disturbance. These cases are to be treated in the same way as bites of poisonous serpents, adapting the measures and the energy of the treatment to the severity of the symptoms.

Wasps, hornets, and bees are capable of inflicting severe stings; domestic insects, like mosquitoes, bed-bugs, etc., inflict minute wounds which sometimes occasion excessive annoyance. Their sting is followed by pain, burning sensation, sometimes intense itching, and more or less swelling. Enough poison is deposited to produce local vasomotor paralysis, as the result of which wheals resembling those of urticaria, or more extensive swellings, quickly result. If the sting of an insect has been broken off in the flesh it may remain and intensify the disturbance. Two or three injuries of this kind create local disturbance, but there are some instances on record where men and animals have been stung to death when attacked by swarms of these insects, death apparently being due to intensification of effect owing to increased dosage of poison. If a sting occur upon loose tissues, like the eyelid, or upon the tongue or lips, swelling and suffering may be extreme. If symptoms of depression present, they should be combated by stimulants, diffusible or other, and by hypodermic medication pro re nata. Local discomfort may be alleviated by ice, by menthol, by chloral camphor, etc.[5]

Many of the lower forms of marine animals are capable of inflicting stings by their rays, or minute injuries in other ways, which give rise to great temporary annoyance. The stinging nettle, etc., is an instance of this kind. The lesions produced in this way partake of the nature of a more or less acute dermatitis.

The arrow poison of various Indian and savage tribes is a composition of variable and usually unknown nature. It is compounded, for the most part, from vegetable substances, and, if one may judge from the specimens of curare sold by importing houses, their strength is unreliable.

While some of these preparations are made by the natives from a species of Strychnos growing in the northern part of South America, this tree is not in universal use for this purpose: in the East Indies they are made from a species of Upas (the deadly Upas of song and story). Some of the poisoned arrows are dipped in putrefying blood. A wound made by these is not necessarily promptly fatal, but would tend to kill by setting up septic disturbance. The vegetable poisons have the property of paralyzing the motor nerves and the circulation to such an extent that death may occur within a few moments after injury. All of these poisons are innocuous when swallowed, and game killed by their agency may be eaten without fear of ill results. Arrow poison of the vegetable variety which is not fatal within a few hours may be recovered from if stimulation be vigorous. Artificial respiration is a factor in keeping such patients alive.

In the vegetable kingdom there is one kind of plant, the so-called poison ivy (Rhus toxicodendron), which is capable of producing intense dermatitis. All persons are not susceptible to this poison—least so those of thick skin and dark hair. It is generally those of blonde type and thin skin who seem most liable to its irritation.

The active agent is toxicodendric acid, and it is capable of setting up an intense irritation of the eczematous type, with a large amount of hyperemia and edema, especially of soft tissues. When the face is involved the eyelids become puffed so as to make it almost impossible to separate them for purposes of vision. Ivy poisoning is usually contracted by contact with the plant. Symptoms supervene generally within twenty-four hours, and in well-marked cases do not subside for three or four days. The itching is intolerable, and is best combated by strong alkaline solutions or brine. A dilute bromine solution sometimes proves beneficial. Salt and soda in strong solution and vigorous catharsis are also useful. Hypodermic injections may be necessary to induce sleep.

Certain species of sumach, particularly the genus Cypripedium, may produce similar symptoms, usually less severe.

CHAPTER XVII. ACUTE INTOXICATIONS, INCLUDING DELIRIUM TREMENS. — DELIRIUM TREMENS. — TRAUMATIC OR POSTOPERATIVE MANIA. — TOXIC ANTISEPTICS.

Delirium tremens as an expression of acute or subacute alcoholic poisoning is in no essential degree a surgical condition. This form of toxic delirium may occur while the individual is still drinking inordinately, or not until several days have elapsed after active drinking has ceased. It is precipitated in many cases, where otherwise it would simply remain imminent, by surgical injuries and operations. In one in whom it is feared, the surgeon should become apprehensive in proportion as the muscular system becomes unsteady and tremulous, the mind disturbed, and the individual sleepless.

Patients in a well-marked condition of delirium tremens may become so uncontrollable and so lost to sensation of pain that it may be practically impossible to enforce the physiological rest which their surgical condition demands. The restraining sheet will answer for general purposes, but the strait-jacket and even the most carefully applied plaster splint or mechanical restraint will not always be sufficient to carry out the indication.

Ingenuity may be taxed beyond its limit to enforce the needed rest, for patients will tear off bandages and injure themselves in various ways.

Treatment.

—The local indications are in the direction of physiological rest. Constitutionally the indications are in two directions: First, to keep up nutrition and excretion; secondly, to properly medicate. Nutrition is difficult unless excretion is maintained. Hot-air baths, laxative enemas, preferably of cold water, when necessary, and administration of a fluid and easily assimilable diet are measures of the utmost importance. Should the case present features of an acute alcoholic gastritis, stomach feeding may be abandoned and the rectum utilized for this purpose. Medication should consist mostly of stimulants, with such sedatives, laxatives, diuretics, etc., as may be necessary. In surgical cases it is not wise to abruptly deprive these patients of the alcohol which they have so abused. Consequently in many instances a mild degree of alcoholic stimulation, at least for a time, should be continued. Two stimulants rank higher than all others as substitutes for alcohol, and in some degree antidotes to its effect. These are strychnine and digitalis. The former should be given preferably subcutaneously; the latter by the stomach if tolerated, otherwise by the rectum or beneath the skin. My own preference for the use of digitalis is in the direction of large and few doses. I have not hesitated in many instances to give 15 Cc. of ordinary tincture, repeated once or twice at intervals of a few hours, and then to discontinue it. The effect is to brace up the heart and to equalize the circulation, while at the same time it acts as an efficient diuretic. Adrenalin may be necessary, but should be used with discrimination.

Of the sedatives, bromides, chloral, and remedies of that class are those most often resorted to, and should be given in doses sufficient to meet the symptoms. They are all more or less depressant, and stimulation by strychnine, etc., is necessary even while they are being administered, in spite of the apparent physiological antagonism between them. Opium is the remedy of choice, and is best given in the form of morphine introduced beneath the skin.

The first indication is in the direction of ensuring rest and sleep, even at the expense of inconvenience or misfortune in other directions. I write this with a realizing sense of its significance, yet with positive conviction as to its truth.

Upon the assumption that this form of delirium is a toxemia of complicated type, only benefit can accrue, in aggravated cases, from a free venesection, followed by intravenous infusion of a pint or more of saline solution, at a temperature of 105° F.

It is difficult to distinguish this form of mania from that known as puerperal mania, the two conditions being essentially similar. This, too, is to be regarded as a complicated toxemia, in which products of defective metabolism, of insufficient elimination, and of phagocytic activity mingle in a blood whose corpuscular elements are already much disturbed by injury or hemorrhage. Regarding these cases from a surgeon’s standpoint, and carefully avoiding any attempt at minute explanation of the phenomena, such cases are met with in the practice of operating surgeons, as in the experience of obstetricians, presenting themselves either as mild forms of harmless mental aberration, or assuming almost any of the types of insanity as made out and classified by experts in that subject. From the mildest mental alienation up to intense and even homicidal or suicidal mania, one may meet with all degrees of departure from the normal standard. Bowel washing, hot-air baths, hepatic stimulants, and carefully regulated nutrition will usually restore to the brain its natural food supply, and hence its normal function. I have repeatedly seen much good result from the exhibition of small doses (0.30 to 0.50) of potassium iodide.

As stated above, it is generally recognized that in people of peculiar idiosyncrasies the administration of certain drugs ordinarily considered harmless is followed by more or less toxic symptoms. Obviously if this were universally the case, or true in the majority of instances, the use of these drugs would speedily be abandoned. As it is, it is well to have in mind the consequences which are occasionally known to ensue, and perhaps to weigh in every case the chances as to whether it is worth while to use a given substance of known occasional toxic power as against another which is not known to possess it.

Of the less active antiseptic agents, boric acid is considered absolutely innocuous, yet is known sometimes to cause intestinal disturbance, while in one instance serious toxic effects followed its use. Naphthalin will sometimes produce vertigo or vasomotor symptoms, especially when administered internally. Many of the antiseptic materials used are more or less irritating to the skin, and such local expressions as eczema, etc., provoke little comment.

Iodine is a drug whose activity should be borne in mind. Applied upon the surface, it tans the skin and does no good. Injected in solutions of varying strength into serous cavities (for example, hydroceles, etc.) it gives rise to symptoms which may be alarming. Fatal poisoning following its injection into an ovarian cyst has been reported, and alarming symptoms have been produced by injection of the ordinary solution into a hydrocele sac. Much of the virtue ascribed to iodoform is credited to the liberation of free iodine by its decomposition. Whether or not this be true, iodoform is one of the most frequently toxic of the antiseptic agents in ordinary use. In mild cases it produces headache, restlessness, wakefulness, and often a distinct taste of iodoform in the mouth. In more pronounced degrees of poisoning there is fever, often with mental derangement which may amount to delirium or even to acute mania, and may cause well-founded suspicion of meningitis. Death after its use has repeatedly occurred from syncope or in coma.

Carbolic acid produces unpleasant effects, both upon patient and operator, or with whoever it may come in contact. Aside from its local effect upon the skin, which is most unpleasant, but which usually passes away within a few hours, it seems to affect especially the kidneys, causing often temporary albuminuria with discolored urine, deranged secretion, and sometimes more acute forms of disturbance, similar to those met with after its internal use. Carbolic poisoning was observed most frequently during the era when Lister’s original directions were scrupulously followed, and at a time before it was learned that it is much better to remove dirt than to try to antagonize its action. Eminent surgeons were compelled to discontinue its use because of its unpleasant effect upon themselves as well as upon their patients.

Among the powerful antiseptic agents in common use are the soluble preparations of mercury, ordinarily corrosive sublimate, in solutions of varying strength, which are used for irrigation, douching, etc., and for preparation of dressings. An intense eczema may follow its local use, and symptoms of mercurial poisoning may appear in individuals of peculiar susceptibility to this drug. Salivation, intestinal irritation, and other phenomena of mercurial poisoning have been produced, with the result that the solutions and preparations of corrosive sublimate are much weaker than those which were used at first. The drug eczema produced by corrosive sublimate interferes with one of the essentials of ideal wound healing—i. e., physiological rest. The area involved should be protected with a sterilized powder or by anointing it with sterilized ointment.

PART III. SURGICAL PRINCIPLES, METHODS AND MINOR PROCEDURES. — CHAPTER XVIII. DISTURBANCES OF BLOOD PRESSURE; SHOCK AND COLLAPSE. — Symptoms. — Diagnosis. — Treatment.

The maintenance of the normal pressure of the blood is a material factor in the welfare of surgical cases. Deviations in the direction of lowered pressure constitute the most important features of shock and collapse. Prevention of loss of blood is but one of several complex indications in prophylaxis and after-treatment.

Blood pressure is maintained in large part by the vasomotor system of nerves, whose prime centre is in the gray matter of the fourth ventricle, with subsidiary centres in the spinal cord and great ganglia. Stimulation of these centres causes contraction of the peripheral arterioles and increases intravascular pressure. If, however, it be long-continued or excessive, these centres become exhausted, vasomotor paralysis results, the arterioles dilate, and pressure is lowered.

Three factors coöperate to maintain this pressure:

• 1. Regular and normal rhythmic heart action;
• 2. Normal vascular contractility;
• 3. Normal quantity of suitable fluid in the vascular system.

Departure from the normal in any one of these factors causes perceptible disturbance, but when in all three of them it may prove fatal. Whether this be caused by emotion, accidental injury, or deliberate operation is of slight concern, as the effect is essentially the same.

The pulse will usually tell its own story to the experienced observer, but scientific accuracy in measuring blood pressure can only be obtained by certain instruments of precision, such as the tonometer or the sphygmomanometer, consisting of an air-containing armlet which encircles the arm, a bulb by which the pressure of air can be regulated, and the whole connected with a manometric gauge and mercury tube. These instruments can be procured of the dealers, and their employment during an operation gives the operator a continuous record of the blood pressure, by which he may judge at any moment of the degree of shock.

The normal blood pressure in healthy adults is 130 to 140 Mm. of mercury in the tube. In children it ranges from 90 to 110 Mm. Females have an average lower pressure of 10 Mm.

Excitement or slight stimuli will send the pressure up thirty or forty points. It is also higher than the above average in arteriosclerosis. In uremia it is always high. In cases of intracranial tension it is also high, as the brain alone of all the organs of the body has no complete vasomotor apparatus of its own; when it needs more blood this has to be contributed from the general supply. When pressed upon by a clot, depressed bone, or foreign body it becomes anemic, and on effort to furnish the needed blood from other parts the vascular tonus is increased. Cushing has shown the value of these estimations in cases of head injury, for the rise of blood pressure may be regarded as an indication for operation. In typhoid fever a sudden rise of pressure is associated with perforation, or perhaps with the peritonitis which is its immediate result. On the other hand, in this disease a sudden fall of pressure is an indication of hemorrhage.

The course of events in surgical shock is about as follows: Injury to afferent sensory nerves acts as a vasomotor stimulus after it reaches the centre in the fourth ventricle; a reflex impulse is then sent out which produces arterial contraction and raises the blood pressure. When the abdomen is concerned the opening and handling of its contents produce the same result through the splanchnic centres. If, however, the stimulus is excessive, too often repeated, or too prolonged the vasomotor grip is lost, the arterioles dilate, and the blood pressure is reduced. A severe injury to any part of the body may produce this effect without the preliminary rise. The popular impression that a patient “bleeds to death into his own veins” has this to justify itself, that the arterial tonus is lost and the blood is pumped through the arterioles to accumulate in the capillaries and veins, especially the abdominal, thus overloading the right side of the heart and giving it a disproportionate amount of work.

Accompanying these circulatory disturbances are others, secondary and unavoidable, as of respiration, which becomes rapid and enfeebled in proportion to the degree of shock.

Any factor which tends to weaken the heart’s force favors both phenomena. So important is the respiratory action that patients die from cessation of respiration rather than from impairment of the circulation. This shows the importance of maintaining artificial respiration in cases of severe shock.

Cushing and Crile have studied the subject exhaustively in animals. They have shown that certain injuries are likely to be followed by well-marked reduction of blood pressure; for example, those of the brain, the interior of the larynx, the abdomen and testicle, are often followed by a marked reduction of pressure without any preliminary rise. In other words, vasomotor paralysis is sometimes an almost instantaneous effect of certain injuries. When most of the blood is collected in the venous system and the central nervous system fails, because of lack of blood supply, to respond to those normal stimuli which are essential to heart action and respiration, the heart weakness or heart failure is due, not alone to failure of its innervation, but to its reduced output and its diminished content of blood on the left side.

Crile has shown that the more abundant the blood supply to a given part the more it contributes to production of shock; hence, the value of cocainizing the interior of the larynx and the nerve trunks.

Aside from emotional causes—which are sometimes inseparable from even surgical cases—the principal agencies in the production of surgical shock and collapse are those which make a sudden and deep impression through the medium of the sensory nerves upon the central nervous system or the large sympathetic ganglia; ultimately upon the latter in all serious cases. Loss of blood, then, need not play a very important role.

Weakened, anemic, or neurotic patients are predisposed by virtue of these conditions, and also the young and aged. Fright combined with injury increases the degree of the effect. Crile has shown that trifling lesions of the interior of the larynx will cause symptoms which do not occur in animals if the superior laryngeal nerves be divided or if the parts be cocainized.

The upper portions of the abdomen are more sensitive in this respect than are the lower, testicles particularly. The skin is more impressible than the muscles or tissues beneath, save the nerve trunks, which are very sensitive; the bones and large joints slightly so. After shock has been once produced further injury causes a disproportionate lowering of blood pressure.

So-called “concussion of the brain” is essentially a condition of shock following injury to this particular part of the body. (See Head Injuries.)

Shock and hemorrhage are often closely associated, and loss of blood is doubtless a powerful factor in the production of the former, especially in those already reduced or whose blood contains a lowered percentage of hemoglobin. There are, therefore, great advantages in entrusting an assistant with the duty of watching blood pressure during serious operations.

The terms shock and collapse are nearly interchangeable, but, by common consent, the latter is usually the name given to conditions that are more sudden and overwhelming. Shock may be of all degrees—from temporary faintness, from which the patient recovers within a few moments, up to a condition of vital depression which terminates fatally, there being no reaction in spite of all efforts to produce it.

—These vary to a considerable extent according as the patient is or is not under a general anesthetic. The description of types and symptoms includes an expressionless face, pallor of the skin and mucous membranes, with corresponding coldness of the same, i. e., reduction of surface circulation and heat; dilated pupils, reacting slowly to light; irregularity of the heart’s action, with a weak, irregular, thready, or almost imperceptible pulse; irregular respiration, i. e., irregular both in rate and depth; mental inactivity and apathy; loss of voluntary muscle movement; impairment of superficial sensibility; reduction of body temperature; and nausea or actual vomiting. These at least constitute the symptoms and form the apathetic or torpid type of shock.

In the so-called erethistic type (Travers) the patients are restless and excited, uncontrollable, with irregular pulse and breathing, often with dilated pupils.

In a third type, described by Travers as the delayed, the symptoms are as above detailed, but do not appear until some hours after the cause which has produced them, which may be a concealed (internal) hemorrhage. The delayed type is also seen in those who escape serious accident with a minimum of physical harm.

As shock becomes more pronounced, mental depression deepens into coma, or mental excitement subsides into it; the surface becomes colder and bathed with perspiration, and death follows. These symptoms are those generally noted, whether following injury to the head and denoting so-called concussion of the brain, loss of blood, wound of the abdomen with injury to the viscera, blows upon the testicles, gunshot wounds or other accidents which are causes of shock. They follow also after perforation of the bowel, as in typhoid fever or appendicitis; depression following the receipt of bad news, or fright, etc.; in other words, the physical condition is practically the same no matter what the exciting cause.

—Shock is mainly to be diagnosticated from fat embolism; concealed hemorrhage as well as pulmonary edema and suppression of urine are to be suspected. It is unquestionable that many patients have died of fat embolism in whom the actual cause of death has not been ascertained, yet has been ascribed to shock. (See Fat Embolism, Chapter II.)

—The treatment of shock consists essentially in measures directed toward raising the lowered blood pressure. At the outset reaction should not be established too quickly, lest it be succeeded by overaction, with attendant disasters in the shape of secondary hemorrhage, etc. Patients should not be expected to swallow nor act as they would under other circumstances. They should not drink strong liquors, for the irritating fluid may escape into the larynx and induce coughing, which might prove fatal. The same is true of inhalations of strong volatile stimulants, like ammonia. These measures, therefore, should all be resorted to with great care and discretion. Warm, stimulating drinks, if they can be swallowed, are useful; and whisky, brandy, etc., should be given dilute and warm rather than strong and cold. External heat is advisable, and can be supplied by immersing the patient in a bath-tub of warm water, care being taken to keep the face out of the water. When this is not at hand, bottles and other receptacles for warm water may be used, but with caution, since too much heat has been the cause of serious burns.

Numerous drugs have been recommended in the treatment of shock. There are but two or three which are worthy of confidence. Crile, of Cleveland, subjected a large number of animals to tests in regard to the effect of various drugs in influencing blood pressure. He found, for example, that alcohol apparently produces more depression, and in deep shock is dangerous. Nitroglycerin and amyl nitrite seem to increase shock and lower pressure. Digitalis may produce a temporary rise in pressure, but in considerable doses impairs or arrests respiration, and it seemed to him that cases of severe shock treated with it did not live as long as the control animals. Strychnine has been one of the main reliances in these conditions. Crile found that if enough were given to cause increased excitability of the spinal cord it raised the blood pressure, while small doses had little or no effect. Pressure was raised by doses large enough to produce convulsions; repeated smaller doses had little effect, tending rather to increase shock.

These were the experimental results in the treatment of shock, and are to be distinguished from what may be done with the same drugs in the way of fortification and preparation as against shock. Thus strychnine always exalts susceptibility of the cord of the medulla and digitalis may temporarily supplement its use; together they may help to sustain pressure or to fortify as against depressing agencies. They are like whip or spur to a jaded horse.

Morphine alone, or in combination with ether as a general anesthetic, reduces susceptibility to shock, and appears to be an equalizer of pressure and a tranquillizer of an excited heart. Nitroglycerin and the nitrites usually fail to raise or even sustain pressure. Saline infusion and adrenalin are the reliable and efficient means to be used in combating shock and collapse; they always raise blood pressure, and the latter is the most powerful of all known vasomotor constrictors. Adrenalin always produces rise of blood pressure, even after cocainization of the medulla and cord or destruction of the medulla, division of the splanchnics, or arrest of the heart by powerful electrical currents (2300 volts, alternating). Even after death by decapitation and an interval of fifteen minutes, adrenalin salt solution thrown into the veins causes a rise of blood pressure. If this be combined with artificial respiration and rhythmic pressure over the heart, resuscitation is possible in most extreme cases. In one case, reported by Crile, a human heart which had stopped beating for nine minutes was made to resume its pulsation for thirty-two minutes. From all this it will appear that the heart stimulants, so called, have a very limited applicability.

Crile further experimented by raising the atmospheric pressure surrounding the animal, and found that blood pressure was somewhat exalted. The reverse was also found to be true. When he so arranged his experiment that an animal inhaled air under increased pressure he found the tendency was rather to impairment of heart action, blocking the circulation and reducing pressure. Changing the experiment and causing the animal to breathe air at normal pressure while the body was under increased atmospheric pressure, blood pressure was notably raised, but respiration became labored and the heart’s action impaired. After death the heart and the pulmonary vessels were found engorged.

This has its practical interest because it concerns not alone the general treatment of shock, but the management of those cases where the thorax must be opened, as in the surgery of the heart, the lungs, the esophagus, etc., and the mechanical devices recently suggested for maintaining differences of atmospheric pressure, and preventing a traumatic collapse of the lungs.

These experiments also suggested the so-called “pneumatic suit” devised by Dr. Crile, which is in effect a double-layered garment of rubber cloth. The patient is enveloped in the suit, which can be inflated with an ordinary bicycle pump, so that pressure is made upon the surface of the body, and at the same time evenly distributed. By such pressure accumulation of blood in the venous reservoirs is prevented, and the emptying of the arteries, especially those in the brain, is prevented. This is a more perfect and ideal application of the idea underlying the practice of bandaging the extremities or raising them, in extreme conditions of shock; the former requires an elaborate and expensive outfit, while for the latter purpose cotton bandages or rubber may suffice. The latter, however, must be used with great caution lest pressure be overdone. When the bandages are removed they should be taken off slowly, and from one limb at a time, lest the change be too abrupt.

Two other expedients are of the greatest value in conditions of this kind; the first is artificial respiration. This cannot be carried out, as is done on experimental animals, in a well-furnished laboratory, by opening the trachea and making connection with a pump; it must be effected by the usual methods, coupled with the aid afforded by the improved Fell apparatus. If oxygen can be administered at the same time it will enhance the effect.

The second expedient is rhythmic pressure made over the lower part of the thorax, or beneath the ribs, by which is produced a stimulus to contraction of the heart. This may be made slowly at first, but may approximate a rate corresponding to a slow pulse.

The temptation is to use the adrenalin solution too strong or in too large doses. It may be administered in doses of 4 or 5 minims in a small syringeful of salt solution, but when the symptoms are profound and the case urgent, 300 to 500 Cc. of sterilized salt solution, containing the same amount, should be injected beneath the skin into the subcutaneous cellular tissue about the shoulder-blade, the buttock, behind the breast, or into a convenient vein. Much larger amounts, even up to 1000 Cc., may be used, but the adrenalin should never be mixed until just before using it, as it is quickly oxidized and changed, and should be used in the freshest possible condition. With salt solution containing 1 to 50,000 of adrenalin and continuously administered, Crile has kept a decapitated dog alive for over ten hours—that is, the heart continued its action. One may agree with him, then, in the statement that “control of blood pressure is the control of life itself.”

Mathews, after a careful study of the osmotic behavior of blood plasma and saline solutions, has shown that the ordinary salt solution, which has been usually made in proportion of 6 to 1000, is not the best which can be used for purposes of saline infusion. Many observers have added potassium and calcium salts to such a mixture, the latter, especially, because of its property of increasing the coagulability of the blood.

The following mixture meets the indications for what may be called the “balanced” physiological solution: Sodium chloride 0.9, potassium chloride 0.03, calcium chloride 0.02, water 100.[6]

It must not be forgotten that indiscriminate resort to intravenous infusion may do great harm. It is a minor procedure which requires skill. When the lungs are congested from the irritating effect of ether, and the right heart is embarrassed, a too sudden flushing with saline solution may further embarrass it or even check its activity. So with a patient in the Trendelenburg posture, the intestines are crowded up against the diaphragm and its natural downward play impeded, though the brain is better supplied with blood in this than in any other position.

Much may be done in the way of prevention when shock can be foreseen. This includes the general fortification of the patient by overcoming any auto-intoxication which may have been previously noticed, by improving elimination, and by stimulating the heart’s action with strychnine, digitalis, cactus, etc. Atropine is especially a stimulant to the respiratory centres.

Once the operation is begun, and remembering that the depressing influences which tend to reduce blood pressure are transmitted through the afferent nerves, we may take advantage of Crile’s suggestions and temporarily paralyze them, by exposing them and injecting directly into the nerve trunks two or three drops of 1 per cent. cocaine solution. This should be done before division of the main trunks and at a point above the line of section. It is possible during an amputation, by taking a little extra time and pains, to “block off,” as it is called, the nerves in this way and prevent their conveying any depressing sensation. At other times, as in operations on the mouth, and especially the larynx, cocaine solution may be used locally, as by the spray, and the same effect produced. Cocaine seems to be a protoplasmatic poison which inhibits nerve action.

In the description of the treatment of shock there has been little reference made to the result of loss of blood as such. In cases where this has already occurred, or cannot be prevented, it should be atoned for by the infusion of saline solution, either by intravenous introduction or by hypodermoclysis, i. e., its injection into the loose connective tissues in various parts of the body. While a special apparatus has been devised for this purpose, a sterile fountain syringe with an ordinary aspirator needle will be found to be sufficient for nearly all purposes.

The erethistic, or extremely restless type of shock, may be profitably treated by small doses of morphine given subcutaneously.

The question of immediate operation or delay should be carefully considered. Shock is often alleviated by prompt removal of mutilated limbs or parts whose fragments, while still connected with the trunk, seem rather to perpetuate the condition, especially if the principal nerve trunks are cocainized. In serious cases intravenous infusion should be practised.

After commencing with the anesthetic, while scrubbing and cleansing the field of operation it is advisable to scrub an arm where it may be necessary to expose a vein, or the skin at several points, where a needle may be entered, so that there may be no delay for this purpose should infusion or hypodermoclysis be suddenly required.

CHAPTER XIX. ABSTRACTION OF BLOOD; COUNTERIRRITATION; PARACENTESIS; TRANSFUSION; CATHETERIZATION; SKIN GRAFTING; BANDAGING. — VENESECTION. — COUNTERIRRITATION. — PARACENTESIS. — TRANSFUSION AND INFUSION. — CATHETERIZATION. — SKIN GRAFTING. — BANDAGING.

Abstraction of blood, usually of venous blood, known as venesection, was a practice frequently indulged in years ago. At one time in the history of medicine it seemed to be the measure regarded as a panacea for all ills. The reaction from the period of excessive bloodletting came during the previous century, and was so strong that the practice was for a generation or so almost abandoned. The eminent surgeon S. D. Gross wrote a paper entitled “Bleeding as a Lost Art.” Bloodletting is an expedient of great value in a somewhat restricted class of cases, but is capable of affording such relief in certain emergencies that practitioners should be ready to resort to it at any moment when it may be required.

After removal of a certain amount of fluid blood pressure is naturally reduced and at the same time equalized, while when the right side of the heart is overburdened with its task it is thus made to beat more easily and regularly; thus indirectly there may be brought about a subsidence of violent heart effort, a reduction of the respiration rate, a lowering of temperature, and sometimes a diminution in the activity of morbid processes which may be beneficial, and even life-saving. Even after moderate bleeding, say a half-pint, the amount of urine is increased and the proportion of solids raised. More air is taken into the lungs, and oxygenation is thereby much improved.

The indications for venesection are:

• Excessive vascular tension.
• Intensity of pathological tissue activity which is leading to serious disturbances.
• The removal of a certain proportion of toxic material from the blood.

There may be added later the introduction of balanced physiological salt solution as recommended in the treatment of shock, and of some of the acute toxemias, e. g., delirium tremens.

The effect on an embarrassed and overfilled right heart of the abstraction of blood is prompt. Nowhere is this more conspicuous than in the early stages of pneumonia, and in some cases of heart failure during administration of an anesthetic where a dilated heart seems to become so overfilled as to be unable to empty itself. In profound uremia, especially in puerperal eclampsia, the relief afforded by it is usually immediate and permanent.

The question of the amount of blood to be withdrawn must be settled at the time and for each individual case. The pulse is watched, as well as the patient’s face; the best indications when to cease being noted in this way. From 500 to 1000 Cc. may be removed according to the condition of the patient and the degree of emergency. While the operation is a trifling one, it should, nevertheless, be performed with strict aseptic precautions. One of the veins at the bend of the elbow, usually in the left arm, is commonly chosen, although in rare instances, when there is intense cerebral venous congestion, the external jugular may be selected. At the elbow the median basilic vein crosses the brachial artery, being separated from it only by a thin prolongation of the biceps tendon. It was especially in opening this vein at this point with the old-fashioned lancet, which was plunged perpendicularly to the surface and directly into the vein, that injury to the artery occasionally occurred, thus leading to varicose aneurysms and aneurysmal varices.

The skin should be thoroughly cleansed; a reasonably tight constriction is made about the middle of the arm by a bandage, not so tight as to completely occlude the radial pulse; the arm is allowed to hang downward and the patient encouraged to grip some object in order to better fill the vein. This soon becomes prominent, after which an oblique incision is made through the skin above it, so that the vessel itself is exposed. Then with a sharp bistoury the external surface of the vein is pricked with the point, and a cut made outward. The opening in the skin should be free; the skin may be frozen, or in very sensitive patients local anesthesia may be first produced with cocaine. By tightening and releasing the grasp, that is by closing and opening the hand, the flow of blood may be hastened. When it is time to cease, the bandage should be removed and an aseptic pad be applied over the site of the wound, suitable pressure being made, and the arm kept at rest for two or three days.

When the jugular or some other vein is selected the procedure is essentially the same.

Arteriotomy.

—Arteriotomy, or the opening of an artery for bloodletting purposes, is resorted to only in rare instances, and in an emergency. The temporal artery is the one usually selected because of its accessibility and the ease with which its outflow can be controlled. Its position is determined by its pulsation; it should then be exposed by incision through the skin, and opened exactly as is a vein, not cut through, lest it retract and furnish an insufficient amount of blood. It should, however, be divided and tied before application of the dressings.

Cupping.

—By the application of “cups,” blood is drawn to the surface, but ordinarily not abstracted, unless the surfaces have been previously scarified or incised. Dry cupping has the effect of attracting blood to one portion of the body, thus drawing it from another and congested part. It has the temporary effect of a venesection. Cupping glasses are small tumblers which are rinsed in alcohol; their edges are wiped and the remaining film within the glass is ignited from a candle or flame. The glass is then instantly applied to the affected area. The oxygen within the contained air is sufficiently consumed to create a slight vacuum and the skin quickly becomes congested, being sucked upward into the glass. These cups may be allowed to remain for a few moments, or until they drop off. Care should be exercised with alcohol and a lighted lamp around a patient who may be unconscious or excitable, as serious burns have followed carelessness in this regard. Small vacuum pumps, like the Allen surgical pump, have been provided for this purpose, and give very satisfactory results.

There was formerly employed for the purpose of wet cupping a small spring instrument, containing several sharp knives, by which a series of incisions were made in order that blood might be drawn. This instrument cannot be kept clean and is not used at present. When wet cupping is desired the part should be scarified with a sharp knife and the cup applied as above.

Leeching.

—Leeches figure largely in literature of the past, but are not often used, although they may be made effective, especially when applied behind the ears in cases of cerebral congestion. The American leech can be relied on only to abstract about a teaspoonful of blood, while the Swedish will draw three or four times that amount. The region to which they are applied must be washed, and, if necessary, shaved. The part should then be smeared with milk, blood, or sugar-water. The leeches should be put in a basin of fresh water, after which they are placed upon a dry towel for two or three minutes. Each one is then taken up in a small glass or test-tube and inverted over the spot chosen. As soon as the animal fastens itself upon the skin the glass may be removed. Leeches are often capricious and will sometimes wait considerable time before attaching themselves. When full of blood they usually relax and drop. If it be desired to remove them a little salt will make them relax. Leeches should never be applied over loose cellular tissue nor over superficial vessels or nerves. If used in the interior of a cavity they should be prevented from passing too far.

Counterirritation is a valuable means of accomplishing that which is sometimes induced by leeches—namely, attracting blood to the surface for the relief of deep congestion. In fact it comprises more than this, since there is some deep influence exerted through the medium of the nervous system; it not only equalizes the circulation, but tranquillizes a disturbed innervation. The milder and more domestic means include the use of the so-called rubefacients—hot water, mustard, and turpentine. These are of little use in surgical conditions which call for counterirritation; their use should be controlled with caution lest mere counterirritation be converted into actual burning.

By the use of vesicants a blister is produced, i. e., an effusion of serum and lymph beneath the superficial and outside of the deeper layer of the skin. Mustard and cantharis are the principal vesicants in common use. The former may be used in full strength, in which case it is active, or it may be reduced with wheat flour or linseed meal. To bring out the full strength of mustard, hot water should not be used in its preparation, as it renders it almost valueless. A mustard paste or plaster should be watched at intervals, and it should be removed when the desired effect has been obtained—at all events, when the surface to which it has been applied is covered with vesicles.

Cantharis, or Spanish fly, is used either in the form of the cantharidal cerate or mixed with collodion, the latter being the neatest and most pleasant preparation. Several layers are painted on the surface where its effect is desired. This is then protected, and vesication will be found to have been produced within an hour or two, except where the skin is most resistant. The stronger chemicals, like ammonia, chloroform, strong iodine, and nitrate of silver solutions, will be found to be active blistering agents, but should be used with caution.

Two other methods of irritation were at one time in favor—namely, the seton and the issue. The former consisted of a bundle of threads or a wick, drawn into a large needle with a lancet-shaped point; the skin was picked up into a fold, the needle made to traverse it, and the wick was thus drawn through and cut off, so as to be left in place. The issue was made by drawing a blister with a powerful agent, and then preventing it from healing by the use of an irritating foreign body. These procedures have been abandoned by the medical profession, but are still in vogue among veterinary surgeons.

The Actual Cautery.

—In some one of its improved forms the Paquelin cautery has replaced all the old cruder methods of cauterization. When properly employed its counterirritant effect can be made most serviceable for the relief of pain, or for any desired form or degree of counterirritation. Applied over the upper abdomen, with the lightest possible touch, in such a way as to deserve the term “flying cautery,” it will sometimes afford great relief in nausea and vomiting, especially when these symptoms are purely reflex.

Used over the course of the larger nerves it does much to relieve the pain of neuritis; while over swollen joints and swollen testicles it affords great relief from the pain of chronic arthritis and chronic or acute epididymitis. In deep-seated congestions and inflammations ignipuncture may be made with a small cautery point, by plunging it through the skin into the underlying tissues, and into bone. The relief of tension as well as the counterirritation will give great relief. When practised in this manner local or general anesthesia may be used. Except when thus used it will rarely be necessary to do more with it than to disturb the exterior of the skin. When skilfully used this can be done with the production of very little pain.

Paracentesis is the technical name given to the act of tapping, or the withdrawal of fluid from any of the closed cavities of the body. It includes aspiration, tapping, and incision.

Aspiration.

—By aspiration is meant the removal of fluid without the admission of air; it comprises the use of a suction apparatus, usually known as an aspirator, which may be had in various forms and sizes. A small so-called exploring syringe will answer for small cavities, while for large collections of fluid, such as may be met with in the thorax, more elaborate apparatus is used, consisting of a suction pump connected by tubing with a bottle in which the vacuum is produced. By another tube this bottle is connected with a hollow needle used for the withdrawal of the fluid. Absolute asepsis should be observed, even in this minor procedure. The skin should be cleansed, and the needle, instrument, and hands should be sterilized. The pain of puncture may be prevented by use of the freezing spray, of cocaine injected locally, or by touching the skin with a drop of pure carbolic acid. The vacuum is commonly resorted to in the removal of fluid from the thorax, the spinal and the cranial cavities, and from joints; also in small collections of pus in any part of the body.

Tapping.

—Tapping means a somewhat similar procedure with a larger instrument known as a trocar and a surrounding cannula, without the aid of the vacuum. Precaution should be taken in every regard that the instruments and the parts should be sterilized.

The trocar, inserted in the cannula, should be plunged quickly into the cavity at the site selected. Considerable resistance will be offered by the skin. If the trocar be small it is enough to anesthetize the skin; if large, a small incision will permit of its better use. The instrument makers have provided cannulas of various descriptions, to which tubing may be attached, so that the fluid may be conducted into a suitable receptacle, and wetting the patient avoided. It is well to draw the skin aside and not to make the instrument pass directly into the cavity to be tapped unless it contain pus and it be desired to keep it open. If this precaution is taken the skin will cover the deep opening after it slips back into its position, and will act as a valve to prevent leakage. In this way infection may be avoided.

When fluid has ceased to be serous and has become purulent, as in empyema, it is often so thick that it will not flow through any hollow instrument. In such an event free incision should be made. When the thorax is involved incision is made between the ribs, and in order to maintain drainage a good-sized drainage tube should be inserted. This at times may be so compressed between the ribs that an inch or more of one rib should be exsected to provide against this possibility.

Though much has been said concerning the indications for these procedures no explicit directions have been given. While they are often emergency measures they are, nevertheless, frequently practised. In well-regulated institutions the conveniences are always at hand for instant resort when needed; but it would be well for every general practitioner to have ready at all times the few things that are required, for at least hypodermoclysis. In country practice, however, a clean fountain syringe, a suitable aspirator needle (both carefully sterilized), some boiled water, table salt (when nothing else is at hand), and soap and water for sterilization of the operator’s hands and the patient’s skin are all that are necessary. In every outfit there should be a needle which may be used for this purpose. It may be carried in a glass tube, always sterilized, and ready for use. No fountain syringe should be used which has not been freshly boiled, except in an emergency. Tablets containing common salt in definite amount, so that a solution of given strength can be made by adding them to a definite amount of water, can be procured. With such a needle, a few tablets, and a fountain syringe the surgeon is prepared for any emergency.

For intravenous infusion for which no pressure is required, an ordinary funnel, with rubber tubing attached, will be sufficient without the use of a rubber bag.

The use of salt solution has supplanted the transfusion of blood. This requires a source of blood which is not always at hand and an amount of attention which can rarely be given in emergencies; moreover, it has been shown that the injection even of defibrinated blood is a dangerous procedure, because of liberation of hemoglobin and destruction of white corpuscles, with the liability to coagulation of the blood from increase of fibrin ferment, and the possible death of the patient. Direct transfusion from another person into the veins of the patient is also difficult, and has rarely been of service.

As already stated in the chapter on Shock, the best solution for infusion is composed of calcium chloride 2 parts, potassium chloride 3 parts, sodium chloride 9 parts, sterile water, 1000 parts. The addition of one part of sodium bicarbonate will sometimes prove of advantage, while in diabetic cases this may be increased to three parts to a thousand. It has also been suggested to add a small proportion of sugar, even up to thirty parts, to this solution, in order to increase osmotic action and better preserve the red corpuscles from injury. It is supposed also to give a certain nutritive value.

When the fluid is injected into the venous system all that is desired is that it barely enter; consequently the receptacle containing the fluid should be held but a few inches above the level of the opening. When hypodermoclysis is practised more pressure will be needed and a greater difference of level should be maintained. In the veins the amount injected should not exceed 100 Cc. each minute. From 500 to 1500 Cc. may be used altogether. There need be no hesitation in introducing it at a temperature considerably above the body normal, and in cases of shock it may be introduced even at 115° F. The character of the pulse will afford the indication as to the amount of fluid to be used as well as the wisdom of repeating the measure after an interval.

For intravenous infusion a vein in the arm is usually exposed and the needle point carefully inserted. It is an advantage to have for this purpose a special needle, made with a blunted extremity, enlarged a little, so that by the use of a temporary ligature the vein may be held tightly around the cannula, for such it really is, and the escape of fluid be prevented. After withdrawal of the needle a double ligature should be placed for purposes of security. The limb should also be kept at rest for a few days.

For hypodermoclysis from 500 to 1000 Cc. may be employed; the anterior abdominal wall, the flank, the thigh, and the retromammary tissues are the best regions in which to inject the solution. Absorption will be assisted by gentle massage. Local anesthesia by the freezing spray, or by cocaine, will rob the procedure of its discomfort. Adrenalin may be added to the solution, whose formula is given above, in emergency cases where it seems to be especially needed. In instances where infusion is practised for the purpose of washing out the blood, i. e., in the acute toxemia of uremia, alcoholism, etc., nothing of the kind will be required; but in conditions of lowered blood pressure, i. e., shock, it will prove of great value, as already indicated.

Catheters, as such, are intended for the withdrawal of urine from the urinary bladder, or for the introduction and withdrawal of cleansing fluids. They are made of metal, glass, gum, and silk, or other similar material, in various sizes, while some are specially formed or bent in order to pass more easily over the obstruction offered by a median prostatic enlargement. Various forms are sold in the surgical depots, from which the purchaser may make a choice. Next to the simple tubular forms the elbowed or Coudé catheters are of the greatest value.

Catheters should be sterilized before use. Those used occasionally should be cleaned after use and dried, while those in daily use may be kept in an antiseptic solution after cleansing. The cleansing of a catheter should include not only attention to the exterior, but also removal from its bore of all clots, debris, etc. Some pressure behind the fluid used for this purpose is advisable. A clean metal or glass catheter may be sterilized in a flame just before use. All flexible catheters should be boiled just prior to their insertion, or they should be taken out of an air-tight receptacle in which they have been kept in contact with some antiseptic, or in an antiseptic vapor. For the latter purpose paraform offers an excellent material, as there is given off from it formaldehyde vapor, which is a powerful bactericide. It comes in crystals and in tablets. Rubber catheters should be boiled in a 5 to 10 per cent. solution of ammonium sulphate.

The urethra should also be cleansed, especially the meatus, in either sex. Cases of cystitis may be directly traced to infection introduced by a catheter, the result being the same whether the germs be not removed from the instrument or are carried in by it from the anterior urethra. This is particularly true in paralytics who have no power of expelling the urine, and in prostatics who need regular catheterization.

The technique of using the metal catheter in the male is the same as that of introducing a sound. A lubricant is necessary for the easy introduction of the instrument, and a sterilized ointment or oil will serve the purpose. Olive oil, mixed with iodoform, as often used, is not sterile. The hands of the operator should also be clean, and no part of a clean instrument should be allowed to come into contact with any portion of the patient’s surface. On this account the parts exposed should be covered with sterile towels.

The catheter being intended to afford relief with the least amount of discomfort, a smaller instrument may be used than would be inserted were it meant for the dilatation of a stricture. Occasionally, and in a sensitive patient or hyperesthetic urethra, a little cocaine solution may be used to advantage, especially if force or pressure need be made in order to overcome spasm of the cut-off muscle. The metal instrument is too rigid in some cases, while the gum catheter is too flexible. Under these circumstances, the silk instrument may be used.

If the tip of the instrument be kept close to the floor of the urethra it will rarely catch in any fossa or lacuna, particularly if the size has been correctly chosen. When apparent obstruction occurs at the triangular ligament the instrument should be withdrawn a little, tilted differently, or lifted a little so that it is made to hug the roof of the urethra rather than to press upon its floor. By a little manipulation of the end of the instrument any obstruction at the neck of the bladder may also be overcome. A sudden depression of the outer end as the catheter reaches this part, or a little pressure by the finger of the disengaged hand in the perineum, will give much help. It is well, occasionally, to introduce one finger into the rectum in order that by it the instrument may be better guided along its course. Only in cases where there has been previous disease or where unsuccessful attempts have already been made to pass an instrument will much real difficulty be found; that is, only in those already suffering from stricture, or from enlarged prostate with the difficulties which it affords, will one have to resort to manipulation requiring more than ordinary dexterity. In some of these cases even the expert is likely to meet with difficulty, rarely with absolute disappointment. Should it be impossible to empty a distended bladder with a catheter suprapubic puncture with the aspirator needle should be made.

When difficulty is experienced it is enhanced by spasm of the deep muscles, as a reflex from the soreness produced by repeated efforts and by hemorrhage.

Hemorrhage from this source is rarely of serious character and quickly ceases. In certain instances where it is aggravated much can be accomplished by leaving the catheter in situ for a few hours, or even for two or three days.

False passages will occur sometimes in spite of at least ordinary care, and are always serious in their nature. Extravasation of urine may result, with more or less disastrous consequences, or speedy septic infection may quickly terminate the life of the individual. They are to be avoided, as far as possible, by the use of instruments of large rather than of small size, with blunt tips, and by delicacy of manipulation. For this purpose it is well to avoid the use of catheters which require a wire stylet for the maintenance of their proper curve, lest during manipulation the point of the wire may work injury. The various accidents due to or connected with catheterization will be dealt with in their proper places in connection with the surgery of the urethra and bladder.

There are certain constitutional complications, however, which deserve mention. One of these is known as urethral fever, which comes on usually with a chill, followed by more or less rise in temperature, and with general disturbance of the system. It is to be regarded as a manifestation of septic intoxication, the hope being that the disturbance may not go beyond this degree. In cases that have once suffered from this intoxication precautions should be doubled. The deep urethra should be irrigated before and after the withdrawal of the urine, the patient should be kept in bed, and urotropin and quinine may be administered before and after the discharge of urine. Much may be done in the prevention of this as of other unpleasant occurrences, such as pain, excitement, suppression of urine, syncope, etc., by the previous use of cocaine and by due regard for gentleness. Should a septic process be set up in the deep urethra it may lead to sapremia of urethral origin, and to septicemia and pyemia. Septic complications accompanied by any local indications, such as swelling, should make the surgeon watchful for the time when an incision must be made for relief of tension or escape of pus.

Postoperative suppression of urine, which may occur even after catheterization, may be treated by giving 0.08 to 0.15 Cg. of sulphate of sparteine every three or four hours (McGuire).

The whole method of skin grafting is based on the fact that if epithelium be removed from any portion of the body and planted on favorable soil elsewhere it will take root and grow, reproducing only itself and no other kind of tissue. It is closely analogous to sewing seed upon a favorable soil, or even to sodding. Furthermore it is not necessary that epithelium be furnished from the individual upon whom it is to be implanted; it may come from another of the same species or even from a different species. Thus the skin of the frog has been used for grafting upon human beings, and even the lining membrane of the egg. Nor is it necessary that the epithelial cells should be apparently alive when thus employed. Very thin shavings of human skin which have been dried, or have been kept from decomposing by some antiseptic, have been successfully used; nevertheless the ideal method consists in taking what is needed from the individual who needs it.

The term skin grafting is now applied to the employment of very thin layers of the epidermis, i. e., as thin as can be shaved off with a sharp razor, and it does not apply to the autoplastic methods of skin transplantation.

Hamilton, of Buffalo, and Reverdin, of Geneva, a number of years ago independently discovered that minute particles of healthy skin might be implanted upon healthy granulations and that from such minute grafts epithelium would be produced and a fresh epidermal covering be afforded. This method was in use for years and was a great advance on what had previously been done. Then Hamilton, of Edinburgh, suggested the use of thin slices of clean sponge, in order that thereby a trellis might be offered for the growing and climbing granulation tissue; this served a good purpose in many cavities. But the greatest advance came when Thiersch demonstrated that large areas might be covered with skin shavings, and that thus in a few days there would be accomplished that which took weeks or months by older methods. His original plan comprehended only the use of these grafts upon granulation tissue; later it was found that they might be applied to fresh raw tissue, even to denuded bone. Thus originated the so-called Thiersch method of skin grafting.

The surface to which these grafts are applied must be thoroughly cleansed as well as the surface from which they are removed. If an ulcerated surface is to be prepared for grafting it should be scraped thoroughly with a sharp spoon; all sloughing or suspicious tissue should be carefully removed, and all oozing allowed to subside. Not until the surface is prepared is it advisable to remove the grafts. These are best removed by putting upon the stretch the skin of the selected area, so as to render it taut and as nearly flat as possible. The razor used for the purpose should be sterilized and sharp. Salt solution may be allowed to drip upon the razor while the surgeon is using it. It is rarely practicable to remove a strip over 5 Cm. wide or 25 Cm. long. The endeavor should be to remove only the superficial layer of the skin, and when properly done this removal should be followed by but a trifling oozing of blood. If bleeding be profuse the layer removed has been too thick. Grafts of sufficient number and size are removed to nearly cover the desired area. The more completely it is covered the more acceptable will be the final appearance of the surface. If the grafts adhere, we may confidently rely upon their furnishing enough fresh epithelium to fill in the irregular defects between the edges. The grafts when cut should be raised with a razor and a spatula and gently spread out upon the prepared surface, and so pressed and treated that no air bubbles are retained beneath them. If the surface be dry enough they will adhere to the very thin coagulum of blood which glazes it, and after a few moments it will take friction to disturb them.

Should the margin of the surface to be grafted be old and indurated it is best to trim off any depression that exists, so that the new skin may not be let in below the surface of the surrounding skin.

The dressing should consist of a layer of sterilized oiled silk, gutta-percha tissue, or green protective, laid on in strips, in order that excessive fluid may escape between them. A little antiseptic powder may be dusted upon the grafts, if such be the choice of the surgeon, but if the operation has been properly managed this will hardly be necessary. Careful regulated pressure should be made outside of the protective, by cotton and a suitable dressing, and then the part, if a limb, may be bound upon a splint in order to ensure physiological rest. Silver, tin, or aluminum foil also make a good protective, and, on theoretical principles, are even better than the textile materials.

Some surgeons leave these dressings for several days. I have found it an advantage to remove them within thirty-six hours, as sometimes the grafts appear to be macerated in the fluids and to lose their first cohesion to the prepared surface. The main thing about the dressing is that it should be non-adhesive and restful. After three or four days, when the grafts have completely adhered, any ointment dressing may be used. It may happen that only a portion of the entire number of grafts serve their purpose, and that others fail to do their work. Even when the failure has been apparently considerable it will often be seen that individual epithelial cells have adhered and later will grow. The unhealed portions of such a surface now fall within the definition given earlier of an ulcer, and should be subjected to the same treatment.

Grafting may be repeated as often as seems to be necessary. The best surfaces from which to take the grafts are usually the outer aspects of the arms and thighs. The places from which they are removed need only the simplest antiseptic dressings. If the grafts have been of sufficient thinness the scars left by their removal are scarcely permanent and rarely disfiguring.

Wight, of Brooklyn, has suggested that advantage be taken of the properties of high-frequency discharges from a suitable apparatus to secure their hemostatic and coagulant effect. He has shown that such electrical discharge will clot blood and coagulate albumin, this effect being partly due to the formation of nitric acid from the air. In this way it is theoretically possible to so seal the surfaces as to fix grafts firmly in place. The apparatus calls for a pointed electrode, passed at a distance of about 1 Cm. above the entire surface, until the clot is firm and reasonably dry, all serum that is expressed in the process being removed with sponges. Where the apparatus can be employed this affords an effective way of fixing the grafts and preventing their displacement.

Surface epithelium from an animal source may be used when necessary—as from a young pig after it has left the packing-house, a young calf, or some smaller animal. All that is required is epithelium. That from a negro will reproduce only pigmented cells like the original. At the time when amputating a limb about which there is still left healthy unbroken skin, shavings may be removed from it and preserved for a week or two between dry sterilized towels or in a weak antiseptic solution; these may then be utilized for skin grafting during the ensuing few days.

Fig. 30

Figure-of-8 bandage of leg.

Fig. 31

Velpeau’s bandage.

Fig. 32

Ascending spica bandage of the groin.

 

Bandaging is a subject now taught so generally by actual demonstration, and so simplified, that it scarcely seems necessary to more than present a few illustrations showing how simple bandages can be applied in the most effective manner.

The purposes of a bandage are either to afford means of retaining splints and dressings, to exert pressure, or to afford physiological rest. After every operation of importance it is necessary to apply and retain an occlusive and aseptic dressing, under which the wound may heal or into which wound discharges may be received; but the ideal dressing affords more than this—it furnishes support and rest.

Fig. 33

Fig. 34

 

Spica bandage of shoulder.

Fig. 35

Fig. 36

 

Third roller of Desault’s bandage.

There is danger in the injudicious use of any bandage, as by the exertion of undue pressure it may interfere with wound healing, or may even lead to gangrene. If applied loosely at the extremity and too tightly above it will lead to venous obstruction and possibly secondary hemorrhage. Moreover a bandage which seems properly arranged may become so tight as to be painful and even unbearable after swelling has occurred. There is but one safe rule, and that is to take note of the appearance of the part as well as of the sensations of the patient. An abdominal bandage may have been placed with a proper degree of snugness at the conclusion of an operation, and yet be altogether too tight when the abdomen becomes distended with a little gas. There is then always room for discretion and good judgment in the matter of bandaging. It may be necessary to apply a bandage quite firmly at first in order to repress hemorrhage, with the intention to relax it after a few hours.

A splint may be a necessary feature in a surgical dressing; after amputating at the lower part of the leg it is advisable to bind the limb upon a splint in order that the necessary physiological rest may be thus afforded. The first requisite of a bandage is not its appearance but its effectiveness; a due regard for the esthetic in surgery will, however, dictate that it be made as presentable as possible.

Fig. 37

Fig. 38

 

T-bandage.

Kelly’s bandage with perineal straps.

For the roller bandages of cotton cloth, universally in use twenty-five years ago, there have been substituted bandages of thin gauze or crinoline, which have scarcely body enough to be applied, as was the roller, or else of flannel, made wider and necessarily thicker, which are more flexible, comfortable, and applicable.

Fig. 39

Barton’s head bandage as employed for suspension in applying plaster-of-Paris bandage.

Crinoline impregnated with starch is also in general use and makes a serviceable bandage for head injuries. When prepared with plaster of Paris it is capable of affording absolute support and even rigidity.

CHAPTER XX. ANESTHESIA AND ANESTHETICS, GENERAL AND LOCAL. — ETHER. — CHLOROFORM. — A. C. E. MIXTURE. — ETHYL BROMIDE. — METHYLENE BICHLORIDE. — ETHYL CHLORIDE. — OTHER VOLATILE ANESTHETICS. — NITROUS OXIDE GAS. — THE CHOICE OF AN ANESTHETIC. — THE DANGERS OF AND ACCIDENTS FROM ANESTHETICS. — ARTIFICIAL RESPIRATION. — MORPHINE AND SCOPOLAMINE. — LOCAL ANESTHESIA. — INTRASPINAL COCAINIZATION.

To Oliver Wendell Holmes we owe the term anesthesia, as generally employed and made to mean insensibility to pain, no matter how produced. A more strict definition would limit the term to conditions comprising not only insensibility to pain but loss of consciousness. For mere loss of sensation we should, strictly speaking, use the word analgesia. This is a distinction with a difference. Thus I have on rare occasions seen a patient under chloroform absolutely oblivious to pain but perfectly conscious, and chatting intelligently throughout the operation. This is a rare phenomenon, but has been noted by various observers. So after intraspinal cocaine injections we secure complete analgesia of the lower portion of the body, but not complete anesthesia, the former being what we are most anxious to produce.

The discovery of anesthesia is essentially to America’s credit. Long, of Georgia, had produced anesthesia by ether as early as 1842; Jackson, of Boston, also claims credit for the discovery; but to Morton, a dentist of Boston, is undoubtedly due the honor of having introduced it for surgical purposes. The first public demonstration of its properties was made by Morton and Warren, October 16, 1846, in the Massachusetts General Hospital. Chloroform seems to have been exploited independently by Guthrie, of Sackett’s Harbor, N. Y., and Simpson, of Edinburgh, in 1847. It is a curious historical fact that the patient to whom Simpson meant first to administer chloroform in his clinic did not receive it because of some failure to have it on hand; she took ether instead and died, presumably of the anesthetic. Had she died under the influence of chloroform it would have been a serious setback to any general appreciation of its merits. Nitrous oxide is also an anesthetic for which America may take the credit. These are the three drugs in common use today, although there are others which are coming into general favor.

It can be stated as an axiom that when a surgeon tries to abolish human sensibility, or pass an instrument through the human skin, he introduces elements of danger which can never be certainly and completely controlled—that is to say, the administration of an anesthetic is never to be undertaken as a trifling matter, but should be entered upon as carefully for a minor procedure as for a dangerous and prolonged operation.

Anesthetics are sources of danger, not only for the moment while they are in use, but because of the disturbances which may follow in their train. These drugs should never be administered carelessly nor thoughtlessly, nor by inexperienced individuals, but entrusted to the wisest and the most discreet. More is expected of the anesthetizer than that he shall barely keep the patient alive; he should be so expert as to keep the patient safely on the side of complete anesthesia and muscle relaxation. Nor should he be willing to yield to the importunities of an impatient operator who may be continually appealing to him to crowd the anesthetic. When thus given, and by an expert, such postanesthetic distress as nausea, vomiting, coughing, etc., may be avoided. So generally are these facts now realized and appreciated, that in many of the large hospitals a regular anesthetizer is employed, whose sole duty it is to administer the anesthetic for the attending surgeons. The management of an anesthetic has much to do with the allied subjects of the preparation of the patient, the management of shock or reduced blood pressure, and the status lymphaticus, which have already been considered.

Fatal accidents from anesthetics are the appalling ones which have generally occurred in cases where it has been assumed that the patient is in good condition, and where neither preliminary examination nor preparation has been made. In the presence of unmistakable cardiac disease, or of great arterial tension, the surgeon may, by foreseeing the possibility of trouble, do much to prevent it; but when an apparently healthy individual is placed upon the operating table without attention to these matters it may happen that his heart will stop as suddenly and unexpectedly as though it had been transfixed. In other words, the accidents of anesthesia usually occur when least expected; on the other hand, accidents will be few and far between when all cases are handled as though promising to be severe ones.

The odor of most anesthetics is so distasteful to patients that they inhale at first with difficulty and with signs of irritation. Much of this can be guarded against by spraying the nasopharynx with a 1 or 2 per cent. solution of cocaine. This expedient will make anesthesia much easier for them. The mouth should be examined; all false teeth or foreign bodies, such as pins, chewing-gum, etc., should be removed. Unpleasant burning of the sensitive mucosa of the nose and lips may be avoided by anointing these parts with cold cream. Attention should be given to the avoidance of irritation of the eyes or the careless escape of an anesthetic into the conjunctival sac; with a struggling patient, or a careless administrator, this may easily happen.

Circumstances which would justify the administration of an anesthetic without the consent of the patient, or the friends or parents, occur but rarely; still in an emergency case, with a patient incompetent to decide for himself, the surgeon must assume the responsibility, in which in all probability the law will sustain him.

The anesthetizer should always be accompanied by an assistant; preferably in the case of a female patient, by a female nurse, who may not only be of assistance to him at the time, but an actual protection should the patient experience any erotic delusions during or after her period of anesthesia. This applies equally well to dentists giving nitrous oxide for the extraction of teeth, or physicians attending cases of accident, convulsions, and the like.

The anesthetics in general use are ether and chloroform. If statistics alone are appealed to it can be easily shown that ether is the safer of the two by a large ratio. But the recovery of consciousness by no means indicates the conclusion of the period of danger. The harm which chloroform does is largely done promptly, whereas the unpleasant effect of ether lasts through a much greater period, and the statistics which give ether an advantage are in many respects fallacious. Chloroform is doubtless the stronger and the more subtle agent of the two, and in careless hands would, in all probability, become the more dangerous. But no anesthetic should be given carelessly, and no one should give it who cannot give it properly. There may be emergency cases, especially in the rural districts, in which the surgeon may have to act in the capacity of anesthetizer and operator as well, and where he may have to transfer the inhaler to some lay assistant who knows nothing of the action of these drugs. If this happen it would be safer to use ether.

When administered by a thoroughly competent person chloroform is the safer anesthetic of the two, and is usually to be preferred. So largely does the personal equation figure in this consideration that it seems unnecessary to reproduce here statistical tables in regard to its efficiency.

The writer’s intention is to confine his views on anesthesia to the practical application of certain drugs whose chemistry, materia medica, and ordinary therapeutic properties are appropriately treated of in other works.

Ether anesthesia has by some been considered to be simply one form of carbon dioxide poisoning; that it may be all of this, in certain cases, may be granted; but it is certainly something more, as is shown, among other things, by the peculiar odor which persists in the breath of the patient for hours or even for days after its use. Various ways of administering it have been recommended. Some give it well diluted with air, and some give it as strong as a patient can possibly bear it, and from the outset. Some keep mixing air with the vapor, while others have devised inhalers, by which the same ether-ladened air is breathed over and over again. These latter produce a certain degree of the carbon dioxide poisoning above alluded to, and are not ideal even if effective.

Even when well diluted with air the vapor of ether causes irritation of the air passages, in both the nose and throat, and leads quickly to a sensation at first of oppression and then almost of suffocation, which is trying to the self-control of intelligent patients and disturbing to those having little or none. An inhaler saturated with ether should not be pressed tightly over the patient’s face, as it is likely to produce struggling to such an extent that weakened bloodvessels may give way and by their rupture produce serious disturbance.

The first momentary period of irritation having subsided, there will likely follow a few deep inspirations, and then perhaps a fixation and immobility of the chest, so that for half a minute or a minute it would seem as though the patient had forgotten to breathe (Hare). But deep respiration is quickly reëstablished, or may be stimulated by slapping the chest, by a few movements at artificial respiration, or at least by compressing the thorax. Then follows the period of “primary anesthesia,” so called, or a period of excitement, during which the patient may rave or become quite disturbed, and in a manner sometimes quite at variance with his ordinary temperament. As this period subsides the state of complete anesthesia begins, and when muscular relaxation is complete, or even before, the surgeon may commence his work. The respiration under complete anesthesia is usually deeper and sometimes more rapid than in health, while as the muscles become more relaxed a positively stertorous breathing is noted, along with an increase in flow of saliva, due to the irritation of the ether vapor. As anesthesia passes into complete narcosis, and this into asphyxia, the color of the surface, especially of the face, changes to a cyanotic hue, the skin becomes moist and clammy, and the pulse, which had been accelerated, fails. The blood also becomes exceedingly dark from lack of oxygen. Under these circumstances the heart may continue to beat feebly for a short time after respiration has ceased. As Hare puts it: “In producing its effects ether first attacks the perceptive and intellectual cerebral centres, next the sensory side of the spinal cord, next the motor side of the cord, then the medulla, and with this last depression death ensues.”

Ether is more pungent and less agreeable to breathe than chloroform, but the chief advantage usually connected with its use is its supposed factor of safety.

On the other hand, the accidents which are due to ether are in a large measure those common to the use of any anesthetic agent. Among the most prominent is arrest of respiration, which may be caused either by mucus or some foreign body in the air passages, or by the tongue dropping back in the pharynx, and the impediment to respiration thereby offered. When the cause of the difficulty is ascertained it is usually easily removed. Should great pallor accompany these symptoms, then, it is usually because the heart as well is at fault, and vigorous stimulation of this organ should be promptly instituted.

Another disadvantage pertaining to ether results from the irritation which its vapor produces in the bronchi and lungs, or in the kidneys during its elimination. From the former may result bronchitis, congestion, or even pneumonia; the latter more often of the catarrhal type than of the croupous. As the result of renal irritation there may be temporary albuminuria, or the congestion resulting may assume so serious a type as to produce absolute suppression (anuria), which is practically always fatal. Ether is said to be particularly undesirable in cases of diabetes, because of the resulting acetonuria. Patients have even been known to pass from anesthesia into diabetic coma.

It has been found that complications are more common in males than in females, but more severe in the latter. Vomiting following the use of ether is a frequent and most unpleasant sequel. It is to be prevented by previous lavage, as well as by the same measure at the conclusion of the operation. It will rarely subside when present until the ether vapor has been eliminated. So far as it is possible to suppress it with drugs probably 2 Gm. doses of chloral and one of the bromides, with a little laudanum, given by the rectum in salt solution or a little starch-water, will give the best results.

As already stated, it was formerly held that anesthesia was carbon dioxide poisoning, plus something else which was vaguely described by different authorities; much clearer notions now prevail regarding the mechanism of anesthesia. A few years ago Meyer and Overton concluded that anesthesia is produced by solution of the fatty constituents of the cells by the anesthetic absorbed, this being true at least with chloroform and ether, both of which are solvents of fat. The absorbability of the anesthetic varies with the blood temperature, this varying widely between the cold-blooded and warm-blooded animals. They estimate that 1 part of ether to 400 parts of serum is necessary for complete anesthesia in man, while one part in 4500 to 6000 parts is a sufficient proportion of chloroform. According to these views the dissolved fat is not removed from the cells, and no satisfactory explanation yet accompanies this theory, even assuming its accuracy.

Of no small importance are the experiences of Snel, who found that anesthetics decrease the bactericidal properties both of the blood and of the tissues, but that this power is quickly recovered after the elimination of the anesthetic. He furnishes reason for the theory that the thus lowered resistance of the lungs is an important factor in the production of the pneumonia which occasionally follows operations.

There is a belief that ether is more irritating to the kidneys than chloroform. This, however, does not seem to be justified by evidence, neither is the prejudice against the use of ether during the existence of albuminuria or in the presence of casts. In the presence of a high degree of albuminuria any anesthetic is dangerous, and here ether would be the less desirable of the two. Nevertheless in ordinary mild albuminuria one need not fear to give ether.

About twenty years ago it was suggested that ether anesthesia could be induced by passing its vapor into the colon through an ordinary rectal tube. There are many obvious reasons why it would be of great advantage if anesthesia could be safely practised in this way, not only in operations about the face and head, but because of the avoidance of pulmonary and gastric irritation.

The method was to thoroughly empty the colon and then connect a rectal tube with a receptacle containing ether, which was placed in warm water and the vapor passed into the intestine. It was found that patients could be readily anesthetized in this manner, but unfortunately it was also found that a considerable degree of intestinal irritation was produced.

The writer recalls one case in which this method was practised, which terminated fatally within twenty-four hours after the operation, where the autopsy disclosed a violent degree of acute colitis.[7]

It is important that pure chloroform should be secured for anesthetic purposes. It should be kept in dark bottles, and in the dark, as it is liable to undergo decomposition in the presence of sunlight. It is less volatile than ether, and mixtures of the two drugs are not stabile, since the ether is likely to evaporate first. In its anesthetic effects it resembles ether, acting first upon the perceptive and last upon the motor centres.

The British Chloroform Committee estimate that from 1 to 2 per cent. of chloroform in the inspired air is sufficient for anesthetic purposes, and may be safely used; that 5 per cent. is more than adequate, and that anything stronger than 2.5 per cent. is dangerous.

The effect of chloroform upon the heart is to quicken and then slacken it. The former action is due to a depression of the vagus centre, while subsequent slowing is due partly to vagus stimulation and partly to direct weakening of the heart muscle. While chloroform does not materially affect the excitability either of the vagus or accelerator nerves its main effect is on the strength of the heart action, and is less marked on the auricles than on the ventricles. Ether has a more marked tendency to raise blood pressure than chloroform, while the latter is likely to be more responsible for sudden falls in blood pressure even after its administration has ceased.

The question of the relative dangers of the two drugs has engaged the attention of investigators the world over, and one of the side questions to be discussed is whether chloroform kills by arresting the circulation or the respiration. Chloroform produces a fall in blood pressure (see Chapter XVII) but as long as the blood pressure within the brain, and especially the medulla, is maintained this effect is of secondary importance; but when the respiratory centres lack their natural stimulus, and respiration becomes irregular, then, as it were, the patient “bleeds into his own vessels.” It is under these circumstances that adrenalin produces its most marked and prompt effect.

The first effect of chloroform inhalations is to raise blood pressure, but this is soon followed by lowered tension. The pupils may dilate slightly at first, but usually contract and remain contracted during anesthesia. When they dilate suddenly means should be adopted to avert the danger threatened, as the relaxation of the iris is the first visible relaxation of death. While the pupils react to light there is little danger.[8]

Death from chloroform usually occurs when it is assumed that no accident is likely to happen, as when it is given to an athlete, or to drunkards who are supposed to be secure from any reflex influences. Patients with weak hearts can be conducted safely through a prolonged anesthesia if there be time to prepare them. (See chapter on the Preparation of Patients.)

The after-dangers of chloroform are smaller than those of ether, due in part to the fact that a much smaller amount of the drug suffices; in other words—that it is the stronger.

After anesthesia has been produced and the patient is unconscious it requires but small additional amounts to maintain unconsciousness, as it is necessary to add only as much as may be required to replace what is lost by evaporation and exhalation. It is sometimes advantageous to commence with nitrous oxide gas, for there are fewer unpleasant reflexes, less salivation, and less disturbance of every kind. Shallow breathing may be improved at almost any time with a few drops of ether.

Many anesthetizers have a habit of testing the degree of anesthesia by touching the cornea with their fingers. A piece of sterile gauze will prove equally effective and less irritating.

When the mask upon which chloroform or ether is given is held over the face free salivation will frequently be excited, and the patient will be tempted to swallow as well as inhale. In this way the vapor of the anesthetic is taken into the stomach as well as into the air passages, and when the stomach is empty this comes into direct contact with the gastric mucosa. This may produce not only irritation, but, in extreme cases, gastritis. It has been suggested that to allow the patient to drink a quantity of water at intervals before taking the anesthetic, and especially a half-pint or more immediately before beginning it, will be to permit of absorption and dilution of the anesthetic vapor without their causing this irritation.

Fig. 40

Harcourt inhaler.

The simplest method of administering chloroform is upon an ordinary mask, the covering of which should be thin in order to permit of easy play of air. By this method a patient can always be anesthetized, but with a waste of the anesthetic and with absolute uncertainty as to the proportion of chloroform vapor in the inspired air. A variety of expedients have been suggested in time past, and chloroform inhalers of various patterns are constantly upon the market. The Junker inhaler, introduced some twenty-five years ago, was a great improvement upon its predecessors, but only recently has a really scientific measuring inhaler been placed before the profession. This is the one devised for and introduced by a committee of the British Medical Association, and is the result of the study and ingenuity of Prof. Vernon Harcourt. It has already been stated that more than 2 per cent. of chloroform vapor in the inhaled air is dangerous. The Harcourt apparatus consists of a two-necked bottle, nearly filled with chloroform, into which are dropped two colored glass beads, which serve to indicate when the temperature is between 55° and 59° F. If the temperature be below 55° F., both beads will float; if it be above 50° F. both will sink. If the former, the proportion of chloroform will be below that indicated by the pointer; if the latter, it will be greater. Inasmuch as during inhalation the chloroform is cooled by evaporation, it is necessary to occasionally place the warm hand over the bottle until the blue bead has sunk and the red bead is beginning to sink, indicating that the temperature is again approaching 59° F. A stopcock is so constructed that when the pointer is at one end of the arc the maximum amount of chloroform which may be taken up is 2 per cent.; when the pointer is at the opposite end, the patient breathes only pure air. There are valves which prevent the entrance of expired air into the apparatus, and which show whether the stopcock is working. They also show the character of the respiration. Administration is begun with the pointer at 0.2, and while it may require 2 per cent. of vapor to produce narcosis; i. e., the complete and final stage of anesthesia, it will take scarcely more than 1 per cent. to maintain it. The mouth-piece has an expiratory valve, and the apparatus can be held in any position, but should be kept nearly vertical. The mask is fitted with an air cushion, which can be molded in hot water so as to fit the patient’s face. Buxton, who is the leading authority on anesthetics in London, has abandoned all other apparatus for this. While he is a most skilled expert, he has shown that by means of this apparatus chloroform can be given with almost absolute safety.

Aside from the danger and discomfort pertaining to the use of chloroform in apartments lighted or heated with natural gas, there is another similar danger in connection with ordinary city illuminating gas. In the presence of a flame produced by the latter the vapor of chloroform is broken up not only into chlorine and hydrochloric acid, but into a carbon oxychloride, known also as phosgene, which is toxic and produces a sense of suffocation by producing decomposition within the blood. A fatal occurrence of this kind led to experiments on animals by an Italian observer, which showed that the substance produced rapid disintegration of hemoglobin, which fell rapidly to 40 per cent., and that accompanying this there was suppression of urine with convulsions.

Unless chloroform be given by one familiar with its use, it is best given from a dropping bottle. If this be so arranged that it will discharge but one drop at a time, and the anesthetizer so administer it as to allow perhaps one drop to fall each second, the patient will at no time get an overdose, nor will there be struggling or choking. Irregularity of breathing is usually the result of insufficient air, and the mask should be at once removed, so that the patient may take one or two deep inspirations. When the cornea is insensitive the patient will stand almost any manipulation except, perhaps, stretching of the sphincters. When the sphincter can be stretched without provoking any effect except a prolonged inspiration, then the patient is, in all probability, completely relaxed and ready for any procedure. When the breath becomes stertorous the mask should be removed even though the cornea be sensitive. It will quickly lose its sensitiveness again within a few seconds. Proper breathing must be maintained. Free supply of air is important above all other things, and it is better that the surgeon should wait rather than the anesthetizer.

Additional safety in the use of chloroform may be afforded by the simultaneous use of oxygen gas, by which cyanosis is usually avoided and vomiting often prevented. It may be safely used with chloroform, but not with ether. If ozonized air be conducted into anhydrous ether it forms a thick liquid, probably ethyl peroxide, which explodes if heated (Hare). It is a mistake to so manage the administration of chloroform with oxygen that the patient receives no pure air. Oxygen is of great value, but it is not physiologically breathed in its pure state. When the gas is allowed to bubble through a bottle of chloroform, carrying with it the vapor, no idea can be formed as to relative percentages. A better way is to administer the chloroform upon a mask, and the oxygen by a tube from a wash-bottle filled with water and passed into the nostril under the edge of the inhaler (Hare).

Gwathmey has introduced a modification of the well-known standard Junker inhaler, by which oxygen and chloroform, or nitrous oxide and ether, may be given together, or by which any desired combination can be effected. Its special advantage is the same as the Harcourt apparatus, that the percentage of chloroform or ether vapor can be estimated or controlled. So far as the administration of chloroform with oxygen is concerned, Roth has shown that oxygen does not decompose the chloroform, but diminishes the danger of its administration.

Gwathmey refers to the advantage of keeping an open airway by turning the head a little to one side and pressing the jaw well forward; he also advises that when the anesthetic is removed from the face it is well to replace its odor by some other perfume, such as cologne or smelling salts, as it is presumed that the olfactory nerve is responsible for the initial symptoms of nausea and gastric distress.

In some States natural gas is used as fuel, usually in open fireplaces or stoves. When chloroform is administered in a room thus heated, or even lighted by natural gas, formaldehyde gas is the result of a mutual decomposition, and this is exceedingly pungent and irritating, and will soon produce violent coughing in all who are present in the room. It may be impossible to avoid this, but natural gas flames should be extinguished and some other source of illumination should be depended upon when practicable.

Under this term are known various mixtures of alcohol, chloroform, and ether, the intent being to counteract the depressing influence of chloroform by alcohol and ether. It may be said of every mixture of anesthetics that it is no less dangerous than its strongest constituent. Thus a mixture of chloroform and ether should be given with as much precaution as pure chloroform.

Mixtures of this kind should be made fresh for each administration, as the most volatile ingredient may evaporate in unknown amount and thus change the proportions. This is true of the mixture even after it is poured upon the inhaler, and the patient will thus be subjected to a chloroform mixture of varying strength.

The administration of ether for a few seconds during chloroform anesthesia will often prove beneficial in regulating or deepening inspiration, but it would be best to have the two drugs separate, and use the ether as it may seem called for, rather than to rely upon any such mixture. Moreover the vapor of alcohol is of itself irritating and undesirable.

For operations of but short duration ethyl bromide offers some advantages, in that its effects quickly pass away and that there are few unpleasant sequels. Indeed, patients may take it for a few minutes with almost as little disturbance as is produced by nitrous oxide; nevertheless it cannot be regarded as being as free from danger as was originally claimed. Only a pure preparation should be used. When given as ether is usually given, upon a cone or mask, complete anesthesia may often be produced within one minute. It can hardly be relied upon to produce muscular relaxation and it frequently causes great congestion of the face and head, consequently it is not as convenient for short operations on the nasopharynx as its other good qualities might render it. It is not unpleasant to take, and ordinary ether anesthesia may well be begun with it.

For a number of years this anesthetic agent was in favor, especially in Great Britain, where it was warmly advocated by Spencer Wells. Its odor is agreeable, its action rapid, and recovery from its effects is usually prompt. But it proved to be unsafe, since it was found that the substance commonly used under this name was really chloroform diluted with one-fifth of methyl alcohol, while the genuine methylene bichloride was found by experiment to be a dangerous substance, and its use has been discarded.

This, like every other drug used for the purpose, should be used in perfectly pure form. While this can be obtained from manufacturers in this country, there seems to be a tendency to rely upon the imported preparation sold here under the name of Kelene. For certain short operations, such as those upon the eye, nose, and throat, and for children, it has many advantages and appears to be a reasonably safe drug for the purpose. Consciousness is quickly recovered after its use, and the after-effects are slight. It is in general use preparatory to one of the stronger anesthetics, like ether or chloroform, and affords a means of putting patients under the relaxing effect of either of these drugs. It should be administered upon a cone or mask, from which evaporation should not occur too easily, because it is extremely volatile. In the hands of one accustomed to its use, operations of considerable magnitude and duration may be successfully maintained. A special valveless mask has been devised for its use, consisting of a rubber mouth-piece which can be snugly fitted to the face, and a movable tube over which two or three layers of gauze may be stretched, upon which the ethyl chloride is allowed to drop or is ejected from the tube in which it is sold. Sometimes the expired air will freeze upon this gauze. This is of no disadvantage.

Local Use.

—On account of its extreme volatility, chloride of ethyl affords a ready means of producing local anesthesia. It boils at 50° F., and when the tube containing it is held in the hands and its capillary tip is opened it issues in the form of a fine spray, which being directed upon the part to be desensitized first chills and then freezes it. Whether this part be skin or mucous membrane the effect is the same. As soon as the desired area is covered with a thin layer of small frozen crystals, looking like hoar-frost, the surface is anesthetized and the necessary instruments may be used. Blowing on the part to be anesthetized will favor evaporation and shorten the time necessary for the purpose.

The purposes to which this drug may thus be used are numerous and obvious. For instance, in dentistry it will do much to allay the pain of tooth extraction; in genito-urinary surgery such operations as incision of the prepuce, the cauterization of venereal ulcers, and circumcision may be done with little or no pain. The small operations required in various skin diseases, the incision of small abscesses, the use of caustics wherever they may be needed, may all be made easy under its effect; while in cases of neuralgia, stings, bites, etc., it will often alleviate the symptoms. The skin may also be anesthetized in this way before the introduction of the needle through which antitoxins are injected or hypodermoclysis practised. Before venesection or before exploratory puncture it may also be used.

Somnoform.

—This agent, composed of ethyl bromide 5 parts methyl chloride 35 parts, and ethyl chloride 60 parts, was introduced by Rowland, of Bordeaux, as a convenient means of producing an analgesic condition, i. e., something between complete anesthesia and conscious sensibility. The dose is about 5 Cc., to be sprayed upon a tightly fitting mask. The patient should be told to breathe and swallow as naturally as possible, and the effect is obtained within a few seconds. The agent is so speedy in producing its effects that it is sometimes difficult to tell when the proper degree of unconsciousness has been secured. A patient may be directed to hold up an arm in order that when it drops the surgeon may proceed. There is neither cyanosis nor corneal reflex, and nausea does not usually occur. The essential point of administration is the exclusion of air. Twenty seconds of administration will give from one to two minutes of anesthetic effect, during which various brief operations can be performed. By proper management this period can be lengthened many times.

Petroleum Ether.

—Petroleum ether was introduced by Schleich for the purpose of diluting chloroform. By itself it has a weak anesthetic power, and seems to possess some dangers of its own in the way of depressing the heart’s action and producing convulsions.

Schleich was among the first to demonstrate that the retention of an anesthetic within the body depends upon its boiling point. W. Meyer carried Schleich’s views still farther and showed the at least theoretical value of an anesthetic mixture whose boiling point was that of the normal blood temperature. If the evaporating point be much higher than the blood it is volatilized too easily, while if it be lower it reduces body temperature as it evaporates. After considerable experimentation Meyer recommended a mixture by volume of chloroform 3 parts, ether 2 parts, and ethyl chloride 1 part, and introduced this mixture under the name of anesthol. This composition does not seem to have met with great favor as yet, although it has theoretically much to commend it, as it seems slower in action and but little more satisfactory in other respects.

This is by all means the most rapid general anesthetic in use. Patients can be placed under its influence in from twenty-five to sixty seconds. For a long time its employment was confined to dental practice, but it is now in general use by surgeons, as a preliminary to the use of ether or as the sole anesthetic agent. When managed properly patients can be kept for a half-hour or even an hour under its influence. Two disadvantages attend its administration: (1) It is difficult to completely relax the muscles and so maintain them that no difficulties are placed in the operator’s way, e. g., in certain operations upon the abdomen where muscle rigidity delays and makes difficult the operation. (2) The use of nitrous oxide alone so far impairs proper oxygenation of the blood that this fluid becomes dark or almost black and frequently obscures the field of operation. These difficulties, especially the latter, can be overcome by the skilful simultaneous use of oxygen gas, by which the blood is kept well oxygenated, and by which the deep stupor of nitrous oxide poisoning can be made so safe that it can be prolonged to the degree necessary to afford relaxation.

Nitrous oxide anesthesia is thus proved to be something more than mere asphyxia, or it would be completely counteracted by oxygen. Suitable apparatus can now be procured by which both gases can be blended together as desired; considerable experience, however, is necessary for their successful use. It is generally stated that nitrous oxide alone should not be given to persons with fatty hearts or atheromatous vessels. From a brief period of nitrous oxide anesthesia patients usually recover within a few minutes and without after-effects; still, relaxation of the sphincters may occur. After its prolonged use there may be considerable headache and vertigo.

This will depend upon who is to be the anesthetizer as well as upon the actual condition of the patient. If an inexperienced person is to administer the anesthetic, ether is safer than chloroform, though slower. On the other hand, when given by an expert, and after due preparation of the patient, chloroform is ordinarily preferable. The latter is especially indicated in the young and aged, as well as in those who have bronchitis or chronic cough, and those who have advanced renal diseases or atheroma, because it is not likely to produce such high arterial tension.

Ether should never be given near an unprotected flame, and lamps or gas-jets should be held above the level of the operating table, as the vapor of ether is heavier than air and will tend to sink. The disadvantages of chloroform where natural gas is in use have already been mentioned.

Efforts should be made to prevent struggling, as in the violence of this unconscious act an overtaxed heart might yield, or at least undergo dilatation. Chloroform is notably less likely to be followed by nausea and vomiting than ether, and yet nausea cannot always be prevented. There can be no doubt that morphine, alone or with atropine, may be given with advantage to most patients before administration of a general anesthetic. The treatment of postanesthetic nausea has been referred to in the chapter on the Preparation and After-care of Patients. By general consent, chloroform is the anesthetic of choice during labor.

The principal dangers from any of the volatile anesthetics come from interference with circulation and with respiration. The heart may give rise to alarm by gradual failure in strength, while the pulse becomes more rapid and irregular, or by sudden and apparently complete cessation of activity. When the pupils suddenly dilate and do not react to light danger is close at hand, if it have not already manifested itself, and then is the time to discontinue the anesthetic and resort to vigorous methods, which may include artificial respiration, but must include attention to the heart. It is customary to use injections of strychnine, which are often too weak or too small to be of service, nothing less than ¹⁄₂₀ Gr., which may be repeated in a few moments, will be of any service. If ¹⁄₁₅₀ to ¹⁄₁₀₀ Gr. of atropine be given with the strychnine it will prove a much more effective stimulus. It is right and proper to administer these drugs in this emergency, but still more reliable measures are at hand.

Sudden stoppage of the heart, being the most disastrous accident during or after anesthesia, has attracted no small amount of attention on the part of experimenters. An active massage of the heart seems to furnish the basis for all the newer methods of treating it, all of which are accompanied by artificial respiration. Some of Crile’s work in this connection was alluded to in the chapter on Blood Pressure and Shock.

Fig. 41

Showing how proper traction on the tongue pulls on the epiglottis. (Hare.)

Numerous investigators have revived the hearts of experimental animals by massage and saline injections, and Crile has shown the advantage of adding adrenalin to the latter. It is better to begin the efforts while the heart is still feebly beating than to wait until it has ceased. Ordinarily this massage should be made through the intact thorax, but the time is coming when it will be esteemed life-saving either to open the abdomen and massage the heart through the diaphragm, or to open the thorax and do it directly. The former can be done during almost any abdominal operation. The greatest obstacle to success has been the formation of clots in the cardiac cavities. These are formed within a few moments after the heart has ceased to act.

Massage of the heart, coupled with the use of adrenalin, will prove of service.

Approaching cardiac weakness is always indicated by failure of capillary circulation, which may be easily and instantly estimated by making pressure upon the finger-nails. The rapidity with which the blood will return to give them a natural appearance, after such pressure is made, will be the index as to whether or no stimulation is necessary. Tardiness in return of color, or absence, is a better indication of the approach of shock than is coldness of the nose or moisture of the skin. It often precedes acceleration of the pulse.

Respiration may be interfered with by a variety of causes. Not infrequently the tongue is allowed to drop backward into the pharynx as the patient lies upon his back, which, by its pressure, causes the epiglottis to fall backward upon and close the glottis. The indication here is to lift the tongue forward and carry the epiglottis upward so as to restore the air channel. Extension of the head and neck will accomplish much in this direction, as well as holding the lower jaw forward and upward by well-regulated pressure exerted behind the angle and at the same time by upward and forward traction upon the hyoid bone. But when it is necessary in cases of emergency to carry out this maneuver forcibly and extensively, then the tongue should be drawn upward and forward in the direction indicated in Figs. 41 and 42.

Tongue forceps are often resorted to for this purpose, and can be procured in various forms and shapes. To the writer their employment has always seemed far more barbarous than the much simpler expedient of passing a curved needle, armed with silk, through the tongue in either direction, 3 to 5 Cm. back of its tip. The suture thus drawn through is knotted and made into a loop, and may be employed through a long operation to make all the traction that will be required. This really makes the tongue less sore and produces less swelling and after-discomfort than does the use of forceps.

Fig. 42

Showing how dragging the tongue over the teeth fails to pull on the epiglottis. (Hare.)

Respiration may also be impeded or suddenly checked by the presence of a foreign body. This may possibly be a plate which the anesthetizer has failed to require the patient to remove, or it may be material ejected from the stomach; this latter is especially likely to happen when emergency has required anesthesia without due preparation. When this happens the fingers should be passed behind the epiglottis and the obstructing body removed. In rare instances some portion of food may have been so impacted in the glottis as to completely obstruct it. If such an emergency arise the trachea should be opened and relief thus afforded. Only in this way can life be saved. Embarrassment of respiration is caused at other times by the patient apparently “forgetting to breathe” or by his taking such shallow inspirations that nothing is accomplished. This may be combated in several ways. In the former instance the use of ether or injections of atropine will frequently afford the necessary stimulus to the respiratory centres. In the latter class of cases especially the most valuable expedient is the dilatation of the sphincter ani, which may be stretched with a speculum, or with the fingers. Long-drawn, even gasping inspirations may follow this expedient.

Finally in certain cases artificial respiration will be required, combined with rhythmical traction upon the tongue. The tongue should be grasped, or controlled by a suture, and retracted from the mouth at the rate of at least sixteen times a minute, while the chest is compressed at the same rate, the traction being made at the moment of relaxation of chest pressure. Tongue traction alone will sometimes renew respiratory movements in extreme cases.[9] Figs. 43 and 44 from Hare, show the combined manipulation of inverting the patient in order that the brain may not lack for blood supply, and carrying out artificial respiration.

While these measures are to be regarded as emergency expedients, they will often need to be supplemented by others, the use of adrenalin and of salt solution, either beneath the skin or in the veins, and the use of the Crile pneumatic rubber suit described in the chapter on Shock.

Fig. 43

Showing inversion of patient and method of performing artificial respiration simultaneously. (Hare.)

Fig. 44

Same as Fig. 43.

 

There is a delay in the management of the patient after the conclusion of an operation which is too often neglected—namely, prevention of such exposure as shall produce a sudden checking of perspiration. The patient should be wrapped in several thicknesses of blanket, leaving only the face exposed; and only when fully conscious should he be uncovered gradually and well dried with a bath towel. Such procedure takes away much of the danger of congestion of the lungs, or of the kidneys, which may cause serious disturbance should they occur.[10]

All foreign bodies should be removed from the mouth and pharynx. If the patient have been in water he should be suspended head downward, in order that the water may escape by gravity from the lungs. In all of these methods rhythmical traction upon the tongue will be found a valuable aid in the procedure.

Sylvester’s method utilizes the arms as levers by which to expand the thorax, by means of the muscles which pass between them and the chest. The patient is laid on his back, the shoulders somewhat elevated and the head thrown backward. The forearms are seized just below the elbows and carried upward over his head, by which movement the chest is expanded; here they are held about two seconds, and then brought down to the side of the chest and actual compression of the thorax made with them, for the same period of time. When the chest is compressed, an assistant may also press the liver upward and thus help to empty the lungs. The intent is to make from sixteen to eighteen of these movements in a minute. In children the movements are made more rapidly, and in infants considerably more. It is usually necessary that traction be made upon the feet to prevent pulling the body upward when the arms are moved to expand the thorax. If the manipulations can be carried out upon a table whose feet can be somewhat elevated this will also help, as the blood is thereby induced to enter the cranium.

Marshall Hall’s method is to roll the patient from his back on to his side, the uppermost arm being utilized to make pressure upon the side of the thorax in order to expel air. Then the body is rolled over on to the back, by which movement the chest is expanded. This method is not nearly as efficient as that mentioned above.

Fig. 45

Fell’s apparatus for forced or artificial respiration.

In case of drowning Howard’s method is quite applicable. The maneuvers are as follows:

1. Turning the patient upon the face, with a large firm roll under the stomach and chest, and protecting his mouth from the surface upon which he is lying, press with full weight two or three times, for four or five seconds, each time upon his back, so that the water is expelled from his lungs and stomach.

2. Then quickly turn him face upward with the roll beneath his back, with his head hanging downward and his hands above his head. The operator then kneels astride over the patient, with the hips between his knees, and grasps the lower part of the patient’s chest firmly, bracing his own hands with his elbows firmly against his own hips. With his full weight he then makes pressure upon the patient’s chest, compressing it laterally for two or three seconds, gradually leaning forward while doing this, and then with a sudden jerk pushing himself backward. The intent here is to imitate the ordinary respiration rate as above, or perhaps a little less often. This may be continued for a half-hour or even for an hour, sometimes with eventual success.

There should be also massage of the heart, in addition to traction upon the tongue. Artificial assistance should not be discontinued until the patient is breathing regularly and sufficiently without help. In Fig. 45 is represented the Fell apparatus for making forced artificial respiration, this being a great improvement on the so-called mouth-to-mouth inflation. The essential feature of it is a bellows, by which the air is forced into the lungs, through a mouth-piece made to fit tightly over the face, or through a tracheotomy tube. In accident cases other measures, such as artificial warmth, etc., should be employed.

Morphine offers no little aid in the production of anesthesia in many cases. Those patients who are terrified by the thought of operation, and who are in a semihysterical state when anesthesia is begun, may be greatly tranquillized by a hypodermic injection of 0.01 to 0.015 of morphine, fifteen or twenty minutes previously. Given in this way it acts as a heart tonic and general equalizer to the circulation. If a small dose of atropine be added the effect upon the respiratory centres is much enhanced. Again, in those cases where anesthesia is begun without it, and patients prove very rebellious, it will have the same happy effect. The only objection to its use is the nausea which may thereby be produced. There is no way by which to dissociate this from the nausea due to the anesthetic, elsewhere considered under the heading of the After-care of Patients.

Patients can rarely be so completely put under the influence of morphine as to justify its use alone.

Scopolamine.

—The Germans sell under this name an alkaloid made from the Solanaceæ, which seems to be identical with the hyoscyamine of the U.S. Pharmacopœia. Schneiderlin, in 1900, published a method of producing anesthesia with little discomfort by using it combined with morphine. The mixture seems more effective than either alkaloid alone, but is rather slow in action. On the day preceding the operation a trial dose of 0.02 of morphine and 0.008 to 0.01 of scopolamine may be given. This will demonstrate the susceptibility of the patient to the mixture. One hour and a half before the operation this dose, or a larger one, should be administered, and, if necessary, another one of smaller size fifteen minutes before the time of operation.

According to this method an interval of sixty to eighty minutes should elapse between the first dose and the operation itself. When anesthesia is thus produced it lasts from three to several hours. Others have advised to divide the dose into three injections, giving the first about two and one-half hours, the second one and one-half hours, and the third one-half hour before operating. In some cases this has produced complete and satisfactory anesthesia; in some it has not been complete, while in others serious symptoms have been produced. The statement that each alkaloid counteracts the dangerous effects of the other is not substantiated; it is probable that the combined effect is greater than would be that of either used alone. This mixture should rarely be used, save in those cases where general anesthesia is inadvisable, and where there are difficulties, even about the employment of local anesthetics.

The use of ethyl chloride, as the most volatile of the ordinary drugs, by which chilling or freezing of the skin may be produced, has been already mentioned. Other agents which chill or freeze may be used, e. g., a spray of common ether or of rhigolene, or the local application of ice and salt.

Liquid Air.

—Liquid air, when available, affords an excellent means of benumbing sensibility, since one or two very light applications, two or three minutes apart, admirably serve the purpose. It is, however, rarely available and should be used with great caution.

Cocaine.

—Of the local anesthetics cocaine, or some of its compounds or substitutes, will give the best results; although it is said that injections of pure water, if sufficiently bulky, will also answer the purpose of a local anesthetic. Cocaine has marvellous properties upon mucous surfaces or in the tissues, but none upon the unbroken skin. Where the parts to be operated are covered with skin it is necessary to inject the drug with a hypodermic syringe, as in the case of all deeper tissues. About the eye, the drug is used in from 1 to 4 per cent. strength; in the nasopharynx, from 2 to 4 for ordinary purposes; about the genitals, 2 to 5 per cent.; beneath the skin, ordinarily in strength of 1 to 2 per cent. In operations upon the nasopharynx and larynx it is often advisable to make a local application of a small amount of an almost saturated solution, by which a more complete effect is gained.

Cocaine is not without dangerous toxic properties, to which some persons are peculiarly susceptible. It will seriously disturb heart action in some; in others produce vertigo and mild delirium, and in still others peculiar erotic symptoms. Warm solutions are more quickly absorbed than cold ones. The use of more than 0.06 (1 grain) should be avoided.

When the skin alone is to be anesthetized the injection should be made into and not beneath. The nearer the cocaine solution is deposited to the principal nerve trunk or branches the more promising will be its effect.

The use of cocaine in operations, under general anesthesia, for the prevention of those depressing influences which cause lowered blood pressure and shock, has been alluded to in the chapter on Shock. For instance, it is well to spray the larynx after opening it and before making further operation upon it; while in all major operations in which large nerve trunks are exposed or divided, e. g., amputations, etc., the injection into the nerve trunks of a few drops of 2 or 3 per cent. cocaine solution prevents this kind of disturbance.

For small and localized operations the direct injection of cocaine into and around the area involved will prove sufficient. It is rarely necessary to use for this purpose a solution stronger than 1 or 2 per cent., especially if it is deposited drop by drop around the entire margin of the area and if the part have been previously made bloodless by pressure, as by the Esmarch rubber bandage. But when extensive operations are to be undertaken the method of “blocking,” so called, should be carried out. This consists in cocainizing the principal nerve trunks which supply the part, for which purpose an accurate knowledge of regional neural anatomy is necessary, with the intent to inject into or closely around the nerve trunks a few drops of a 1 or 2 per cent. solution. Working in this way by combination of injection, then of incision, by which the nerve trunks are better exposed and more fully protected in order to be more completely injected, and then proceeding farther with the operative part, extensive operations have been and may be done; such for instance as amputations, not alone of the limbs but even of the shoulder girdle, removal of large tumors, etc. In this way, for example, Kocher now removes most of the goitres which he attacks. The essential feature of this work is to first get the cocaine inside of the nerve sheaths. In this way a minimum of the drug is used with a maximum of effect. Nevertheless when a large nerve trunk is thus to be paralyzed temporarily it is best to inject the solution directly into it as well as around it inside the sheath. Cocaine is a temporary protoplasmic poison, and for the time being shuts off the afferent power of the nerve. One advantage of this method is the avoidance of shock as well as of pain. Another method, devised by Schleich, is to be preferred. He uses three different solutions, of which the second is commonly used. Tablets for making these solutions can now be obtained. In order to secure the best effect with them the parts should be made bloodless. The solution is deposited subcutaneously in a series of drops around the margin of the area, and then massage may be made to distribute the fluid more uniformly in the tissues. When the tissue to be operated upon is inflamed the injections should be made first into the healthy area on the proximal side.

Schleich’s formulas are as follows:

Various substitutes for cocaine are now on the market. Some of these are soluble and some insoluble. Eucaine is most commonly used, especially in form known as eucaine B., or beta-eucaine. It is weaker than cocaine, especially so in toxic properties, and solutions of twice the strength can be used, often with satisfaction, and almost always without danger. For urethral and eye work, e. g., it answers the purpose; nevertheless, it will sometimes prove disappointing. Orthoform is a crystalline, sparingly soluble artificial product, which is too light and too coherent to be generally serviceable. It often gives satisfaction mixed with other powders or in ointments, and it is usually free from toxic properties. Nervanin is another laboratory product, not equal in activity to cocaine, but almost free from unpleasant properties. Anesthesin is another similar product, which is practically free from physiological properties save that it acts as a local anesthetic. The latter may be employed for infiltration anesthesia in the following proportion, recommended by Dunbar:

Stovaine and alypin are among the latest synthetic substitutes for cocaine. The latter seems to offer promise of usefulness.

Adrenalin may be added to any of these solutions in proportion of 1 per cent. of a 1 to 1000 solution, and will have a beneficial effect in all cases.

The intraspinal injection of remedies was first suggested by Corning, of New York, in 1885; it remained, however, for Bier to perfect the technique in 1899, and to make it so popular that the same maneuver has been practised for various other purposes; as, for instance, for withdrawal of cerebrospinal fluid in cases of hydrocephalus, etc., or the injection of tetanus antitoxin. (See chapter on Tetanus.)

The intent in this use of cocaine is to spread the solution over the surface of the cord and beneath the arachnoid. For this purpose a needle about 4 inches in length, with a point not too sharp, preferably gold or platinum plated, is used; with this also a syringe which will hold 2 to 4 Cc., which can be firmly, yet easily, attached to the needle. The accompanying illustration (Fig. 46) will give an idea of the technique. The patient should be seated leaning forward so as to curve the back and open the intervertebral spaces. A sterilized towel is stretched tightly across the back from one iliac crest to the other; its upper edge should then pass just over the spinous process of the fourth lumbar vertebra. The injection is usually practised between the second and third lumbar spines, or between the third and fourth; the latter having been identified, the former are easily made out. The needle is entered about 1 Cm. to the right of the middle line and passed forward, inward, and upward, to a depth of 7 or 8 Cm. in the ordinary adult, until the resistance offered by the tissues is felt to have been passed and the point to have entered a cavity. If the needle has been passed alone the escape of a drop or two of cerebrospinal fluid will indicate that the spinal canal has been entered; if the syringe is attached to the needle the piston should be withdrawn in order to show the same result. It is possible to practise this operation with a patient in the recumbent position, but it is done more easily as above outlined. The skin may be frozen by the freezing spray, or may be anesthetized by the local injection of cocaine solution with the ordinary hypodermic syringe.

It is astonishing what beneficial effects can be gained from the use of a small amount of cocaine. It is rarely necessary to use more than 0.03 (¹⁄₂ grain) of pure cocaine in order to procure analgesia of the entire lower part of the body.

Beta-cocaine or tropacocaine may be used for the same purpose, in double this amount, but they do not give as reliable results. Morton, of San Francisco, has suggested that ¹⁄₂ Gr. powders of cocaine be wrapped in such a way that they can be repeatedly sterilized by a heat of 200° F., and that one of these be dropped into the syringe barrel, that this be attached to the needle, and the cocaine itself be dissolved in the cerebrospinal fluid withdrawn through the latter, and then thrown back again. This is probably the neatest and most serviceable method yet devised, and its originator has assured the writer that with 1 Gr. of tropacocaine used in this way, thrown into the spinal canal with considerable force, i. e., in such a way as to more completely distribute it, he has been able to practise operations even upon the tongue with little or no pain to the patient. The solution used for this purpose should be sterilized, also the needle, the syringe, the patient’s skin, and the operator’s hands. The water with which the cocaine solution is made should be first pure, then measured, and the solution made in such strength that not more than the amount indicated above will be used. This should then be again heated, but not quite to the boiling point, since cocaine solutions are impaired by too much heat.

Fig. 46

Technique of intraspinal injection.

The advantages of intraspinal anesthesia are many and obvious, and were it not for disadvantages this method would have supplanted all others for certain work. It is, however, by no means free from danger, both from the maneuver and from the drug itself. Carelessness in its introduction may lead to septic meningitis, while the drug itself may produce considerable and even serious or fatal disturbance, though these cases are rare. It has been claimed that 2 per cent. of the cases in which this method has been employed have, in consequence, terminated fatally. The immediate effects are largely confined to the stomach and the nervous system, and include nausea, intense headache, and profound depression. The remote effects are less positive, but have been stated to include serious changes in the cord itself. It is often a disadvantage to have the patient mentally conscious of what is going on, even though oblivious to pain. Inasmuch as cocaine produces analgesia rather than anesthesia, nervous patients will be likely to mistake the general sensation of lifting a limb, or manipulating it, for actual pain. There are not a few cases where chloroform and ether are so plainly contra-indicated that if it were possible to use any other agent with safety this would offer a valuable substitute.

The effect desired is not produced immediately, but comes on slowly, after the expiration of ten to twelve minutes. As ordinarily used, anesthesia of the surface will be produced up to the height of about the waist. Should it be desired, however, to increase or enhance the effect the solution might be injected between some of the dorsal vertebræ, although at this point it will require more skill to introduce the needle, and the operator should be cautious not to injure the cord. Below the second lumbar vertebra the cord breaks up into its segments and the patient would be almost exempt from this danger. It is occasionally necessary to tranquillize the patient’s fear by using morphine subcutaneously at the same time. It is a question whether this can be safely combined with cocaine for the subarachnoid injection. Failing in this it may be necessary to supplement the use of cocaine with ether or chloroform.

The intraspinal injection of normal saline solution, or even of pure water, has been shown by Eden to be almost as effective in some cases as the cocaine solutions. Bier has largely modified his statements about the value of intraspinal cocaine injections, and speaks of them as more dangerous than he had first appreciated.[11]

PART IV. INJURY AND REPAIR. — CHAPTER XXI. WOUNDS AND THEIR REPAIR. — CONTUSION. — LACERATED WOUNDS. — PUNCTURED WOUNDS. — INCISED WOUNDS. — REPAIR OF WOUNDS. — INJURIES TO VESSELS. — INJURIES OF NERVES. — INJURIES TO MUSCLES AND TENDONS. — INJURIES TO BONES. — CONTUSIONS OF THE VISCERA.

The old classification of wounds divides them into contused, lacerated, punctured, and incised. For descriptive purposes these adjectives are self-sufficient; they can be criticised only in case the injuries differ in character. The adjectives thus employed allude to the character of the injury as well as to its cause, but no meaning should be conveyed by any of them other than to indicate a severance of continuity in tissues. In either case cells are rudely torn apart. But whether the injury be subcutaneous and the tearing make a ragged surface; or whether the wound be an open one, with the possibility of introduction of germ-laden air and grosser impurities, even though the surfaces separated present an even plane, as in an incised wound; or a channel or tunnel, as when made by a pointed instrument or a gunshot missile, the principle is the same, and the same processes of repair are brought to work to undo the harm. There is but one natural method of repair, and that includes the exudate, or the utilization of the fluid portion of the blood already poured out, and the activity of cells, those which lie in the vicinity and those which are furnished from a distance, i. e., leukocytes and wandering corpuscles. It is of advantage to have the injury subcutaneous and protected from contact with the air, yet extensive injuries of this kind are often much longer in healing than those inflicted by the surgeon’s knife, when the parts can be brought into complete apposition with each other by sutures.

It is the writer’s intent to simplify the description of the healing processes and to insist that it is always the same, not modified in character but in duration and extent, according to the nature of the injury.

The term contusion implies a subcutaneous injury of varied extent, in which laceration cannot be left out of consideration. Even in the mildest contusion mechanical harm has been done, permitting a dilatation of the vessels and the escape of fluid. Should this occur in linear form, as by a whip-lash, there may be what is called a wheal. In loose tissues swelling occurs more easily, as in the eyelid, the scrotum, etc. Injuries of severity will produce laceration, at least of capillaries if not of arterioles, and the result is the escape of an amount of blood which will infiltrate the surrounding tissues and discolor them and produce an extravasation or ecchymosis. The blood barely escapes and coagulates before its absorption begins. The fluid portion disappears before the solid, and the pigment is usually the last. There results a black and blue spot; the color when near the surface is at first indigo or purple, and fades out through bluish and greenish tints into a yellow, which may not disappear for two or three weeks. Should blood collect in a cavity or in large amount the mass is called a hematoma; this is especially common in the pelvis and in the cranial cavity. Should a vessel wall give way from weakness caused by disease instead of by accident the result is the same.

Contused wounds of the surface often cover excessive and even fatal injuries within, as when a heavy object falls upon or injures the abdomen or a limb. The skin is resistant, and the writer has seen a limb pulpified by being run over by a heavy car, the skin being but slightly torn. In such accidents exploratory incisions are imperative. Better results will follow opening the abdomen in cases of severe contusion, for the purpose of exploring the viscera, than will follow the “let-alone” policy of waiting for something serious to appear.

An outpour of blood should be expected in every contusion, save the most trifling, while clot formation may ensue. Whether the clot will be absorbed or require the aid of the surgeon will depend upon its size, its location, and its liability to infection. Clot in some locations, e. g., pressing upon the brain or spinal cord, may justify extensive operation for its removal.

Pain produced by contusion is variable. When nerve trunks of considerable size have been injured pain is frequently aggravated. In general it is proportionate to the amount of swelling, i. e., to the density or laxity of the injured tissue. When exudate occurs beneath unyielding membranes, for instance the periosteum and the capsules of certain organs, the pain may be severe. The appearance of discoloration is proportionate to the depth of the injury and the amount of hemorrhage. The time of its appearance will depend upon the distance from the surface; after fracture of the neck of the femur it may not be observed for several days. The general condition of the patient will depend greatly upon his temperament. When there has been considerable extravasation the release of the fibrin ferment may produce a mild rise in temperature.

Treatment.

—So long as air or other infection can be excluded the treatment of contusions is simple. Cleanliness of the injured parts should be enjoined; also physiological rest, by their confinement within dressings or splints, or by placing the patient in bed. An antiseptic application, dry, watery, or in ointment form, should be applied upon a surface which has been abraded. Differences of opinion exist as to the respective values of heat and cold. When the case is seen early, before much swelling has occurred, the exudate may be limited by the application of cold dressings; whereas if seen after the swelling is at its height the use of moist heat may favor a more speedy re-absorption. The effect of extremes, either of heat or cold, is sedative, although hot applications afford more relief than do those of ice. Of domestic remedies in use among the laity it may be said that those which have any value owe it to the alcohol which they contain. Elastic constriction will reduce the amount of exudate and assist in the absorption of that already present. It is a measure, however, to be used with great caution lest venous return be interfered with and edema or gangrene be the consequence. A joint tensely distended with fluid as a result of combined contusion and laceration, called a sprain, may be emptied by aspiration, but this should be used only under antiseptic precautions. Finally any collection of blood which fails to disappear may be incised and cleaned, its cavity mopped out with compresses, and its surface made to come in contact by pressure. In hematomas and large extravasations of blood, sometimes in joints, but rarely in the pleural or peritoneal cavities, this method may also be used.

Lacerated wounds differ from contused in the character of the tears in the tissues affected and in the exposure to infection by contact. They vary in extent and severity. Not infrequently tissues or organs of the greatest importance are lacerated, e. g., the globe of the eye, the liver, the intestines. The term laceration itself implies such open injury that part of it may be exposed to infection. The first danger is from hemorrhage. This may subside spontaneously, or may have been checked by some first aid, or may prove nearly fatal by the time the patient is seen by the surgeon. The first measure will be hemostasis by the readiest and most effective measures at hand. This may mean the application of compresses or of a tourniquet, or even of manual pressure, until surgical procedures can be instituted. Shock should be treated by lowering the head and raising the extremities, or bandaging the latter, and the subcutaneous administration of morphine or atropine. Emergency treatment of these cases should include removal of foreign bodies, and such cleanliness and attention to antisepsis as may be possible at the time. Support of the injured part should be effected temporarily until dressings can be scientifically applied. If cane sugar will keep fruit and meat from decomposition it will have the same effect in human tissues, and a laceration with or without compound fracture of bone may be filled with granulated sugar until a suitable dressing can be applied.

The surgical treatment of laceration should include the following measures: Hemostasis; the removal of foreign bodies, as well as of tissue which is so injured as to make repair impossible or even questionable; a careful study of nerve supply, in order to be sure that no nerve suture should be made; a similar study of muscles and tendons, in order that tendon suture may be promptly made; careful antisepsis throughout, asepsis being impossible; closure of the wound by buried and superficial sutures, and such drainage tubes or outlets as may permit free escape of whatever products of inflammation or disintegration may result. There should also be provision for physiological rest of the injured parts as well as of the patient’s mind and body.

When large areas of skin or deep tissues are destroyed or torn away, as in scalp wounds, avulsion of limbs or parts of limbs, it may be necessary to retain that which can be saved and to remove that which would slough if left to itself, thereby providing for flaps of skin by which the wound may subsequently be covered, or leaving them in case removal of a part must be made.

Everything which has vitality should be spared; on the other hand, that which has lost its vitality should be removed at once. Thus amputations may be sometimes called for because of extensive lacerations with destruction of vascular and nerve supply, even though the bones be uninjured.

In cases where the question of viability of tissues cannot be promptly decided it is best to keep the injured part immersed in water as warm as can be borne. In hospitals the entire body may be kept immersed for days. By the use of warm water parts which have been seriously injured may be restored. Ulcerations which are seen after the sloughing process has begun can be best treated by immersion or by the application of brewers’ yeast upon compresses or cotton. No other substance, perhaps, will so quickly clear up an indolent or foul surface as this; it hastens the time of separation of all that is dead or dying and restores healthful activity to the surrounding tissues.

Extensive lacerations leave frequent opportunity for operations by which function may be restored or improvement affected.

The essential features of punctured wounds are sufficiently indicated by the descriptive name; but harm may be done through a small external opening. An important subvariety of punctured wounds is inflicted by gunshot missiles, which will receive consideration by themselves. Injury to important vessels may lead to serious hemorrhage; while injuries to nerve trunks may be followed by paralysis of sensation and motion, or, as in the case of a sympathetic trunk, by the well-known consequences of division of vasomotor nerves, e. g., in the neck. When the punctured wound bleeds freely and externally it may be assumed that some large vessel has been injured. When it bleeds into one of the cavities of the body delay in recognition may occur. This is true of a puncture of the skull by which the middle meningeal artery or one of the sinuses is wounded, when the symptoms of brain pressure may tardily or rapidly appear. In the chest the intercostal or internal mammary artery may be so injured as to bleed into the pleural cavity and cause death. A puncture of the heart frequently leads to fatal hemorrhage into the pericardial cavity, and in the abdomen puncture of the various viscera has led to consequences beyond help save when prompt relief could be afforded.

The dangers attending punctures pertain to the introduction of infectious material which may produce sepsis or may slowly produce tetanus. No ordinary weapon or tool is clean in a surgical sense, while a rusty nail is even less so. It will be seen, therefore, that the danger inherent in such a case is not to be measured by either the size or the depth of the wound.

In dealing with these cases the first attention is to be given to hemorrhage. Obviously punctures in certain regions are much more likely to be followed by hemorrhage, and any puncture in the vicinity of one of the large vessels should be managed with caution, especially if the surgeon ascertain that it had bled profusely when first inflicted. Such a puncture, when seen a few hours later, may have become occluded by clot, or a considerable hematoma may have formed beneath the skin. It is safe to presume that there is more danger of septic infection than can accrue from later attention, and it would be advisable in such cases to anesthetize the patient and lay open the parts freely under full aseptic precautions, in order that the clot be turned out and any bleeding vessel secured. A brief study of such a case will decide the question of injury to the principal nerve trunks. A principal nerve which has been injured or divided should be carefully sought for and its ends freshened and sutured. This is true also of any tendon whose function is evidently lost. If the thorax have been punctured and the physical signs indicate the presence of fluid, i. e., blood in the pleural cavity, it should be incised and the blood withdrawn. This method should also be applied to punctures of the heart. These measures will be more completely dealt with in treating of the surgery of the chest and its contents.

Punctured wounds of the abdomen may give rise to great anxiety. If none of the viscera have been injured they may be let alone, but if doubt exists as to the safety or injury of any of them the abdomen should be opened. (See Surgery of the Abdomen.)

Treatment.

—For emergency purposes antiseptic occlusion is the best procedure, and all punctures inflicted by ragged and infectious materials, as rusty nails, should be treated by free incision, with thorough cleansing and packing with antiseptic material, that the wounds may heal by granulation.

Incised wounds are those inflicted by a sharp object which divides the tissues abruptly and with a minimum amount of disruption. They invariably bleed, sometimes seriously, even to a fatal degree, the hemorrhage in such cases being due to severance of large vascular trunks. Like contused wounds they vary as infinitely in extent as in locality. According to their locality and dimensions important structures may be severed, e. g., the trachea, the large nerve trunks of the body, the tendons, etc., while visceral and joint cavities may be more or less widely opened. When death occurs soon after injury it is generally from hemorrhage. They are attended by the same dangers of septic infection as are punctures, especially when there is neglect in the emergency dressing. Should the pleural cavity be opened there may be collapse of the lung.

Hemostasis is the paramount indication in all incised wounds which bleed seriously. Hemorrhage is to be controlled temporarily by any expedient, later by ligation or suture, or both. The remarks above in relation to possible injury to vessels and nerves are of equal force in this consideration. Every divided nerve trunk, as well as every severed tendon, should be reunited by suture. If a joint have been opened it should be cleansed and drained, even though the incision be closed. Should there be injury to any of the viscera, the wound may be enlarged in order that exploration may be made and suitable remedies applied. This is true of every punctured or incised wound. No hesitation need be felt about enlarging it so as to permit of investigation. Hemorrhage having been checked and all required attention having been given, the closure of an incised wound may be made partial or complete according to its condition. If fresh and clean it may be almost completely reunited, using deep and buried sutures in order to bring into contact its deeper portions, while superficial sutures will suffice for the skin. Drainage may be by tubes or gauze or by loose suturing of the surface; but no incised wound whose surfaces have become contaminated should be completely closed by primary suture until all such surfaces have been freely cut away and appear healthy and uninfected. An old infected and gaping incised wound may be cleaned by the application of brewers’ yeast, and when granulating it may be closed secondarily with sutures, by which granulating surfaces are brought into close contact.

Of wounds in general it may be said that there are mixed types as well as illustrative examples. Thus a wound made by a hatchet or axe may partake of the nature of contusion and of incision. In instances where personal violence has been applied multiple wounds of varied character may complicate the case. The statements made above pertain to their conventional and common characteristics. Treatment which would be proper in one case may be impossible in another. There is always room for discretion and good judgment, though there are fundamental rules which apply to all cases, and include exact hemostasis, surgical cleanliness, repair of severed nerves and tendons, removal of foreign bodies and involved tissue, and the enforcement of physiological rest.

The process of repair is essentially the same, being modified only by the needs of the wound and the tissues involved, and by their environment. Whether soft tissues or bones are being repaired the differences are apparent rather than real, as bony tissue is temporarily decalcified, and then, as soon as the process permits, is once more stiffened by deposition of calcium salts.

The process of repair should be begun immediately after the cessation of the disturbance which has produced the wound, and as soon as the bleeding is checked. It may be materially influenced and retarded by the presence of bacteria or other foreign bodies, but its character remains unchanged. Healing has been described as occurring by primary union, or by “the first intention,” and by granulation, or the “second intention.”

Wounds which have been permitted to remain clean, with their edges brought together so that the surfaces are in contact, are healed with a minimum of waste of reparative material, the process being as follows: The small vessels are occluded with thrombi up to the first collateral branches; the leukocytes begin to penetrate the film of blood, which, having coagulated, serves as a cement to help hold the surfaces together. By their proliferation and more complete organization the gap between the surfaces is bridged with both fibrous and capillary bloodvessels, and within sixty or seventy hours the clot has become largely replaced by organized cells. Meantime from the endothelial cells of the vessels and vascular spaces, as well as from the fixed cells of the connective tissue, the so-called fibroblasts are formed, which are later converted into connective tissue. Many of the cells which have wandered to the scene of activity, or have been there reproduced in unnecessary numbers, disappear again, either into the circulation or they serve as food for the fibroblasts. Branching cells attach themselves more intimately, and thus the original clot is completely converted into fibrous and connective tissue, and this becomes a scar, which extends as deeply as did the original injury. New capillaries are rapidly formed by a budding process, and supply the pabulum required for nourishment of the new cells. By fusion or amalgamation of neighboring vascular buds complete new vessels are formed, extending through the new tissue from one side to the other, while around them the fibroblasts or connective-tissue elements arrange themselves. From this it will appear that the coagulum which forms within a wound is desirable as a scaffolding upon which the process of repair may be begun. But it is desirable that this coagulum should be small in amount, in order that these processes may not be too long delayed; hence the advisability of removing all clots within a wound when closing it, and preventing the formation or leaving of dead spaces in the tissues in which blood clots may collect.

The process of granulation is not dissimilar to that described above, save only in its gross appearances. Granulations consist of vascular buds surrounded by leukocytes and lightly covered by them, while around the base of each bud epithelioid and spindle cells arrange themselves, these fixed cells organizing themselves more and more, as the wound fills up, with the more superficial layers of granulations. In time they are converted into a dense fibrous tissue which forms later what is known as the scar. As before, also, the spaces between the young capillary loops are filled with large nucleated cells derived from the fixed cells of the tissue, and from the endothelial lining of the newly formed vessels. Thus fibroblasts are produced in each case, and are often more or less mingled with giant cells, especially if some foreign body, such as a silk ligature, be embodied in the tissues. The particular function of the leukocytes seems to be the removal of red corpuscles and fibrin from the original clot.

The granulation tissue thus constituted by capillary loops and proliferating cells constitutes the basis of all wound repair. Later this tissue assumes more of the fibrous and less of the cellular character, while the fibroblasts arrange themselves in accordance with the mechanical requirements of the tissues and the stress or strain placed upon them. This tissue is at first vascular, but as it condenses its capillaries become less numerous and smaller, and the final white fibrous scar is usually almost bloodless.

When there has been loss of skin, or when skin edges are not brought together, the deeper process of granulation needs an epithelial covering, which cannot be afforded by mesoblastic or endothelial cells. The formation of an epithelial or epidermal covering is a process peculiar to epithelial tissue alone, and takes place mainly from the cells of the rete Malpighii.

Epithelial elements of the skin will afford a large amount of covering, and yet even their activity sometimes is insufficient and has to be atoned for by skin grafting. Should the granulating surface be small, and so situated that the fluid upon its surface may dry by evaporation, there will result a crust or scab, which, while it conceals from observation what is going on beneath, serves as an admirable protection, beneath which proliferation of epithelium takes place. A spontaneous detachment of the scab may take place when this process is complete, and with the loosening of the crust it is apparent that repair has become complete. This is known as healing under a scab or under a crust.

Two clean and healthy granulating surfaces may be so placed in contact with each other as to blend together by exactly the same process as that by which granulations are first formed. This is called secondary adhesion, or by the older writers the “third intention.” Advantage is taken of this possibility in the application of what are called secondary sutures, which may be placed some days before they are utilized, with the intent to bring together surfaces so soon as they shall present granulations.

One of the most interesting of all healing processes is that by which severed tissues, when promptly replaced, often reëstablish vascular communication and grow again in a satisfactory manner. Thus a severed ear, nose, or finger-tip may be replaced, and, if carefully held in situ, the parts being kept at rest, will prevent disfigurement and the loss of important tissues. In these cases the severed tissue remains passive several days until it has become vascularized. Meantime its nutrition seems to be maintained through the medium of the living tissues to which it has been affixed, probably by absorption of their blood plasma.

Two human tissues are essentially non-vascular, the cornea and cartilage. The former appears to be nourished by cellular interspaces which may admit leukocytes from the surrounding tissues, and through these proliferation and vascularization occur; while a scar in the cornea remains permanent, and the new tissue by which repair is brought about never becomes transparent like the cells composing the cornea proper. In cartilage scar tissue is produced, as in other tissues, by a similar process, in spite of the extent of the cartilaginous layer and its non-vascularity. In general the more specialized a tissue the less completely does it heal, and the specialized tissues, like the retina, etc., seem to be incapable of reproducing themselves. Low down in the animal scale some parts can be more or less reproduced. In the ascending forms there is less tendency in this direction; in man there is little reproduction of an original tissue, scar tissue taking the place of most of that which has been lost. An apparent exception to this is seen in the osseous system, where a large amount of bone may often be reproduced. Epithelium, also, whether on the external or internal surfaces of the body, can regenerate itself in large degree and amount. From every small island or mass of epithelial cells which can be retained new cells may thus be reproduced; hence accrues the advantage of leaving such epithelial collections whenever possible, and wherever they may be beneficial. If upon a burnt area it happens that epithelium has not been completely destroyed, new skin may be confidently looked for from each clump of epidermal cells. It should be remembered, however, that with the epidermization of a surface under these circumstances merely an epithelial covering is secured. The distinctively dermal appendages, such as hair, sweat glands, and sebaceous glands, are not reproduced. If the highest ideal results are to be secured in any case the parts must be put in the most favorable condition, which means early surgical attention to every wound.

Bloodvessels are subject to contusion, to laceration, and to incision. They may be contused by superficial blows, compressed against underlying bone, torn in the replacement of old dislocations, or punctured or incised by accidental or homicidal injuries. A vessel which is not abruptly divided but is seriously injured will usually sustain a separation of its internal and middle coats, which curl up within the external coat, occlude the channel, and lead to thrombosis. A vessel thus occluded may tend to gangrene of the parts supplied by it or to a temporary ischemia, with numbness and pallor if an artery, or to passive edema if a vein. In cases of such injury it is always hoped that the blood supply will be provided through the collateral circulation. If a vessel be torn or cut across there may result a hematoma which may lead to immediate prostration, from hemorrhage, and to gangrene by stopping the blood supply. Such blood tumor rarely pulsates, but may cause extreme pain. The character and the size of the swelling will depend upon the tissues which surround the injured vessel. Cessation of the pulse on the distal side of an injury nearly always implies temporary occlusion. Traumatic aneurysm may be produced by lateral injury to an arterial trunk, by which its continuity as such is yet not completely disrupted.

If a large outpour of blood has occurred it will be safer to incise and turn out the clot and secure the injured vessel. In milder cases the surgeon should do all that he can by rest and by position to favor restoration of blood circulation. After the subsidence of acute symptoms massage and gentle motion will serve to promote absorption of the escaped blood. Cases will occasionally occur in which the principal arterial trunk of a limb should be tied, hoping thereby to save the member. Amputation may be the last resort when gangrene is impending.

Injury to the veins is of a less serious nature in so far as immediate consequences are concerned; nevertheless a punctured wound or a large vein is always a serious matter. The pressure of the blood may produce gangrene, or cause so large a hematoma that it should be incised.

Fine silk sutures may be applied to wounded vessels, arteries or veins, when they have been partially severed.

The healing process in all these cases is essentially the same. It may mean the formation of a clot in or around a vessel, followed by absorption of its principal portion and organization of what remains. A vessel itself which has once been occluded by thrombus will usually remain closed, a cord of fibrous tissue taking its place. Only in rare instances is continuity of the blood channel preserved or regained. In such cases the collateral circulation affords the life-saving feature. The granulations which intrude themselves into the clot gradually substitute tissue for coagulum, the conversion beginning promptly, but often occupying weeks for its completion.

Lymph vessels may be lacerated in almost any injuries and more or less lymph escape with the blood. When the skin is torn from the underlying parts lymph collects in the cavity thus made, while its wall may undergo more or less organization, and formation of a lymph cyst results. Should one of these connect with a good-sized lymph duct, as, for instance, in the neck the thoracic duct, then lymph cysts of considerable size might form. Should these rupture or be opened lymph fistulæ might result.

By small hemorrhages into a nerve sheath nerve function may be either temporarily or permanently disturbed. A compression too long-continued may lead to degeneration within the nerve fibers. Providing this do not occur there may be complete restoration of function, or there may result chronic neuritis, with pain and irritation. A later consequence of all nerve injuries is more or less serious disturbance of sensation, while still later parts supplied by the affected nerves may undergo more or less atrophy as well as spastic contraction, by which loss of function and deformity are produced.

There is a form of nerve injury which is due to the temporary pressure of the elastic tourniquet, frequently applied around limbs previous to operations, or to pressure which is made by crutch handles upon the axillary plexus, and called crutch paralysis. Limbs carelessly allowed to hang over the edge of the operating table during prolonged operations also have suffered in the same way. Such lesions are of the character of a contusion, but are often followed by paresis, paralysis, and by various sensory disturbances.

Injury to a nerve trunk having been recognized by a study of the local features of a given case requires special treatment in case laceration or more localized division can be assumed. The nerve known to be lacerated and torn across should have its ends freshened and be reunited by fine catgut sutures; also a nerve trunk known to be punctured or divided. Such injury is not necessarily inflicted from without, as it may be produced by a fragment of bone; in this case the operation should be directed toward the bone as well as toward the nerve trunk itself. A divided nerve trunk, if neatly sutured, heals by the organization of blood clot, as in other instances, actual nerve communication being made across the intervening clot by a process of regeneration or reduplication of the true nerve elements, the peripheral neurilemma playing an important part. Autogenetic power decreases with the age of the individual. By careful nerve suturing disability may be prevented.

Even months after injury much can be accomplished by nerve suture properly performed. Symptoms similar to those of division may occur when a nerve trunk is surrounded and compressed by bone callus after fracture, as when the ulnar nerve is thus caught. If too long a time have intervened it may be necessary to exsect the injured portion and then bring the ends into apposition by sutures. Other methods of atoning for these nerve injuries by nerve grafting, etc., will be described in the chapter on Surgery of the Peripheral Nerves.

Neuritis may be overcome by counterirritation, preferably with the actual cautery, i. e., the “flying cautery,” by massage, and by galvanization. The pain in many of these cases can be mitigated, if not completely relieved, by the x-rays, or by the high-frequency current. In some cases nerve elongation may be brought to bear and a tender and irritable nerve be thus brought under subjection.

Lacerations or divisions of muscles are usually repaired at first by fibrous tissue, the result of organization of a clot. Later a true muscle regeneration takes place and muscle scar finally disappears. Atrophy of a muscle is not a sign of injury directly to itself, but often results from injury to the nerve which supplies it; for example, the circumflex nerve may be injured in shoulder dislocations, while the deltoid muscle, which is supplied by it, speedily undergoes atrophy.

Muscle fibers may be torn by violent exertion. Such an accident may be followed by pain and loss of function. An interval can often be felt, even from the outside, between the torn muscle ends. The injury will produce considerable hemorrhage. The amount of function regained in a muscle will depend to some degree on the extent of its injury. If it have been injured by an incised wound it will depend upon the way in which it is brought together after an open incision. The origin and insertion of such a muscle should be approximated by proper position, and so maintained by the dressings, in order that perfect rest may be more easily maintained. When a portion of the fascia or aponeurosis is torn the muscle fiber may protrude and form a hernia of muscle.

Tendons often suffer from contusion, in consequence of which they may become adherent within their tendon sheaths; this leads to stiffness of the part and more or less loss of function. Sometimes they calcify, as does the adductor magnus tendon in the formation of the so-called rider’s bone. The tendon most frequently injured is that of the quadriceps, near the knee.

If it can be decided that a tendon has been divided or torn across its prompt reunion by suture should be always practised. Also a divided muscle, if exposed, should be drawn together with sutures, chromic or hardened, so as to make them more reliable. Tears of aponeuroses and fasciæ should also be sutured. Tendon suturing is nearly always successful, especially if it can be done in a cleanly manner; while tendon grafting is a measure which may be reserved to overcome the consequences of injuries to muscles and tendons not disposed to repair.

Aside from simple and compound fractures, which are essentially bone wounds, there may be seen hemorrhages beneath the periosteum or in the immediate vicinity of bones, which are usually small in amount, yet may cause considerable disturbance. The traumatic hematoma of the scalp which often follows delivery is an illustration of an injury of this class, the periosteum itself being sometimes separated. Collections of blood under these circumstances which fail to disappear by absorption may be incised and the contained clot turned out.

PLATE XII

FIG. 1

Young Granulation Tissue Following Bur., a, aa, thin-walled capillaries. Large nuclei, fibroblasts horseshoe nuclei, leukocytes. × 250.

FIG. 2

Young Scar. Numerous capillaries perpendicular to surface. Spindle elements, fibroblasts considerably smaller than in Fig. 1. × 250.

FIG. 3

Mature Scar. Dense fibrous connective tissue with a few fibroblasts. At a, a small bloodvessel. × 250.

Granulation Tissue organizing into Cicatricial Tissue. (Karg and Schmorl.)
Illustrating statements made on several of the foregoing pages.

Contusions of the viscera may be followed by many and disastrous consequences. They compromise such lesions as rupture of the liver, kidney, spleen, laceration of the bowel, bladder, or gall-bladder, and may occur by blows which do not break the surface; or any of the viscera may be lacerated, punctured, or gashed by gunshot, punctured, or incised wounds. These will be more completely considered in Chapter XLV.

CHAPTER XXII. GUNSHOT WOUNDS. — 1. Hemorrhage. — 2. Shock. — 3. Pain. — 4. Powder Burn. — 5. Localizing Symptoms Due to the Presence of the Bullet. — 6. Multiple Wounds. — 7. Entrance of Foreign Material. — 8. Explosive Effects. — 9. Perforation of the Large Cavities of the Body — Diagnosis. — Prognosis. — Treatment.

Gunshot wounds are usually considered with the special subject of military surgery. Military surgery as such, however, consists in the application of general surgical principles. Nevertheless a gunshot wound is essentially the same whether it be received upon the battle-field or in civil life, and the injury inflicted by a piece of flying shell is in no sense different from that which may be received in a blasting accident.

A gunshot wound is always contused and lacerated, and often punctured. According to its size and shape, its location, the nature and velocity of the missile, the distance at which the weapon was discharged will depend its severity and prognosis.

Shot vary in size from those which weigh but a fraction of a grain to buckshot which weigh nearly one-third of an ounce. Revolver and pistol bullets vary in diameter from 0.22″ to 0.45″, and in weight from twenty-five grains to ten times that amount, and nearly always of conical form. They are usually made of compressed lead, sometimes hardened by the addition of tin or antimony.

The old military weapons, such as the Springfield rifle, have been entirely abandoned, and for them have been substituted rifles of smaller bore, projecting bullets of from 0.25″ to 0.31″, varying in weight from one-fourth to one-half ounce and attaining a muzzle velocity of nearly 2500 feet per second. They have, therefore, a much increased range and may kill at two miles. Their trajectory is flatter and the character of the wound caused by these modern weapons is different from those inflicted, for instance, during the Civil War. The bullets now in use in the armies and navies of the world are nearly all encased in a thin covering of steel, copper, etc., which is known as the jacket or mantle. They are from 3.5″ to 4″ in length, possessing a much greater range than a shell bullet, while the rifling of the weapon is so made as to give them a more rapid rotation. In active service, moreover, these are usually fired with smokeless powder. The so-called “dangerous zone,” i. e., that where mounted men or infantry can be injured, is much wider than formerly.

In India the practice has been introduced of leaving the point of the bullet uncovered by the mantle, so that when it strikes it would “mushroom”—especially in the bone. These “Dumdum bullets,” as they are called, from the place of manufacture, inflict much more serious injuries than do the relatively smooth perforations made by the others, and have been considered so cruel that they are excluded from use in civilized warfare.

During the Russo-Japanese war, in which nearly all previous records were broken, the deaths from gunshot wounds constituted but a small proportion of the entire loss in camp and warfare, a larger number of soldiers dying from disease and exposure. Statistics also show that out of every 100 cases of gunshot wounds 12 per cent. have been produced by bullets, the remaining portion being caused by shell, etc. De Nancrède has epitomized some interesting figures which may be here quoted: In the United States army during the Spanish war 4750 casualties were accurately studied; of these wounds of the lower extremities constituted nearly 33 per cent., those of the upper extremities nearly 30 per cent., those of the trunk a little over 22 per cent., and those of the head and neck a little over 15 per cent. During the South African campaign the mortality among the wounded was 5.7 per cent., essentially the same as that during our Cuban and Filipino campaigns, and in marked contrast to the 14 per cent. mortality of the Civil War. Considering that with our Mauser weapons the trajectory is practically flat up to 500 yards, and they may kill up to a distance of two miles, it will be seen that this difference in figures is important. The British discovered in their campaign against the Afghans, who were using antiquated weapons, that their own Lee-Metford bullets would pass through their enemies without disabling them, while the British soldiers who were once struck by the large, soft-lead bullets of their antagonists were far more seriously injured or absolutely disabled.

As one explanation of the injury inflicted by modern projectiles there has been advanced the theory that a bullet with a high-muzzle velocity, striking an object while it still retains most of its original speed, compresses and forces ahead of it into the wounded tissues a small column of air, which, exercising an expansive force, produces more or less explosive effect, that may be seen along the bullet track or at the point of exit. These explosive effects are proportionate to the size of the bullet, its bluntness, and its velocity. This theory was more tenable in the days of large and blunt projectiles than today, for in time past experiments have shown that when a bullet is dropped into water from a height there is forced into the water along with it a certain amount of air, estimated by Longmore at twenty times the actual volume of the bullet itself. It may be doubted, however, whether the rifle projectiles of today can produce sufficient air pressure to cause the destructive effects thus attributed to it.

Fig. 47

a, completely shattered after perforating a horse’s thigh-bone at 220 yards; steel mantle stripped; b, ball with mantle torn off and rolled up, core deformed, after shattering human tibia at 60 yards; c, wholly disorganized ball, which destroyed middle metatarsal bone of horse at 660 yards, steel-mantled; d, ball which shattered a human femur at about 750 yards, steel-mantled; e, remains of steel mantle and part of core lodged in human femur, wound inflicted at about 1100 yards; f, g, fragments of mantle found near the orifice of the wound of exit at about 1100 yards’ range, steel-mantled; h, piece of steel mantle split off by striking a dried horse’s metatarsal at over 1300 yards; i, steel-mantled ball which perforated the internal femoral condyle and lodged beneath the skin at nearly 2200 yards. (Recent foreign report.) (De Nancrède.)

Another method of accounting for shattering effects noted in many of these wounds is hydrodynamic pressure, depending upon the incompressibility of fluid and of tissue containing it, and the narrowing of the space occupied by fluid as a result of the transfer of pressure in all directions. Other things being equal, the most marked effects would be manifest in organs containing the most fluid, the effect increasing with the amount of fluid, the speed of the bullet, its size, and any alteration of shape which it has undergone in transit. It has been shown that the hydrodynamic pressure of steel-jacketed modern bullets varies from six to eight atmospheres. This theory accounts for the peculiar destructive effects seen in the brain, the heart, the stomach, and intestines when struck at short range.

Another method of accounting for the results of a bullet wound takes account of the peculiar effect due to the rapid rotation of the bullet, the movement given it by the rifling of the barrel from which it is fired. It appears that a bullet travelling at the rate of 620 meters per second will average about four rotations per meter. Even in passing through a human body this would scarcely give it but two rotations in transit, while in passing through any given bone the force would be too slight to be appreciable.

While the theories mentioned above, the hydraulic and hydrodynamic, are attractive, yet they are unsatisfactory; we can do little more than sum up the damage done by a rifle ball as due to arrest and divergence of its energy, penetration depending upon its remaining velocity, its preservation of its original shape, and the resistance offered by the part injured. If the latter be great, and its shape be but slightly changed, there are pronounced explosive effects. Moreover, one end of the bullet is a little heavier than the other, and this will tend to produce a certain amount of tilting, by which a key-hole wound may be also produced. Fig. 47, from De Nancrède, shows the many alterations in shape which may be produced under various circumstances. Again, hard-metal jackets or mantles may be stripped off bullets before the latter reach the body, or in passing through it, as has been shown.

Bruns has shown that with the ordinary small arms the size of the wounds of entrance and exit diminishes with the decrease in velocity or increase of the distance, although allowance should be made for the manner and angle at which the bullet strikes the surface, the wound being circular or oval according to these conditions. The wound of exit will depend upon the direction of the axis of the bullet at the instant it leaves it; thus it may be oval or irregular. When the bullet in transit shatters or comminutes a bone the wound of exit may be made much larger and more ragged than otherwise. In a general way Bruns makes the statement that, other things being equal, the damage inflicted by the escape of a projectile from the body varies according to distance from the weapon. Thus up to fifty meters a considerable amount of destruction of muscle, etc., may be produced. The area is small and the track of the bullet is smooth and little larger than the caliber of the projectile. Between 100 and 300 meters there is little destruction of muscle, and the wound of exit is smooth and may contain some bone debris. Thus Bruns would make it appear that the distinguishable characteristics of near and distant shots appear in the variations to be noted between the wounds of entrance and exit.

After a careful study of the alterations in the shape of the bullets themselves, Coler and Schjerning reported at the Twelfth International Medical Congress that only in 4.5 per cent. of all hits does deforming of the bullet occur; if hits in the bones only are considered, the percentage would be much greater. In wounds of the other parts alone there is rarely any deforming effect upon the projectile. They also show that careful distinction must be made between the deformity of the bullet caused by the body and that resulting from impact upon some object before reaching the body. Thus if a bullet have first struck a branch of a tree, or some object upon the ground, it may have become so altered in shape as to correspond almost to a Dumdum bullet. The harm done by such a ricochet shot depends upon its unexpended energy and its altered shape, but will always be greater than if it had struck in the direction of its long axis.

The question of the heat imparted to a projectile in its course and the possibility of its being sterilized by such heating are questions which have been carefully investigated. The heat of a bullet produced by penetration into a hard material will depend upon the striking distance and the density of the material. In the human tissues the heat attained by a bullet, even when penetrating a bone at short range, is rarely 100°C., while at long range it will scarcely amount to half of that. There is no accurate measure of the heat that may be engendered in its passage through the atmosphere, but the question is one of interest, in that it brings up the possible sterilization of the bullet and its capacity for destroying such septic material as it may carry in with it. A series of experiments made in Baltimore and elsewhere permit the following conclusions to be drawn:

1. The majority of cartridges in their original packages are free from septic germs, this freedom being due to the precautions observed during their manufacture.

2. As a result of this cleanliness the majority of gunshot wounds are not septic.

3. Such resistant germs as those of anthrax, when applied to the small bullet of a hand weapon, are rarely completely destroyed by the act of firing, and it is possible to infect an experimental animal with such a projectile.

4. The ordinary germs of suppuration are not always destroyed, and may also cause infection.

These conclusions may be epitomized in these two statements: that bullets from small hand weapons are not necessarily sterilized by the act of firing, and that they also may infect.

The principal features to be noted in a case of gunshot wound are the following:

• 1. Hemorrhage.
• 2. Shock.
• 3. Pain.
• 4. Powder burn.
• 5. Localizing symptoms.
• 6. Multiplicity of wounds.
• 7. Entrance of foreign material.
• 8. Explosive effects.
• 9. Perforation of large vessels and the viscera.

—Hemorrhage may be internal or external. When internal it is rarely so accessible as to permit of the saving of life, yet the effort should be made to ascertain the source of the hemorrhage, as only in this way can life be saved. For example: A patient may bleed to death from injury to an intercostal artery, an epigastric, etc., while in either case a very simple expedient would tend to save life. External hemorrhage is generally due to injury of main vessels, and may end fatally unless first help be instantly rendered. Since the introduction into the army of a trained hospital corps, and a widespread diffusion of a knowledge of “first-aid dressings,” this is much less likely to occur than in the days previous to the use of the emergency packet. Recent military experiences have been that hemorrhages from limb vessels are much more likely to subside spontaneously than those of the viscera.

—Shock is present in a large proportion of gunshot injuries, especially those of the viscera and the region of the spine. Experienced army surgeons speak of the peculiar facial expression in those cases of shock which demand immediate attention.

—The symptom of pain is exceedingly variable. It is rarely complained of at the time of infliction, especially when the individual is laboring under stress of excitement. The pain of a wound will be increased by every movement of the body. When momentary pain is followed by local anesthesia, and especially if the latter be permanent, it will indicate the division of a nerve trunk, which will justify an operation for exposure of the site of the injury and nerve suture.

—Powder burn is met with only as one of the complications of a short range and injury of an exposed part. Its degree is modified by the distance of the injured part from the muzzle, by the character of the powder, and the dimensions of the barrel. Fish has shown that in a pistol wound at short range the burning or scorching effects, which he calls the “brand,” are always found on the hammer side of the weapon which inflicted the wound, i. e., if the hammer were held up the brand would be above the entrance wound. The bullet wound in such a case shows the direction of the aim, but the recoil will so far change the direction of the barrel as to divert the stream of gases of combustion, so that they follow the new direction of the barrel, which is always toward the side of the hammer. This is a point in medical jurisprudence which has been testified to in the courts. The use of smokeless powder minimizes any effect of this kind. It has been claimed that a homicide has been recognized in the dark by the flash of the old-fashioned gunpowder used in the weapon, but the use of smokeless powder would obviate this possibility. The most distinctive part of a powder burn is the appearance of the tattooing caused by the lodgement under the skin of grains of unconsumed powder. Such grains, when accidentally or purposely contaminated with germs, are not purified by the act of firing. This is less true of certain brands of smokeless powder. Nevertheless the opinion prevails that gunpowder may serve for conveyance of infection. The so-called smokeless powders are of secret composition, although it is known that in a general way they are composed of gun-cotton, dynamite (i. e., nitroglycerin), or picric acid. Melinite is composed of picric acid and collodium—i. e., gun-cotton. There are many of the modern explosives which depend for their final effect upon the combination of two or more substances. In the smokeless powers there is usually enough nitroglycerin to have a very noticeable effect should they be touched to the tongue, while even the fumes might be disagreeable or disabling.

—The greater the distance and the smaller the velocity the more likely is a bullet to lodge within some portion of the body instead of passing through it. In the Cuban campaign the proportion of cases of lodgement was less than 10 per cent. of the entire number of bullet wounds. A bullet which rests within the body either will or will not produce disturbances which may be more or less lasting. In a large proportion of cases the latter will prevail. The number of pensioned soldiers who are carrying unremoved bullets in some portions of their body is by no means small. A rifle bullet may remain in certain portions of the cranium without producing much disturbance. Bullets which cause no trouble are best left undisturbed. Those which produce serious symptoms should be removed. To Esmarch is attributed the dictum that the harm produced by a bullet is usually done during its passage, and after it has found lodgement it ceases to be a source of trouble. While not invariably true, this is so generally the case that acceptance of this statement has revolutionized the previously prevailing view, i. e., that a bullet should be always removed if it be possible to locate and extract it. In some instances it may be located by a study of the symptoms; as, for instance, in certain areas of the brain, or when lying in close proximity to joint surfaces it interferes with their function; although a bullet embedded in bone often does not seriously interfere with the use of the affected part. The bullet which divides a nerve trunk rarely lodges in such position as to be considered when the repair of the nerve injury is undertaken; such wounds will generally be found to be perforating.

Fig. 48

Multiple shot wounds of arms and back. The ulcer over the spine was produced by pressure, not by the ball (case in Cincinnati Hospital, 1884). (Conner, Dennis’ System of Surgery.)

—The same bullet may sometimes inflict multiple wounds, and, with modern projectiles, these are now more common, as many as six wounds having been made by one missile in its passage, e. g., wounds of the arm and body. Thus multiplicity of wounds may not indicate that the patient has really been shot more than once. In cases of perforation, for each wound of entrance there should be found one of exit, and at the first examination of the patient the discovery and consideration of each of these injuries should be part of the routine. If on examination but one wound be discovered, then the inference is natural and unavoidable that the bullet is still within the patient’s body (Fig. 48).

—The entrance of fragments of cloth or other extraneous matter is now less frequent, for bullets of tremendous velocity rarely carry in any perceptible material, their diameter being small and their surfaces polished. A ricochet bullet may carry tetanus or other spores from the earth, and lockjaw may be the result. In other words, gunshot wounds now are less likely to become infected wounds than they were years ago.

—The shattering and explosive effects of the impact of bullets upon certain of the viscera are sometimes disastrous, and yet not easily seen from the outside. This is especially true in the brain, heart, liver, spleen, kidneys, and bones. Almost complete pulpification of the semisolid viscera may occur as the result of perforation by a small missile, and the general condition of the patient should be relied upon to indicate this fact.

usually implies perforation of at least a portion of their contained viscera. Thus if a man be shot through the chest it may be assumed that perforation of the lung has occurred, while in a case of bullet wound of the abdomen it will rarely be found that the viscera, especially the intestines, have escaped perforation. Still, remarkable cases are occasionally recorded. Thus I have seen a man who had been shot through the abdomen from front to back, the bullet entering just above the pubis and escaping near the lumbar spine, who never seemed to have suffered seriously from his injury, although the bullet was a large soft one from the old Springfield musket.

—More or less characteristic appearances pertain to most wounds of entrance and of exit, which render them reasonably distinct and recognizable, even though no history be obtained. Nevertheless much depends upon distance, velocity, and any deformation of the bullet due to its impact upon some other substance previous to its entering the body. An elongated wound may suggest that the direction of the bullet was at an angle with the surface struck. Such wounds are known as “key-hole” wounds. A bullet already deformed may inflict a wound that will baffle speculation. The wound of exit is usually a little larger than that of entrance. When much larger a bone lesion should be expected. Trifling punctures, perhaps made by particles of the bullet, may be found around the principal wound or in the bone which it has shattered.

Diagnosis may include a recognition not merely of the general character of the injury, but whether it was inflicted by one or more bullets; whether these bullets have escaped; and if not, in what part they are probably lodged. In the preantiseptic days much of this information was gathered by the use of the probe, and the porcelain-tipped probe devised by Nélaton was relied on for much more than it could possibly safely tell. In those days probing was indiscriminately practised, and accomplished more harm than good. Now the probe is rarely used, at least at first, and when used, it is connected with some electrical device by which results are attained with a minimum of handling. For this purpose the telephone probe of Girdner was formerly a popular and ingenious device, which has been more recently supplanted by a simpler mechanism by which, when the end of the probe comes in contact with metal, a little bell, or buzzer, is rung. No probe or other instrument should be introduced into a gunshot wound, for diagnostic or other purposes, without observing aseptic precautions.

The most valuable expedient for the detection and location of bullets, as of other foreign bodies, is the Röntgen ray. With a suitable apparatus of this kind the surgeon can not only decide as to the location of the missile, but whether it is best to attempt an operation for its removal.

—In gunshot wounds not speedily fatal the prognosis depends upon the part injured, the size and shape of the missile, its velocity, the distance from the weapon, the amount of blood lost before attention was given, the character of the attention first received, and the absence of such complications as exposure, rough handling, etc. The dictum that the fate of a wounded man is in the hands of the surgeon who first attends him made its author, Esmarch, famous. The patient having escaped the dangers of hemorrhage and shock is to be carefully guarded from sepsis, and if thus guarded can be protected against most of the other visible dangers save those due to perforations of large cavities. If, therefore, a gunshot wound can be promptly provided with a primary aseptic or antiseptic dressing, and in other respects be let alone, the outlook for the patient will be encouraging. The prognosis often depends upon how completely the patient is let alone after the application of occlusive dressing.

—Hemorrhage is the first consideration, and should be the first care of the surgeon. Digital pressure may be resorted to, which may suffice until a temporary expedient has been supplied. Next in importance is disinfection of the area surrounding the wound and the application of a sterilized absorbent dressing, with pressure to prevent loss of blood. The use of the probe, or any attempt to at once ascertain the location of the bullet, is not advisable. The question is not, “Where is the bullet?” but, “How much harm has it already done?” And the first attention should be addressed to atoning for any harm that may have been done. Even though the intestines have been perforated, or the heart wounded, there is no need in doing anything more than meeting the immediate emergency. If shock be extreme it may be atoned for in some measure by lowering the head and bandaging the extremities; while in extreme cases hypodermoclysis or venous infusion of saline solution, often with the addition of a little adrenalin, will be of service.

Again, physiological rest of the part injured, i. e., immobilization, as well as absolute rest of the patient’s body and mind, must not be neglected.

Primary laparotomy has been done upon the battle-field, and is of itself a testimony to the intrepidity and zeal of those who have done it; yet, as a practice, it is to be condemned. All operations upon gunshot wounds should be done in a well-equipped hospital.

Fig. 49

Gunshot wound of forearm. Bullet in situ in bone.

The probing of bullet wounds is so unwise that it may be well to state the reasons for its general condemnation:

1. As it used to be practised, neither probe nor skin nor the operator’s hands were sterilized.

2. Even when carefully done it is often absolutely disappointing, the probe failing to reveal the presence of the bullet.

3. By the time the probe is introduced the wound will be usually more or less filled with blood clot. To stir this with a probe is to invite a secondary hemorrhage or annoying oozing.

4. Even when properly used the probe may carry in infectious material from the surface.

5. Most wounds made by modern bullets, even pistol bullets, are of such a character that it is difficult to follow their track without using force.

6. I have known a wound on the anterior surface of the body to be probed for a bullet that had escaped, as shown by an examination of the other side of the body, which the attendants had failed to search.

7. If there be good reason for exploration of a wound let it be postponed until the surgeon is prepared to follow a bullet and extract it. When it does not call for extraction, it does not call for probing.

8. The best probe is the surgeon’s finger, and for its use the patient generally requires an anesthetic and free incision.

When muscle is torn and needs suturing, or when tendons or nerves are divided and need the same resource; when bones are shattered and fragments need to be removed; when the skull has been fractured and portions of bone driven into or upon the brain; when the intestines have been perforated; when even the heart has been wounded and the pericardium is filling with blood so that the heart’s action is becoming impeded; in any or all of these emergencies the patient needs surgical relief. But this should be of a kind that, save in an emergency, should be postponed until suitable preparation can be afforded.

Fig. 50

Fig. 51

Wound inflicted at 1300 yards by steel-mantled ball (from a recent foreign report). (De Nancrède.)

Shattering of humerus at long range with modern projectile; fusible metal cast showing extent and character of laceration of soft parts (from a recent foreign report).

 

In regard to regional indications in the treatment of gunshot wounds it will only be possible here to give some brief general hints, the reader being referred to the chapters on Regional Surgery for more specific instructions. Nearly all gunshot wounds of bones are compound fractures, and are comminuted as well. The best treatment is primary aseptic occlusion and immobilization, without effort in the direction of exploration. In an open wound the vessels should be secured, loose pieces of bone removed, and jagged bone ends trimmed; while in some instances a wire suture or other mechanical expedient may be resorted to with advantage. Provision should also be made for drainage.

In the regions of the large joints the same general principles are applicable. Under the old regime a gunshot wound of the knee would condemn a person to amputation in the middle of the thigh. Now, if such a limb be promptly provided with suitable antiseptic dressing, and placed at rest, the patient may save not only the limb, but the use of the joint. Extensive comminution may call for excision. Amputation is seldom necessary, except when important bloodvessels have been divided.

Fig. 52

Perforating bullet wound of head, wound of exit showing brain protrusion. Sloughing pressure-sore of scalp. Complete paralysis of motion and loss of speech. Battle of Mukden. (Major Charles Lynch.)

Fig. 53

Perforating bullet wound of head, with prolapse of brain at wound of entrance. Operation done in Russian Red Cross Hospital at Mukden. Left hemiplegia; mind clear. (Major Charles Lynch.)

PLATE XIII

Radiograph of Head viewed from the Left Side, showing Mauser Bullet Lodged in Brain. (Surgeon-General’s Report on Use of Röntgen Ray, 1900.)

Fig. 54

Perforating gunshot wound of head; two wounds converted into one by removal of comminuted bone. From Russian Red Cross Hospital, Mukden. (Major Charles Lynch.)

Fig. 55

Result of accidental explosion of hand grenade, in a Chinese coolie with Fourth Division of Japanese Army, near Mukden. (Major Lynch.)

Fig. 56

Shrapnel wound of leg necessitating amputation. Japanese soldier at battle of Mukden. (Major Lynch.)

About the head may be seen all varieties of gunshot wounds and their complications. The bullets from small weapons may not penetrate, but those from larger ones usually penetrate and sometimes perforate. Infection is not an uncommon sequel to all of these injuries, even if involving the skin alone; the skull, especially the diploë; the membranes, or the brain itself. (See Chapter XXXVI.) Septic complications are more likely to occur in proportion to disregard of antiseptic precautions in the first treatment. Usually the most serious head injuries are those connected with penetrating bullets. Sometimes the skull undergoes extensive shattering, and occasionally the base is fractured. Instantaneous death, such as occurs when a soldier is beheaded by a cannon ball, sometimes causes a peculiar cataleptic rigidity, which is a species of immediate postmortem rigidity, by which a body may be maintained in the position it occupied when struck. Obviously, lesions at the base are still more serious than those of the vertex, and wounds of the cerebrum are nearly always fatal. I have seen a number of men who had been shot entirely through the head—by Mauser or smaller bullets—who, nevertheless, recovered more or less completely. In one soldier, I recall, the bullet traversed an orbit in such a way as to divide the optic nerve. He was blinded, but recovered most of his other functions; he remained well for some years, and then developed symptoms of insanity. Epilepsy and other psychical disturbances are all more or less frequent after head injuries. Plate XIII illustrates how a bullet may be, apparently, harmlessly embedded in the interior of the cranium. Sometimes years after such injuries active symptoms make their first appearance. There can be no question as to the value of the information usually afforded in such cases by the aid of the x-rays.

The same necessity exists here as elsewhere for primary antiseptic occlusion, including careful shaving and cleansing of the scalp. Inasmuch as nearly every gunshot wound of the skull calls for subsequent operation—just as does almost every compound fracture—the parts should be prepared for it early, and everything else should be left until the time when the surgeon is ready to make a complete operation and meet all the indications. In such a case hemorrhage may be temporarily checked by tampon. The surgeon should not omit to take advantage of all the information which a study of cerebral localization may afford him, since localizing symptoms may reveal not only the course of a bullet, but something regarding its location.

Penetrating wounds of the face are less serious than those of the cranium proper. Occasionally a bullet striking a tooth will displace it and drive it in some other portion of the face, e. g., the tongue. Bullets and loose pieces of bone should be removed in wounds of the face. Hemorrhage can usually be controlled by tampons. Interdental splints may often be used to advantage, and in every case where the mouth has been injured antiseptic mouth-washes should be frequently used; in the case of the nose, an antiseptic spray should be employed.

The neck is often penetrated, but if the spine and the important vessels and nerve trunks escape, little apparent damage may be done. If infection occur and suppuration take place resulting abscesses should be opened promptly, as they might migrate into the thorax or axilla. Even in the neck bullets which are producing no disturbance need not be disturbed; but if positive irritation or paralysis be caused by them they should be removed. Wounds of the larynx or trachea, by involving the parts in subsequent stricture, may call for tracheotomy.

Gunshot wounds of the spinal column below the neck are often complicated by perforations of the thorax or of the abdomen. So far as the spine is concerned the principal question is regarding the injury to the cord itself. In rare instances cerebrospinal fluid escapes from the wound; hemorrhage, or even the possibility of air entering the canal, is a more common possibility. I have seen perforation of the spinal canal, in connection with penetration of the thorax and lung, so that, after the operation of laminectomy, air escaped through the bullet wound in the spine with each inspiration and expiration. Infection in spinal injuries is always to be feared and caution should be observed regarding the maintenance of asepsis. The indications for laminectomy scarcely differ from those in other injuries to the cord. (See chapter on the Spine.)

Wounds of the thorax are more likely to be penetrating than formerly, owing to the conical shape and greater velocity of even small-arm bullets. Emphysema does not necessarily imply perforation of the lung, as air may enter through the external wound with each respiratory effort. When an imaginary line connecting the wounds of entrance and exit would naturally pass through the lung, it may be assumed that this viscus has been perforated. Signs indicating such lung injuries are peculiar pain, disorder of the respiration, more or less cough, usually with raising of blood; when the pleural cavity is more or less filled with blood there will be signs of pressure on the lung from presence of fluid. In other words a bullet wound of the lung will usually lead to a more or less complete picture of traumatic hydropneumothorax. Sometimes external hemorrhage is severe, even though it come from an intercostal or internal mammary vessel; usually the blood from these vessels escapes within the thorax. I have known an intercostal artery to be divided by a small pistol bullet which scarcely penetrated the thorax of a man, who died in consequence, when the insertion of a small tampon would have checked the hemorrhage and saved his life. Lung tissue rarely bleeds seriously. When hemorrhage is from the lung it comes from a divided vessel of some size. A collection of blood in the chest is subject to the danger of infection, and empyema is a frequent but somewhat delayed consequence of gunshot wounds of the chest; while abscesses in the lung or mediastinum occasionally result.

To the primary occlusion, which should be the first attention given to every bullet wound of the thorax, there may be added complete immobilization of the chest. Fluid already present, unless it be clotted blood, may be withdrawn by aspiration. Traumatic, not to say septic pneumonia, is a serious complication. Should any operation be called for, like removal of fragments of rib or the checking of hemorrhage, it is best to make a free opening and a liberal removal of all particles or fragments, with ample provision for drainage. Hernia of any of the viscera through such wounds occasionally occurs.

Fig. 57[12]

Result of frostbite without gunshot. After battle of Mukden. (Major Lynch.)

Fig. 58

Result of frostbite after two days and nights of exposure. After battle of Mukden. (Major Lynch.)

The subject of injuries to the heart will be dealt with in the chapter devoted to the surgery of that organ. Not every perforation of the heart substance is fatal, and there are enough successful cases on record of radical intervention by resection of the thoracic wall, and of exposure of the pericardium, even of the heart itself, to justify this method of attack in any case which will permit of it. Not the least of the dangers pertaining to heart injuries is the impediment to heart action caused by a collection of blood in the pericardial sac. Should anything further be called for it would be warrantable at any time to explore this sac and withdraw fluid through the aspirating needle, through a trocar, or even by incision and drainage.

In the abdomen all conceivable forms of injury may be met with, from contusions produced possibly by a spent cannon ball, to lacerations from fragments of a bursting shell and multiple perforations produced by one or more bullets. A first requisite in all such injuries is immediate antiseptic occlusion. This will not prevent such prompt and further study of the case as may indicate suitable treatment. When shock is extreme, indicating the possible result of contusions or laceration, or when perforation of the stomach, intestines, or bladder is probable, laparotomy should be performed at once. According to De Nancrède the order of probable frequency of these injuries of the abdomen is small intestine, large intestine, liver, stomach, kidney, spleen, and pancreas. Multiple lesions are also common. The immediate dangers are those from shock and hemorrhage, to be supplemented later by imminent danger of septic peritonitis.

Fig. 59

Scene in operating room in Second Field Hospital of Fifth Division of Japanese Army, at Mukden Railway Station. (Major Lynch.)

The modern small bullet causes few surface indications as to the amount of damage done within, as in the thorax. A careful consideration of the location of the wounds of entrance and exit will indicate the probability of perforation, especially of the hollow viscera. The appearance of blood, either in the mouth or from the rectum or urethra, the recognition of a rapidly accumulating amount of fluid, the presence of gas in the abdomen, are all significant indications of perforating injury. Several years ago Senn advised the insufflation of hydrogen gas into the colon, on the theory that its escape from the intestine into the abdominal cavity and thence out of one of the abdominal wounds, where it could be lighted as it passed through a small tube, would afford a certain and unmistakable test as to perforation of the bowel, and such is undoubtedly the case. Nevertheless, it is not one which is always easy or even possible of application, and no time should be wasted in waiting for a supply of hydrogen for this purpose.

The safest course and the most life-saving one is exploration when there is any doubt as to the nature of the injury. This means an operator possessed of good judgment, a suitable environment, rigid antiseptic precautions, and a small incision to begin with, with the finger as the best of all probes. The escape of bloody fluid, bloody urine, or fecal matter will immediately justify a much more extended incision through which complete orientation may be obtained. The first incision may be best made as an enlargement of the bullet wound, but any extensive operation within the abdominal cavity can be made through a sufficiently long median incision. Only in this way can the source of hemorrhage be ascertained. Thus the intestines may be systematically gone over inch by inch. When perforations are found they may be either dealt with as they appear—each opening being closed transversely—or the entire intestinal canal may be exposed. Contused spots will eventually slough, and should be treated as if they were perforations. Injuries, therefore, of short portions of the intestines might justify the removal of several inches. Instead of making multiple resections, it would be better to remove en masse the involved portion of the bowel, and then make lateral anastomosis or an end-to-end suture. Perforations of the mesentery as well as tears in the omentum should be carefully closed. Everything which is not vitally necessary and which has been injured should be removed. The posterior surface of the stomach, the lesser cavity of the omentum, the region of the gall-bladder and pancreas, the kidneys and ureters, and the bladder should be examined, in order that injury may be detected. After operations of this kind the abdominal cavity may be flushed with sterile salt solution; while the question of drainage should be decided upon the individual merits and indications of each case, as it is safer to drain the contaminated peritoneal cavity than to rely upon mere cleansing and drying.

If the spleen or kidney be injured, it is safer to make a primary removal of them; if they are not removed, posterior drainage should be made.

In uncertain cases of abdominal wounds the back as well as the abdomen should be scrubbed in order that if posterior drainage be necessary it can be made without delay.

The after-treatment of such patients does not differ from that of non-traumatic cases. Abstention from stomach feeding, the judicious use of salines, dependence upon hypodermoclysis and rectal nourishment, and the use of opiates are all matters of importance.

When the bladder has been injured there is usually more or less injury of some of the other pelvic organs. An empty bladder will escape more often than one which is full; while the latter will nearly always leak into the peritoneal cavity or along the bullet track, thus infecting one or both. The appearance of blood in the urine is one of the indications of bladder injury, and sometimes the bladder will fill with blood clot, which will produce the phenomenon of retention. Such a case may rapidly succumb to infection if relief be not promptly afforded, and this may come through abdominal section or a combination of it with exploration through the perineum. Particles of clothing and bone and even the bullet itself have been removed from the cavity of the bladder. It is advisable to open the bladder from below and insert a self-retaining drainage tube, by which, especially when combined with the method of drainage by siphonage, as described in the chapter on Surgery of the Bladder, a satisfactory and continuous emptying of the organ may be maintained.

CHAPTER XXIII. PREVENTION AND CONTROL OF HEMORRHAGE; SUTURES; KNOTS. — 1. Extremes of Heat and Cold. — 2. Pressure Directly Applied. — 3. Styptics and Chemical Agents. — 4. Destructive Methods — 5. Mechanical Means. — 6. Ligatures. — TREATMENT OF WOUNDS. — SUTURES AND KNOTS.

The first requisite after the infliction of a wound is to arrest and control the hemorrhage. In many operations upon the extremities precautions are taken to avoid its occurrence, and the so-called bloodless method of operating, which is effected by the use of an elastic bandage of pure rubber, is frequently employed and generally gives satisfactory results. The pure-gum bandage was first introduced into surgery by Martin, of Massachusetts, and its combined use both as an elastic bandage and tourniquet was so promoted by Esmarch that it is generally known as Esmarch’s bandage, and Martin has failed to receive the credit due him.

The elastic bandage used for this purpose should be about three inches in width and five or six yards in length, and made of pure rubber. The operator begins by applying this to the tip of the extremity which is to be made bloodless. It is wound around the limb in spiral turns, with sufficient force to press out the blood from the tissues and to empty the vessels into those of the trunk. It is continued above the site of the operation, and then the limb is either constricted with a tourniquet of the old type or with one of the rubber appliances used for this purpose. A few turns of the rubber bandage may be passed more tightly about the limb at this point and secured with forceps. The rest of the bandage is then unwrapped from the limb, which will be found pale and bloodless. Operation may then be practised without the loss of more than a few drops of blood. All divided vessels should be secured before the constriction is removed and the wound closed.

In septic, tuberculous, and malignant conditions no such pressure should be made, as harmful elements might be forced into the circulation. In such cases the elastic tourniquet is applied high up and no attempt is made to force the blood out of the limb. The limb should be elevated so that its veins may empty before the bandage is applied, and a certain amount of blood will thus be saved.

Care should be taken in graduating the tightness of the constricting band, as well as its narrowness, and in preventing undue pressure upon nerve trunks. Cases are on record of temporary and even permanent paralysis, due to too vigorous application of the tourniquet, and except upon large and stout limbs it is not often necessary to apply it as tightly as is often done. Moreover even a wide rubber bandage when stretched taut becomes little better than a rubber cord or rubber tube and sinks into the tissues. A sterile towel should be folded into a strip and wound around the limb, and then a tourniquet should be applied over it so that pressure may be more equably distributed and danger of paralysis reduced.

Exigencies may require the application of the elastic tourniquet as high as it can be possibly used, either upon the shoulder or the hip. This necessity is usually observed in amputations at those joints, and the special methods required will be more fully dealt with when speaking of these procedures. (See Chapter LVII.)

The elastic bandage should have been unrolled and sterilized with the rest of the surgical equipment required, and even when so protected it would be well to cover the limb with wet sterile towels before applying the bandage, which is usually done at the last in order to avoid contamination. When this is not done the final scrubbing should not be effected until the bandage has been placed, the tourniquet applied, and the bandage again removed.

Fig. 60

Illustrating forced flexion for control of hemorrhage.

The first measure, then, in the treatment of a wound is to prevent loss of blood. This may be done in various ways, and the method should depend upon the circumstances of the case. In emergency cases it may be accomplished either by direct pressure, by constriction of the limb above the injury, or in some instances by mere position. If it be possible to make direct pressure through the medium of some clean—preferably sterile—dressing or material, this of course would be desirable. In all civilized armies soldiers are now equipped with a package of sterile dressing by which an emergency pad for this purpose can be promptly applied. Railroads and steamers are now providing emergency outfits. In injury of the arm or leg advantage may be taken of position, i. e., forced flexion, which is maintained by any measure or material which can be made available for this purpose (Fig. 60). Digital compression over a main vessel may also serve a good purpose. Mere elevation of the part, as, for example, the head, when not otherwise contra-indicated, or a hand or foot, will do much to check venous or arterial flow. Moreover, in these positions reflex contraction of arteries occurs, even in those of the head when the arms are elevated. For this reason in cases of serious nose-bleed it is often advisable to keep the arms raised high above the head.

Of other means resorted to may be mentioned:

—Water at a temperature of 130° to 160° F. is a powerful hemostatic. It stimulates contraction of the muscular coats of the vessels and produces coagulation of the albuminous portions of the blood upon the surface to which it is applied, and in this way plugs the capillaries and small arteries and so prevents oozing. Heat with pressure will be serviceable in many instances. Cold may be employed by means of ice or iced water and may be made serviceable in cavities like the mouth, the vagina, or the rectum, after patients have recovered from the anesthetic and at a time when hot water could not be borne. Cold has more of a constringing effect but less coagulating property.

—This may be made with a tampon in some cavity, or by a graduated absorbent dressing whose effect may be regulated by pressure of a bandage or an elastic bandage. Care should be always given that pressure be not too long nor too firmly made, and it should be released as soon as there appears edema of the part below or any evidence of insufficient circulation.

—There are many substances which contract vessels and cause more or less coagulation of blood, and at one time there were many of these in general use, but they have been supplemented by other products, i. e., cocaine, antipyrine, and adrenalin. The effect of cocaine is temporary, but sometimes is sufficient in the urethra or the nasal cavity. Antipyrine, in 5 to 10 per cent. solution, alone or with cocaine, has a similar effect, but is more lasting. Some years ago the writer stated that by mixing 10 per cent. solutions of antipyrine and tannin there was precipitated a gum-like material of extraordinary tenacity. This will check oozing from any part to which it may be applied, but it may adhere so tightly as to make it difficult to later remove the tampon. Of the hemostatic drugs, adrenalin has the most marvellous properties. It can be procured in solutions of 1 to 1000. A solution of this strength, somewhat diluted, may be spread or applied upon an oozing surface with almost instantaneous effect.

The use of gelatin in checking hemorrhage has given some satisfaction upon the Continent, but has not found much favor in this country. It consists of a solution of 2 parts of pure gelatin to 100 parts of normal salt solution, which should be thoroughly sterilized. It is injected subcutaneously to increase the coagulability of the blood, and has also been injected directly into an aneurysmal sac or its immediate vicinity to induce coagulation. It is likely that if the surgeon have a patient with the hemorrhagic diathesis the combined use of gelatin in this way and of calcium chloride internally would give satisfactory results.

A styptic has recently been introduced by Freund under the name “stypticin.” It is a product of the oxidation of narcotin, one of the opium alkaloids, and is a yellowish powder of bitter taste. Chemically it is cotarnin hydrochloride. It has been used especially in the treatment of uterine hemorrhage, with a certain degree of success, regardless of the cause of the hemorrhage. It may also be given in cases of too profuse menstruation. The average dose is 2 to 3 Gr. (0.15 to 0.20) at intervals of two or three hours. When a speedy result is desired twice the above amount in 10 per cent. solution may be given subcutaneously.

may include the use of the sharp spoon, chemical caustics, or the actual cautery. The curette is usually employed for removal of surfaces which have attained a spongy or easily bleeding condition, as the interior of the uterus, bleeding ulcers in other cavities, etc. When fungoid tissue is scraped to a base of healthy tissue there is usually a cessation of further hemorrhage. Occasionally there are cases of fungating cancer which bleed upon the slightest touch. The most radical way in which to deal with these for temporary purposes is to destroy the spongy tissue which bleeds so frequently. The gross part may be done with the sharp spoon and the cautery may be made to finish the work. Bleeding piles, when it is not permissible to treat them more radically, should be touched with the actual cautery, with stretching of the sphincter. The cautery knife should not be made too hot, as it may act similar to a sharp blade instead of merely searing by its heat.

—When vessels of considerable size or masses of tissue containing them can be made accessible, the best means of control of hemorrhage are those which can be applied directly to the vessels. When this is not possible they should be tied en masse. A method formerly in use was acupressure. To effect this a needle was passed through the overlying skin beneath the vessel and out again, and around this a suture was tied to make pressure. Since the introduction of absorbable materials this method has been supplanted by the use of catgut sutures, which may be tied, cut short, and left to absorb.

Under the term “forcipressure” is included the method of seizing vessels before, or as they bleed, in small forceps, which are variously shaped and constructed, and grouped under the name of hemostats. Small vessels seized between the blades of such an instrument will have their walls so crushed that blood clot is so quickly entangled that the forceps can be removed in a few moments with little or no danger of subsequent bleeding. Larger vessels should be ligated.

Torsion is a substitute for ligature, especially with the smaller vessels, and denotes a twisting of the vessel end after its seizure, breaking up its inner coat, and effectually sealing its lumen. Some surgeons rely on torsion for the large vessels.

Angiotribe is the name applied to strong crushing forceps, by which a pressure of several hundred pounds can be made through a lever mechanism. In this a mass of tissue, as the broad ligament, can be secured and such tremendous pressure brought to bear that its vessels are crushed and destroyed beyond possibility of bleeding. Downes has improved upon this mechanism by adapting to it an electrocautery arrangement, by which not only pressure but also heat is brought to bear. His instrument is called an electrothermic clamp. To all of these instruments there are at least theoretical objections, in that they are more or less clumsy or unwieldy and require special equipment. They devitalize a considerable amount of tissue, all of which has subsequently to be removed either by a process of sloughing or by active phagocytosis; but they serve perhaps a useful purpose in the crushing treatment of hemorrhoidal tumors. They have been used only by a few, and have not found wide acceptance.

—These are also mechanical means of controlling hemorrhage, but deserve to be grouped by themselves. Ligation of vessels may be preliminary or may be performed as needed during an operation.

By a preliminary ligature is meant taking such precaution as tying the carotid before operations on the face, the brain, or the femoral artery before amputation at the hip. There is also the method of temporary ligation of vessels by the application of a ligature which should not be drawn too tightly, but simply serve the purpose of gentle constriction for the half-hour or so during which it may be needed, after which the vessel is promptly released. If this ligature has not been too tightly applied the vessel walls will not have been injured and circulation is restored. Crile has effected the same purpose with the carotids by a small clamp whose pressure may be regulated by a thumb-screw.

Ligation of large trunks is made for the purpose of influencing nutrition by diminishing blood supply, as when the femoral is tied for elephantiasis of the leg, or the carotid is tied or excised, as suggested by Dawbarn, to cut off the blood supply from cancer of the face or neck.

Ligatures are usually made of absorbable material, such as catgut, chromicized or not, as may be desired, or of silk, which disappears after a time, but which is not regarded as absorbable. For special purposes other material has been used at times, such as strips of ox aorta. The surgeon has his choice of these, whether he intends to ligate the end of an artery or tie a vessel in its continuity. For the latter purpose the ligature is threaded into an artery needle, or a specially devised curved forceps known as the “Cleveland” needle. When tying the exposed end of a bleeding vessel it is desirable to tie near the cut end, so as not to leave tissue which should be absorbed, and for the same reason to not include unnecessary tissue. One of the forms of knot similar to the “reef” knot, which will not slip, should be used. Silk has the advantage over catgut in that a knot tied with it will rarely become loose, whereas catgut knots, unless carefully tied, will occasionally slip. The ligature knots should be left as short as is consistent with protection against slipping.

Fate of Ligatures.

—Silk or celluloid thread are the most unabsorbable of ligature materials ordinarily used. Even these usually disappear after the lapse of time. Absorbable ligatures of catgut disappear after a few days or weeks, according to the method of their preparation. Absorption is practically a matter of phagocytosis, the end of the vessel or tissue beyond the ligature disappearing with the latter by the process of tissue digestion.

When vessels of large size are ligated the blood supply is taken up by the collateral circulation. On the possibility or practicability of the latter will depend the success of such operations as ligation of large trunks for the cure of aneurysm. Should the collateral supply prove insufficient, gangrene, beginning at the tip of an extremity, is an assured fact.

The effects of the ligature on the vessel wall will depend upon the security with which it is tied. The damage done to the inner and middle coats by a ligature tied for permanent purposes is usually sufficient to rupture them, after which they roll up inside the outer coat, while the blood contained in that part of the vessel coagulates, the clot extending to the first vessels above and below. This quickly organizes, becomes infiltrated with cells, and brings about the complete obliteration of that part of the vessel and its transformation into a fibrous cord. This can only occur, however, when asepsis has prevailed. Should the ligature prove septic the patient is exposed to two dangers: that of secondary hemorrhage by ulceration and breaking down of the clot instead of organization, and the ordinary dangers of septic infection.

There are circumstances under which it may be well to modify the ordinary methods of ligation and not to tie knots too tightly—i. e., when the vessels are greatly weakened by extensive disease, or so stiffened by calcareous degeneration as to cause them to snap under rough handling. It has been suggested to use pieces of ox aorta to prevent these accidents.

The dangers of secondary hemorrhage pertain mostly to septic conditions. In an absolutely aseptic wound, properly cared for, secondary hemorrhage is almost impossible, but as soon as germ activity begins lymph barriers are broken down, tissues softened, and weakened vascular walls may give way.

Secondary hemorrhage may call for ligation of a main trunk not previously attacked, but in a majority of cases will demand reopening of the wound and further search for bleeding points. Should the patient’s condition be materially weakened the effects of position and of pressure may be tried in suitable cases. But the pressure which may be effective to check the hemorrhage may be sufficient to completely shut off circulation from parts beyond, and such pressure should, therefore, be judiciously practised and its effects carefully watched. The signs of secondary hemorrhage will vary with the location of its source. Occurring on or near the surface it will usually stain the dressing; occurring deeply, as in the pelvic or abdominal cavities, it will produce prompt symptoms of shock, i. e., lowered blood pressure, whose degree will indicate the extent of the blood loss. In these cases, unless the patient’s condition contra-indicate the measure, the wound should be opened under anesthesia, and the source of the bleeding sought out and mastered. The surgeon should never overlook the fact that after the gradual restoration of the force of the heart’s action, as the patient recovers from anesthesia and becomes uncontrollably restless, vessels may bleed which upon the operating table scarcely emitted a drop of blood. Experiences of this kind teach the value of hemostasis during operation, and even of absolute rest induced by an opiate, immediately after.

There are certain conditions in which the surgeon is led by experience to anticipate liability to unusual hemorrhage; such as cases of hemophilia, or anything that savors of it or of scurvy. In patients who claim to be “bleeders,” the surgeon should be extremely chary and careful during his operative work. There are, furthermore, certain toxemias, especially that of cholemia, during which the blood is slow in coagulation. When the time for preparation is afforded no cholemic patient should be operated without a few days’ previous preparation by four or five daily doses of calcium chloride, 20 to 30 grains given in plenty of water. This is known to greatly increase blood coagulability, and thereby to measurably protect the patient against the danger of an oozing of blood difficult to control.

The other measures needful in the treatment of secondary hemorrhage are those described in Chapter XVIII.

The general consideration of wounds in the previous chapters necessarily included many suggestions concerning their treatment. The first essential in the treatment of open wounds is exact hemostasis; the next is the removal of dirt and foreign material of all kinds, i. e., visible and invisible. Accidental wounds are practically never received upon surgically clean surfaces, and it may be always assumed that the possibility of infection is present. It becomes then a question to what extent the surgeon should go in removing or avoiding danger. Obviously all visible foreign material should be carefully removed and all dirt should be scrupulously washed away. Emergency treatment of a bleeding injury in a well-regulated hospital is one thing, and the exigency of a railroad accident or casualty away from civilization is quite another. The canons of antisepsis and asepsis have been elsewhere sufficiently well laid down to indicate what should be done at the time when it can be done.

The protective vitality of the human tissues permits them to bear frightful injuries or resist infection in a surprising way. But occasional escapes from severe accidents by no means justify carelessness when caution can be taken, and cannot be held as excusing the surgeon for any neglect in antisepsis.

A bruise or contusion accompanied by a slight abrasion may seem a trifling injury, and yet by virtue of the injury the resisting powers of the tissues may be rendered insufficient to protect them from infection through a break of the surface. No relatively small lesions of this kind can be safely neglected, but should be cleaned and covered with an antiseptic compress, either wet with some suitable solution or smeared with a protective ointment, or used dry with a suitable antiseptic powder, as, for example, bismuth subiodide. Injuries followed by considerable swelling should be treated according to the time which has elapsed since their reception. If, for instance, a bruise or sprain be seen early and before much swelling has occurred, ice-cold applications can be made in the hope that, by limiting the flow of blood, the outpour of fluids may be prevented. This effort should be seconded by position, and perhaps by gentle pressure. Conversely when a case is seen late, after the tissues have become waterlogged with fluids, heat should be applied in order that by stimulating the circulation reabsorption may more speedily take place. In this case, also, suitable pressure may be of service.

When there is actual hematoma, and the exuded fluid fails to disappear, an incision properly made and in the right place may permit the clot to be turned out, and then speedy recovery secured by coaptation with sutures and pressure.

Poultices are nauseous applications to make to the human body. By their indiscriminate use much harm has been done and suppuration encouraged or brought about, which but for them would not have occurred. There are occasions when a hot flaxseed poultice may be of use, but they are very few and far between. With regard to such remedies as arnica, witch-hazel, etc., the best that can be said of them is that they may be of some use by virtue of the alcohol which they contain; they serve the purpose, then, of a diluted alcohol and nothing else.

There is virtue in the use of a cold wet pack, or compress, especially in the treatment of chronic affections of the joints, and their value can be perceptibly enhanced by using solutions of sodium, or preferably ammonium chloride, and the addition of a little alcohol. Absorbent material wet in such a solution, wrapped around the part, covered with oiled silk or some impervious material, while the part is kept at rest, will render valuable service in conditions of this kind.

In regard to the relative worth of heat and cold for relief of pain, the alleviating effect of heat is more promptly manifested, but that of cold is more permanent, and especially is this true of chronic affections of the joints and bones.

In the treatment of open wounds, bleeding having been first controlled, all the surrounding parts, as well as the wound itself, should be sterilized. In a scalp wound the scalp should be shaved as well as scrubbed. All particles of visible dirt should be carefully picked out, and every particle of tissue whose vitality is so compromised that it apparently cannot live should be excised. The wound may then be irrigated or washed out with hydrogen peroxide, and not until all this is done should the operator consider how he may best close it, as well as whether he needs to provide for drainage. A ragged line of tearing will leave a jagged and more unsightly scar, especially on the face; therefore the margins of such a lacerated wound should be trimmed before coapting them.

The method of closure will depend on the degree of tension necessary for the purpose. Parts that come together easily may require but slight suturing, and with fine catgut which will loosen of itself within two or three days; the intent in such cases always being to assist the sutures by proper support of the external dressings.

Buried sutures will serve a useful purpose in many instances, and upon the face or exposed parts of the body a subcutaneous suture of fine silk or horse-hair may be so applied as to be easily removed by a single pull and leave but trifling disfigurement. Female patients will be doubly grateful if the surgeon can leave but a minimum of unsightly scar. Fasciæ will sometimes retract widely. They should be brought together by distinct separate catgut sutures. Before closure of a wound it is important to determine that no such structures as nerves or tendons have been divided, or, if such injuries have occurred, to reunite their ends by fine silk or catgut sutures. The writer prefers silk for most of these purposes, although in a nerve a fine formalin catgut suture would perhaps be the most ideal.

There are occasions when it seems impossible with the means at hand to tie or secure in any way a deep bleeding vessel which has already been seized with a hemostat. In such case the forceps may be left in situ for thirty-six to forty-eight hours. This may be done, for instance, in the groin, in the axilla, in the depths of the neck, and about the cranial sinuses. Life may be occasionally saved by this procedure which would be lost from hemorrhage without it. At other times a firm tampon of gauze may be forced into the depths of a wound for the same purpose, and maintained there by position, or by the pressure of secondary sutures, which serve the same purpose and require removal in two or three days. These measures refer rather to wounds of veins than of arteries.

If one can be absolutely sure of his asepsis, he may close even an extensive wound with little or no provision for drainage; but unless he is certain regarding it he should provide at least for escape of fluid by omitting a suture occasionally, or by drainage with a tube or a cigarette drain. In compound fractures not only must such provision be made, but the treatment of the wound may also include the introduction of wire sutures through bone ends or the use of other mechanical expedients.

The further and equally important treatment of wounds consists largely in maintaining physiological rest of the injured part, as well as the general welfare of the patient. Pain which becomes unendurable causes the patient to lose self-control and to disturb not only the dressings but apposition of wound surfaces. Pain, therefore, should be controlled by the mildest expedient that may suffice to master it. Elimination must be maintained, because the circumstances attending the injury may act to disturb it. A patient who shows no irregularity of pulse, temperature, elimination, or general comfort may be assumed to be doing as well as could be expected, and the dressings need not perhaps be changed for several days. On the other hand, with rise of temperature or pulse, increase of restlessness, swelling of the parts, or discomfort in the vicinity of the wound, the dressings should be promptly changed. It may be necessary to make such change at the end of forty-eight hours in order to permit the removal of the drain. The second dressing may then often remain a week, but any dressing which becomes saturated, even with blood, may dry and adhere to the skin, and should be removed.

It would be best to inspect the wound in all cases when the temperature and pulse are rising or when there is any disturbance in the wound. The accumulation of blood in an aseptic wound may cause much discomfort, and by its presence interfere with primary union. Should, therefore, a wound be found pouting or its edges reddened and swollen it may be safely assumed that there is something wrong, and as many sutures should be removed as may be necessary to reveal its condition and permit of its treatment.

Wounds which are foul or septic when they come under surgical observation should be treated differently. Here the first attempt should be at antisepsis. In some cases continuous immersion in warm water will give the best results. I have never found anything so prompt, however, in cleaning up a sloughing area as brewers’ yeast. When this can be obtained it should be used in sufficient abundance to get the diseased surface thoroughly wet with it. In sloughing cases moist dressings are usually preferable, and the best are the two above mentioned. This is true of those cases where part of the wound is granulating satisfactorily, while part is acting badly. Dressings in all of these cases require to be frequently changed, that they may be kept effective.

I have elsewhere called attention to the value of granulated sugar as an emergency antiseptic material of great value.

Sutures.

—There are many varieties of sutures which have found favor. Until the surgeon becomes expert by long practice he should confine himself to few sutures and knots. Primary sutures include continuous, interrupted, plate or modified plate, quill or modified quill, chain, and transfixion sutures, and also certain forms of suture used in intestinal surgery. The above forms are illustrated in Figs. 61 to 66. Several of them may be used in making what are known as buried sutures, i. e., those which are tied deeply, whose ends are cut off below the surface and left either permanently or for later absorption.

The purpose of a suture is to bring the parts into accurate apposition and so maintain them. It is a mistake to employ a superficial suture alone, which may leave a “dead space” beneath it. If but one suture is used, as in closing an abdominal wound, it should pass through the tissue layers of the abdomen and bring each layer into contact with the corresponding layer on the other side. Unless this can be done a series of sutures should be used uniting the tissues layer by layer. If these be made of formalin or chromic gut they will remain in situ for a length of time sufficient to serve their purpose. Some prefer silk for this purpose, but it may work out later; if sterile and freshly boiled just before using it will rarely cause this trouble. In closing a thick and fat abdominal wall four or five tiers of buried sutures may be used and their effect may be reinforced by the addition of a modified plate or quill suture, as shown in Figs. 63 and 64.

Fine wire is preferred by some operators, and horse-hair by others. Success pertains rather to the perfection of the method than to the material used. The primary feature of all wound sutures should be prevention of tension and protection against it. Further support in the same direction can be made by the use of adhesive plaster after fastening the dressing upon the wound, thus taking off strain.

Certain expedients have been resorted to in superficial wounds, some of which include the affixion of a strip of plaster on either side of the wound and then the application of the suture material through the plaster rather than through the skin. Plasters with small hooks have also been applied, and then a shoelace suture applied over the hooks, thus lacing the wound margins together. Such measures are convenient for certain cases, although they make the maintenance of strict asepsis difficult or impossible. Fine-wire clips have also been introduced, by which skin margins may be held together for three or four days, or until they have had time to unite with some firmness, after which they may be removed. These little implements can be sterilized and repeatedly used.

Fig. 61

Continuous suture.

Fig. 62

Interrupted suture.

Fig. 63

Modified plate suture, using gauze instead.

 

Fig. 64

Modified quill suture, using gauze.

Fig. 65

Billroth’s chain-stitch.

Fig. 66

Transfixion suture.

 

Fig. 67

Reef knot.

Fig. 68

Granny knot.

 

Fig. 69

Fig. 70

Clove hitch.

Fig. 71

Staffordshire knot.

 

When an absorbable suture will serve the purpose it is desirable to use it, since the necessity of subsequent removal is thereby avoided. Inasmuch as every point through which a suture is passed will show its own minute scar, it is desirable for cosmetic purposes to use a subcutaneous suture, which may be made of chromic gut, silk, or fine wire. If of catgut it may be left to disappear spontaneously; but a silk or wire suture should be left with ends protruding from the wound so that after a few days it may be withdrawn by steady traction in the proper direction.

Secondary sutures are those which are placed at the time of the operation, but either not drawn so as to unite the wound edges, or are tied with a bow-knot, so that they may be untied and utilized later. They are useful when either hemorrhage or suppuration is anticipated, and when it is compulsory to pack a cavity with gauze.

Every suture which has failed of its purpose or ceased to be effective should be removed. Ordinarily they are left in place from four to ten days. They should be removed by dividing upon one side of the knot, which should be seized with forceps and pulled upward and to the other side. The suture should be cut at a point where it is moist, so that only its flexible portion may be drawn through the parts which it has held. Moreover the buried portion is more likely to be sterile. Secondary sutures are usually made of silkworm-gut, celluloid thread, or wire. So soon as they are found unserviceable they also should be removed.

Knots.

—The purpose of a knot is not achieved if it slips, and the “surgeon’s knot” is best for the purpose, since in the first formation one end is carried twice around the other before being tied in the opposite direction. It requires more force in making it taut, but it is safer than the ordinary reef knot (Fig. 67).

Figs. 69 and 70 illustrate the clove-hitch, which becomes firmer the tighter it is pulled. It is rarely used in ordinary sutures or ligatures, but may be made exceedingly valuable. The Staffordshire knot (Fig. 71) serves especially for securing pedicles, which are first transfixed with a double thread, the loop thus formed being slipped over the stump and secured between the two loose ends of the ligature, one end being placed over and the other under it; each is pulled tightly and secured by an ordinary knot. When properly applied it is effective. When knots are improperly applied none of them should be trusted.

When wire sutures are used it is sufficient to twist the ends, unless very fine wire is used, when it may be tied.

CHAPTER XXIV. ASEPSIS AND ANTISEPSIS; TREATMENT OF WOUNDS. — Instruments. — Dressings, etc. — Sponges. — Suture Materials, etc. — Antiseptic Solutions, Applications, etc. — Drainage.

The medical student of the present generation has no conception of the contrast between the results of today and those of a generation ago, or before the introduction of antiseptic technique and its later perfection, asepsis. Under the term “antiseptic” should be included those measures intended to combat sepsis, or surgical infection, from without. The term asepsis is of later date, and was introduced when it was found that the prevention of infection was better than measures calculated to overcome it, or atone for its presence. A perusal of former surgical horrors will afford but an insufficient comparison as to the incalculable benefits for which we are indebted to a small group of men, of whom Lister is the most important; although the names of Pasteur and of Ogston should ever be held memorable in this connection. The two great nineteenth century achievements in surgery were anesthesia and antisepsis, both of Anglo-Saxon origin, one American, the other British.

It was the recognition of the parasitic, i. e., the germ nature of surgical infections, which led to Lister’s first attempts to exclude and combat the infecting agents. And while the original technique which he introduced has been changed in nearly every particular, the correctness of the views upon which it was based has been ever broadened and strengthened. We have learned that simple measures may be as effective as those more complicated, and the principal changes which have been made in three decades have tended toward simplicity and prevention. Thus heat has been made to take the place formerly occupied by carbolic acid. And we have learned that parts made clean need little antiseptic protection. We have learned that healthy tissues are endowed with large powers of self-protection, and also that this self-protection is interfered with by causes over which the surgeon has sometimes but little control. A wound in a body loaded with toxic products is by no means protected against infectious agents by mere external agencies. The appearance of pus in a wound is a reflection upon the surgeon. The ideal aseptic technique will include many days of local and constitutional protection, as has been stated in the sections on Auto-intoxication and on the Preparation of the Patient.

The methods of either antiseptic or aseptic technique include as a fundamental basis the necessity for perfect sterilization of everything which may come in contact with the wound, so far as the surgeon can control it. The atmosphere contains in suspension bacteria, but their contact is no longer dreaded, because of reliance upon the germicidal powers of the fluids and tissues of the body. It is known, however, that in accumulation of fluids there is danger as well to the tissues, either from rude handling, application of large pressure forceps, the insertion of too many stitches, or whatever else may lacerate or impair the circulation.

There are parts of the body where no precautions can afford complete freedom from germ activity, as in the mouth, the vagina, the rectum. Here the surgeon must be cleanly in his work, assuring himself that he introduces nothing new from without. Furthermore, after operation upon these parts he must ensure his precautions by the use of mouth-washes, douches, etc. On the other hand, ample opportunity should be afforded for sterilization of the field of operation, of the hands of the operator and his assistants, the instruments, ligatures, and dressings—everything which may come in contact with the raw surface.

Heat, moist or dry, is the simplest of all sterilizing methods. It is used in dry and in moist form. The most resistant spores are those of anthrax, which is supposed to be a laboratory germ, one not seen in practice. Most of the imported catgut is made from the intestines of sheep, and sheep die frequently (on the Continent) of anthrax; it will thus be seen that the danger of an anthrax infection is not so remote as might first appear, and that no precautions are sufficient which do not include a degree of heat and length of exposure sufficient to kill these germs. In the operating-room, as in the laboratory, has been introduced the method of “fractional,” i. e., repeated sterilization. Most of the materials thus exposed may be left in superheated steam under pressure from thirty to sixty minutes. They are then exposed once or twice more to the same heat at intervals of twenty-four hours. In order to make heat thoroughly useful its effects should permeate everything which it is expected to so sterilize; hence the addition of steam under pressure, especially when dressings, towels, etc., are folded. It is well to have a form of sterilizer that permits steam to be turned off and drying to be accomplished slowly by the aid of dry heat.

Next to steam thus utilized is boiling water, in which nearly everything can be sterilized. Silk sutures and silkworm-gut may also be sterilized in this way; animal suture does not permit of it unless previously hardened. The effectiveness of boiling water is increased by adding to it 1 per cent. of sodium bicarbonate, by which its boiling point is raised.

Dry heat is employed in an oven, or its equivalent, preferably in some apparatus by which temperature can not only be measured but maintained. In such a mechanism it is well to have the temperature raised to 300° F. for at least half an hour, and then let its contents cool slowly.

Another method of sterilization is by using volatile or easily volatilized chemicals, such as formalin in its fluid form, or its equivalent called paraform, which comes in crystals or may be had in tablets ready for use. Formalin is a powerful bactericidal agent, and if used in such form as to be sure of its penetration, good results may be expected. Some materials and instruments which are injured by steam or dry heat may be kept in an atmosphere of paraform, or sterilized by exposure to formalin vapor, being then subsequently protected against exposure in a sealed package. Catheters which have been boiled or cleansed can be thus exposed, as Hutchings has shown, and can be regarded as safe for use. They can, moreover, be resterilized in the same way. Naphthalene has similar properties, but is not quite so strong. The writer is accustomed to use one or the other of these in jars or receptacles containing dry dressings, catheters, and rubber gloves.

If aseptic methods are practised there will be but little use for the employment of any antiseptic, either in solution or in any other form.

Boiled water and sterile salt solution should be available for all purposes. It is customary, however, to have a solution of mercuric chloride on hand, which is colored in order that it may not be mistaken for any other, in which to rinse the hands, especially after they have been in alkaline solution.

The first thing to be sterilized should be that part of the body upon which operation is to be made. In some cases, as about the feet, the mouth, etc., this preparation should be begun two or three days beforehand; in other cases twelve to twenty-four hours will suffice. Preparation should be begun with soap, nail-brush, and razor, the parts being thoroughly cleansed and shaved. It is then customary with most operators to keep a moist and antiseptic dressing applied upon surfaces thus cleansed, which should be protected from drying by a covering of oiled silk or rubber tissue. Green soap is usually employed, which may have added to it a small percentage of carbolic acid or lysol. The mercurial preparations are too irritating to the skin. Carbolic acid has the reputation of being absorbed rapidly. On tender skins and in certain parts of the body it is impossible to make such applications, especially of soap poultices. Under these circumstances repeated washings and some protection should be practised. Feet upon which operations are to be made should be soaked repeatedly and scrubbed. Twenty-four hours previously to operating on the head the scalp should be shaved—preferably forty-eight hours—and prepared as above. For operations in the mouth the tooth-brush and antiseptic mouth-washes should be frequently used. For those in the vagina, douches, etc., should be frequently administered.

The preparation of the field of operation includes a final scrubbing, with a washing of alcohol or alcohol and ether. The hands and external clothing of the surgeon and his assistants should be sterilized, also the towels, suture materials, instruments, and dressings.

Lawson Tait was the first to teach the great value of absolute and mere cleanliness. This applies in large degree to the hands of the chief operator and of the assistants. With a large amount of scrubbing and cleansing of the hands it is not possible to put them into a condition of ideal sterilization. This is perhaps more true of the hands of some than those of others. A realization of this fact has led to the introduction of gloves, either thin rubber or cheap cotton. The former may be used repeatedly. The latter are sterilized by repeated boiling and may then be used again. Rubber gloves may be sterilized by steam or boiling water, and may be cleansed with soap and water or one of the stronger antiseptic solutions. The introduction of rubber gloves has brought great improvement in results. The gloves, however, constitute an impediment to some of the finer work and the easy recognition of tissue. Not the least important of the advantages of rubber gloves is the protection they afford to the surgeon’s hands and to other patients. Many accidental infections may be saved the operator if his hands can be kept out of pus, while the use of gloves permits the operator to pass from a pus case to a clean one without exciting fear. A snugly fitting glove is best drawn upon the dry hand by the aid of sterilized talcum. But the hand which it encloses should have been previously thoroughly sterilized so that it will not be a source of danger should the glove be pricked or torn. The operator can keep his hands in more favorable condition by using gloves dry in this way than by macerating his hands inside of wet ones.

The question of hand sterilization is an important one, whether the gloves are to be worn by some or all of the operating staff. There are occasions when it is important to make the hands absolutely clean because no gloves can be procured. Even the hands encased in gloves should be thoroughly prepared, as there is no knowing when the glove may tear and the surgeon’s bare hand come into contact with the patient’s tissues. Running water is preferable to a basin filled with it, for while it runs it carries away such material as may be detached by soap or nail-brush. If it be not possible thus to wash the hands, then repeated basins of sterilized water should be used, and all the crockery or metal ware used in the process should be sterilized, so that the hands will not be contaminated by handling unsterilized material. Nail cleaners are essential agents, to be vigorously used, and nail-brushes should be sterilized after each using, and there should be a separate brush for each operator. The common soaps and even the officinal green soap are not sterile. The former should be relied on only for the first cleaning, and the latter should be sterilized before use. A dirty hand should not be thrust into a receptacle containing freshly sterilized green soap. The outside coating of dirt should first be removed by an ordinary soap. Vegetable fiber has been recommended by many, but it is not as good as ordinary corn-meal, which should be sterilized before using. It is not as gritty nor as keen as sand, and yet it is sufficiently rough to serve admirably the purposes of a curry-comb. A first scrubbing with common soap and a nail-brush, followed by green soap with corn-meal, and this by a thorough use of the nail cleaner and a clean nail-brush, will ordinarily serve to put the hands in a reliable condition. It is the practice of some to add antiseptics to the soap, e. g., lysol and thymol. A number of years ago I introduced ordinary mustard flour for this purpose, basing its use upon the fact that the essential oil of mustard is one of the most potent of the vegetable antiseptics, in addition to its power as a deodorizer. (Parenthetically it may be said that when unpleasant odor attaches to the unprotected hands after making a postmortem examination, or opening an offensive collection of pus, the use of mustard will quickly remove the taint.) Even mustard is not absolutely reliable, nor is anything else which can be tolerated by the human skin. A method much in vogue a few years ago was to wash the hands in a solution of potassium permanganate, and then to decolorize the skin in another strong solution of oxalic solution. This method was at one time regarded as an effective one, but it is severe upon the skin. Another method in use at present combines commercial chloride of lime with saleratus; here free chlorine is supposed to be the active agent.

The bacteriological side of this subject has been investigated by numerous observers, particularly Dr. E. R. McGuire, attached to the Buffalo Surgical Clinic, who reached the following conclusions: Absolute sterility of the hands is unattainable, but as toward this result nothing takes the place of long and vigorous mechanical scrubbing under aseptic precautions; the use of antiseptics on the skin is of questionable value and often distinctly harmful; the operator whose hands perspire freely should wear gloves in every case; the use of rubber gloves is not ideal, but gives the nearest approach to it.

No material should be used which is so harsh that it will injure or destroy the epithelial cells either upon the operator’s hands or upon the patient’s skin.

Solutions of gutta-percha in its different solvents, or of collodion in acetone, have been suggested as forming a covering for the hands by quickly drying upon the skin. The merit of these preparations is questionable, and the length of time required to dissolve the coating makes them impracticable. They have found little favor among surgeons.

Next to the sterilization of the parts to be operated, and the hands, may be considered treatment of septic tissues or fluids and protection against further infection. Clean and uninfected tissues need no other precautions than those already described, plus extra care in hemostasis, in order that there be no clot left in which germs may find a nidus, and the careful closure of the wound in such a way that no cavities or “dead spaces” may be left in which blood may later collect. Surgeons generally agree that the less clean tissues are handled and the less contact they undergo with foreign materials the more readily they heal. The ideal fluids with which to cleanse parts or to wash away blood clot are sterile salt solution and boiled water. Antiseptic solutions should not be used upon healthy tissue; but when abscess cavities have been opened and when pus or other infectious material have come in contact with fresh raw surfaces, every effort should be made to overcome its effects. It is customary in abdominal operations to “wall off” the site of a pus focus so that contamination of adjoining surfaces may be avoided, by placing gauze packing around it. Other expedients, e. g., the use of a rubber dam in any of its modifications, which will aid in this purpose, should be adopted. Upon brain surfaces, as upon the ruptured perineum, and in vaginal, rectal, and numerous other operations, a continuous fine stream of salt solution may be directed with great benefit.

An abscess of any kind, no matter where located, should be thoroughly cleansed, its cavity disinfected, and easy access made to the outer wound. The interior of such cavities should be scraped with a sharp spoon. After curetting, a thorough washing or swabbing, often with the use of hydrogen dioxide, will often prove serviceable. Even a treatment of this kind does not afford as complete disinfection as may be secured by free application of pure carbolic acid or of a strong solution of zinc chloride (50 per cent.). The effect of this is not only to more completely sterilize, but to so sear the cauterized surfaces as to make them incapable of absorption. Excess of the caustic should be wiped away, or antidoted, in the case of carbolic acid by further swabbing with alcohol, or in the case of zinc chloride by merely washing out. Such a surface should heal naturally after sloughing, yet it is rarely safe to completely close such a cavity. A light packing of clean gauze, or, as the writer is fond of using it, of gauze sopped in balsam of Peru, will permit such a cavity to quickly close by the granulation process without further disturbance. Bone cavities, especially, are well treated with zinc chloride, it being difficult to so thoroughly disinfect such a focus that it may be safely closed without drainage; or they may be filled with bone chips or paraffin.

Visible tissue which is sure to slough should be removed with scissors or the sharp spoon, in order to save valuable time. Sometimes the actual cautery may be used to great advantage, as in chancroidal buboes, where every particle of raw surface will be infected by the pus which flows over it, and where it is advisable to cauterize not merely the suppurative focus, but everything which may come in contact with its pus.

—Instruments are now all made of metal, usually nickel-plated, which will stand at least a certain amount of exposure to heat. It is not sufficient, however, to sterilize instruments alone, but basins, irrigator nozzles, and everything else which may be wanted during the course of an operation should be equally prepared for it. Inasmuch as hard rubber does not well stand even boiling water, instruments should be made, so far as possible, of metal or of glass. Boiling water, or “live” steam, are universally employed for this purpose; while to the water is often added 1 per cent. of ordinary washing soda, which enhances its serviceability. Fifteen to twenty minutes’ actual boiling, or its equivalent, will be sufficient for ordinary purposes. All instruments, such as knives and scissors, deteriorate after repeated use in this way and need to be frequently sharpened. Catheters also may be sterilized by boiling and should be constantly kept exposed to some volatile antiseptic, such as formalin (see above). Sterile material should be used upon the inhalers, and the metal parts of these, as well as mouth-gags, hypodermic syringes, and the like, should all be boiled.

—Not only the dressings which are to be employed after an operation, but the gauze, the cotton, or the sea-sponges which may be used during the same should have been twice sterilized either by dry heat or steam, in order to ensure security. No absorbent material should be packed tightly if it is to be subjected to steam, as it is not easily penetrated, even under pressure. Moreover, not only these materials but the sheets, gowns, aprons, towels, splints, and everything which may come into near approach or actual contact with the wound should be prepared in the same way. After sterilization all these materials should be enclosed in germ-proof, sterile wrappers of some kind or in sterile jars or boxes.

As a postoperative precaution, all materials which can be destroyed after use in a septic case should be burned. If this be not practicable, they should be soaked for twenty-four hours in a strong solution of corrosive sublimate, say 1 to 500. At the conclusion of operation there should be no opportunity left for dissemination of infection.

—In place of sponges, gauze or absorbent cotton wrapped in gauze are now generally in use, prepared as above. There are some purposes for which sea-sponges are very convenient if they can be made reliable. Those which are received fresh from the dealer should be freed from sand by beating in a mortar, placed in a solution of 1 to 500 of potassium permanganate, and then transferred to a solution of sodium sulphite containing 5 per cent. by volume of pure hydrochloric acid; in this they remain until they are bleached out, which will take but a few minutes. They are then thoroughly washed in sterile water and stored in 5 per cent. carbolic solution.

—Wire, silkworm-gut, horse-hair, and silk or linen thread may be sterilized, if not rolled too tightly, by twice boiling for a half-hour, and then being allowed to dry, or preserved in 5 per cent. carbolic solution or in sterile alcohol. Disappointment often comes from rolling these materials so tightly upon spools that sterilization of the deeper layers is not complete. This is true of catgut as well as of the other animal sutures.

Catgut.

—Catgut, so called, is usually made from the intestine of the sheep, and must be freed from anthrax germs or spores. It should be rolled loosely on spools or rods, each layer separated from that beneath by a piece of gauze. The writer prefers to free it from animal fat by a preliminary soaking in ether or benzene. After this it may be sterilized by boiling in alcohol, preferably absolute, which must be in a container not tightly closed. This is placed in water, raised gradually to boiling, and should boil for two hours. This process should be repeated at least once after the expiration of twenty-four hours. This is the simplest of all procedures and generally proves reliable. Other methods are those of exposure, for instance, to cumol, a volatile paraffin oil, in which it is boiled under pressure in a special apparatus, the temperature being raised considerably above the boiling point of water (300° F.). When the receptacle is opened the cumol is drawn off or evaporates and the catgut is left dry and sterile. It should be either kept dry in a sterile jar or in alcohol. Some prefer to add to the latter a small amount of oil of juniper, which has a little hardening effect upon the animal material.

Catgut should be tested repeatedly to be assured of its sterility. Special methods of preparing catgut are as follows:

Formalin Gut

is prepared by placing the gut, wound as mentioned, in a 3 per cent. formalin solution for three hours. If the sterility of that which is used be not assured, then this preparation should be boiled in water for fifteen minutes. Catgut of large size should be immersed in a solution stronger than the above. It will probably be sufficient to give this a final boiling at the time of operation. This is almost as lasting as chromicized gut.

Chromicized Gut.

—Gut to be thus prepared should be wound in single layers on spools and immersed in a solution of potassium bichromate 1.5 to 2.5, carbolic acid and glycerin each 10, and water 1000 parts. It is allowed to remain in this solution for twenty-four hours, then dried and boiled in water, or in alcohol under pressure, in which it is subsequently stored. According to the length of exposure and the strength of the solution, this gut will resist absorption from ten to thirty days.

Iodine Gut

is growing in favor with some surgeons. It is prepared by immersing catgut in a 10 per cent. solution of iodine, in which it is kept for a week. After removal it is allowed to dry and is stored dry, but should be kept protected from exposure.

Silkworm-gut

may be boiled in a 2 per cent. lysol solution for one hour, which makes it pliable. Sometimes it is convenient to have it stained black in order that the sutures may be better distinguished when removed. In this case it is allowed to stand in a 1 per cent. silver nitrate solution for from twelve to twenty-four hours. This gives it an almost black stain, but tends to make it more brittle. It may be kept in alcohol, or dry in a sterile receptacle.

Silk.

—Silk should be spooled loosely, boiled in a similar solution for one-half hour, and again in plain water just before using. It may be stored dry or in alcohol. It may be also stained black.

Celluloid Thread.

—This should be washed and scrubbed in green soap and hot water, after which it is spooled, and then boiled for thirty minutes. It may be stored dry or in alcohol. This is a linen thread covered with a film of celluloid.

Kangaroo and Reindeer Tendons

are prepared essentially as is catgut, but if boiled in alcohol they must be kept covered with the fluid, as they tend to disintegrate.

Drainage Tubes

of rubber should be boiled in soda solution for fifteen minutes, and may then be stored either in 1 per cent. formalin solution, or dry in a suitable tube.

Oiled Silk and Rubber Tissues

are first prepared by washing in 1 to 500 sublimate solution, then dried, and exposed in an air-tight jar to the vapor of formalin or paraform.

The above are the methods usually in vogue in the writer’s clinic, and may be relied upon. These materials should be frequently tested by dropping fragments into culture tubes and watching the result, but only after taking the precaution to precipitate or neutralize the antiseptic previously used in their preparation.

—In well-regulated clinics sterile salt solution is always at hand. As has been stated the old six per mille solution may be improved by adding 1 part of potassium chloride and 2 parts calcium chloride. For emergency purposes tablets are now prepared which will permit the rapid preparation of these, of any desired strength. To this a little corrosive sublimate may be added without producing decomposition. When sublimate is used alone, or in other combinations, a little vegetable or mineral acid, such as tartaric or hydrochloric, should be added, as most of the water used contains lime.

When a maximum of bactericidal effect is desired with a minimum of irritation, the silver salts, either the lactate or the citrate, will probably afford the best results. The former may be used as strong as 1 to 300, the latter 1 to 500. The writer has frequently used these solutions for washing out the peritoneal cavity, in cases of tuberculous peritonitis, where they serve their purpose admirably. For washing out tuberculous joints and many other abscess cavities, solutions of silver nitrate of 1 to 1000 to 1 to 2000 are most serviceable; or, for the same purposes, boiled water, to which has been added sufficient tincture of iodine to give it a mahogany color. In caring for such cases it is good practice to alternate the solutions, using them on alternate days.

Antiseptic powders or applications in dry form are useful for many purposes. At one time iodoform was very popular; it was supposed to act by virtue of the iodine set free in the presence of decomposing organic material. It is now seldom used, partly because of its tell-tale odor, and partly because of the disappointment which its use often brings. It is, moreover, an active toxic agent of itself, and has many times given rise to symptoms of intoxication, such as mental depression, delirium, nausea, and anorexia. Under all these circumstances free iodine can be detected in the urine.

There are numerous substitutes for iodoform, many of which are superior to it in antiseptic properties, while most of them are free from odor and toxic qualities. Two substances, however, are used extensively—naphthalene and bismuth subiodide or red iodide. The former has a marked odor and is more or less volatile, which makes it particularly valuable. The latter is odorless, non-toxic, and of much greater value as an antiseptic than most of the others, because it will give off free iodine under favorable circumstances. A good plan is to use it in the preparation of gauze and dressings, as well as for a dusting powder upon the skin.

The absolute value of these local applications is questionable, because a wound will sometimes heal under the protection of a piece of foil or gutta-percha tissue as well as when dressed in any other way. This is true only of wounds in part surgically clean.

—Drainage has been resorted to, more or less intermittently, since earliest historical times. It is provided for the removal of deleterious fluids or of superfluous exudates or transudates. It is a recognition sometimes of a necessity, at other times a confession of fear which may or may not be justified. It is bad practice to cover a focus of previous gangrene or suppuration in such a way that the infected cavity is closed to the escape of accumulating fluid. This may be prevented by the use of a suitable drain. At times a clean operation may be made, and yet in such loose tissue, or to such an extent, that it is preferable to provide for the escape of blood rather than let it occur and force apart surfaces which should be in close contact. A drainage tube may serve as a vent through which blood may escape that has oozed after closure of the wound. After pelvic operations provision should be made for the withdrawal of accumulating fluid which might serve as a culture medium for germs. Drainage is therefore necessary in many instances.

It will suffice sometimes to suture loosely a part or the whole of a wound, so that should tension occur from retention there may be spontaneous escape. This may be termed indirect drainage, and sometimes has to be made still more complete by leaving out some sutures, or by placing secondary sutures, which are only utilized some days later, when previously infected surfaces have become healthy and are granulating, so that they can be brought together.

By direct drainage secretions and fluids are guided toward the dressings, which should be absorbent or so arranged as to provide for their accommodation; thus in drainage of the gall-bladder or of the urinary bladder the tube may be connected with a suitable receptacle by siphonage. Capillary drains may be made of a few strands of silkworm-gut, which is non-absorbable, or of catgut, which is absorbable, and to which, perhaps, no further attention need be paid. This will answer for conducting away small amounts of fluid which exude. Gauze, or its equivalent in the shape of some form of wicking, affords an excellent material for removing fluid by osmosis. The thinner the fluid the more perfectly it serves this purpose. The gauze must be changed frequently, as these lesions may become filled with coagulated material, in which case it would act merely as a plug. The so-called cigarette drain consists of folds of gauze, or a small roll of it, surrounded by sterilized oiled silk or gutta-percha tissue, in which are cut numerous holes. The same purpose may be achieved, but often not so well, by a piece of rubber tubing split down one side. The gauze drains by osmosis, and the rubber prevents any adhesion to the wound margins and any pain in the removal of the drain; while a certain amount of fluid may escape around and outside the smoother surface.

When the fluids to be removed are more dense—e. g., pus—tubular drains should be provided. These vary in size from that of a lead-pencil to that of the finger. A tube which is too small becomes easily plugged. They are perforated with numerous openings for the ready entrance of fluid save in those cases, like the gall-bladder or the pelvis, where it is desirable to drain only the depths of a cavity. These tubes are usually made of rubber, the purer forms of gum being preferable. For some purposes, especially in the pelvis, tubes of glass or aluminum are used; these are non-collapsible. They may be emptied by a capillary drain, or by the frequent use of a small syringe with a long nozzle, by which they are pumped out at regular intervals. Metal and glass tubes can be resterilized and used again. All other drainage material should be burned as soon as removed. There are occasions when it is well to use a dressed drain—i. e., a tube surrounded by absorbent gauze, and this again by rubber tissue or oiled silk. In many instances it is well to prevent the loss of a drainage tube by passing through its outer end a safety pin, or by stitching it to the margin of the skin wound. Tubes have been lost, especially within the thoracic cavity after operating for empyema, more often than is perhaps generally known, and for a lack of precaution in this respect.

Tubes of decalcified chicken bone have been used and are occasionally serviceable. They are made by cleaning the cooked bones of the fowl, soaking them in 20 per cent. hydrochloric acid solution until decalcified, trimming the ends, cleaning the interior, and are then sterilized by boiling in a saturated solution of ammonium sulphate. They are then washed in sterile water and preserved in alcohol. They correspond to catgut, and will ordinarily last in the tissues for about eight days. They may be chromicized, as is catgut, in which case they endure considerably longer.

CHAPTER XXV. PREPARATION OF PATIENTS FOR OPERATION AND THEIR AFTER-TREATMENT. — Prevention of Peritonitis. — AFTER-TREATMENT.

At the risk of some repetition it is proposed to epitomize here a few directions on a subject of great importance, to which, as well in theory as in practice, too little attention is often paid. For present purposes patients may be divided into two classes: those who have sustained accidents or sudden surgical diseases, where no time is afforded for preparation; and those who, having chronic conditions, are subjected to surgical measures which are, however, sometimes made abrupt by sudden decision. In the former case the surgeon is compelled to work hastily; for the latter, time for preparation should be always afforded. Experience teaches that a few days, sometimes even a few weeks, may be well spent in preparing a patient for a surgical operation.

In emergency cases, aside from the usual scrubbing and shaving, there may be several matters to which it is well to give attention. The stomach should be washed out just before the administration of the anesthetic, or soon afterward. If there be time the rectum should be emptied, and the bladder always; too much care cannot be given to these performances. The degree of shock should be estimated and appropriate treatment given, according to principles stated in the chapter on Shock.

Foresight will often dictate the preparation of some part of the body not directly involved in the field of injury; for example, in any gunshot or stab wound of the abdomen or in a case of acute pancreatitis the back should be scrubbed and cleansed and the patient laid upon sterilized material, so that should posterior drainage be required it may be promptly made without waste of time required for preparation. In head injuries, if the scalp or cortex of the skull be involved, the entire head should be shaved. In preparation of patients for operation upon the mouth, tonsils, or stomach an antiseptic mouth-wash should be used in order to avoid, so far as possible, contamination from these germ-laden regions. It Is especially in cases undertaken for the chronic pathological conditions that time can be afforded for careful preparation. It may be assumed that every patient suffering from a chronic surgical malady has been so disabled, in at least some function, that elimination has been interfered with. The emunctories of the body comprise essentially the skin, the lungs, the intestines, and the kidneys. Every one of these should be made to perform its work more fully.

The skin should be stimulated by hot-air baths, for which purpose patients may be sent daily to the Turkish baths, while others should take their sweats in cabinets or in bed. If it be possible after the skin has been made to perspire profusely the patient should be put into a hot bath and the skin thoroughly scrubbed.

The lungs may be stimulated partly by improving the heart’s action, partly by certain exercises, and by getting the patient out into the open. The intestines should be made to perform their work, preferably by the mildest measures that may prove effective. Mercurials are agents of great value, as they not only stimulate secretions but are antiseptic in their effects. Sodium phosphate is useful when something stronger is not required.

Many patients who are found in this class will have impaired digestion, for which a regulated diet should be supplied; and such cases may call for lavage, as well as for a careful examination of stomach contents, in order that appropriate aids to digestion may be given. Most patients suffer from intestinal torpor, especially of the large intestine, and the daily administration of a high-up colon wash, with the patient in the knee-chest position, will give gratifying results.

It has been suggested that in all operations upon the upper alimentary canal it would be of great advantage to feed the patient during the previous forty-eight hours upon sterilized food.

A careful study of the urine should be made, both quantitative and qualitative. The gross measurement of the amount excreted in twenty-four hours is of importance. It is necessary to know what amount of solids is being daily excreted, as well as the amount of fluid. Renal insufficiency is one of the difficulties with which the surgeon has often to deal, and caution should be used when operating upon a patient suffering from this condition. Extra work is thereby imposed upon other emunctories. A depraved blood circulation through the brain will often impair its function and lead to delirium in mild or serious form. The heart’s action will be impaired and septic infection is made more possible, in spite of every precaution included in antiseptic technique. In the chapter on Infection it was stated that certain cases of surgical sepsis commence as infections from within, due to failure in unloading the body of its content of disease germs.

Hyperacidity should be also corrected. In order that this may be properly done, the urine should be tested by a more accurate method than by litmus paper. The restlessness and consequent wound disturbances which may ensue after operation may be due to failure in the elimination of uric acid and the oxalates; alkaline diuretics, therefore, are an important feature in the preparation of many surgical patients.

The blood and circulation should not be neglected in these cases. These patients are frequently anemic. A high degree of anemia is recognized by methods described in the chapter on the Blood. Much may be done, even in a short time, to improve the quantity and the quality of the blood, by attention to nutrition and elimination. By these same measures the heart’s action will be also greatly strengthened, but much can be accomplished in this direction by the use of digitalis, cactus, or other of the heart stimulants, and by the administration, preferably subcutaneously, of strychnine. This is usually given in too small doses. Two hypodermic injections of ¹⁄₃₀ Gr. (0.002) a day will have a pronounced effect. While the heart is thus fortified as against shock before the ordeal, adrenalin will prove the most effective agent during it and after it is passed.

Intestinal fermentation or decomposition is a prominent feature of many of these cases. If it be possible to select a drug which has antiseptic properties that may be effective in the intestine and in the kidneys, it will come near to being the ideal in this respect. The attendant has here to choose from many remedies, and his choice will depend largely on his personal experience. It is better to use a few remedies and use them well than to be indiscriminate.

Salol, benzosol, betanaphthol, sodium sulphocarbolate, and the salts of mercury and arsenic will furnish sufficient compounds from which to select. When the urine is alkaline, as it often is in certain kidney and bladder diseases, urotropin may be advantageously combined with one of the others.

In the way of general preparation of those patients who have to undergo operations upon the mouth, the nasopharynx, the esophagus, trachea or larynx, and upper alimentary canal, they should be sent to the dentist in order that their teeth may be put in good condition and accumulations of tartar removed, and then use an antiseptic mouth-wash, or, when necessary, a nasal spray, in order that there may be avoidance of infection from the bacteria which abound in these parts. Patients often have diseased and carious teeth, and, in hospital patients especially, the mouth is often in a dirty condition. So long as any wound surface is so situated as to be in danger of contamination from these sources, this should be minimized as far as possible.

—Experiments have been made by Mikulicz with regard to the value of nuclein in producing an artificial and protective leukocytosis before abdominal operations, hoping thereby to accomplish more or less in the way of prevention of peritonitis. The procedure is based upon the well-known property of nucleinic acid, or nuclein, to produce a prompt but transitory increase in the number of leukocytes. To take advantage of this, 3 to 5 Cc. of nuclein solution is administered beneath the skin, say twelve hours and again six hours previous to the operation. Should any septic agent be introduced or liberated during its performance, the leukocytes will be present in additional numbers to act as phagocytes and exert their active protective powers.

The care of patients after operation is a factor in a surgeon’s success and calls for discrimination and judgment. The fact that the odor of chloroform or ether persists about the patient and in his breath for hours after their administration shows to what extent they have been dissolved and are circulating in the blood. If elimination have already been attended to, and so far improved as to permit the emunctories of the body to do work up to their capacity, these anesthetics may be promptly eliminated. The longer they circulate in the blood the greater the disturbance to other functions and the more difficult it is to get normal function equalized.

The things especially to be guarded against, so far as one may prevent them, are nausea, vomiting, extreme restlessness, pain, inactivity of the bowels, insufficiency of the kidneys, and the toxic action of any antiseptics or drugs which may have been used, e. g., iodoform.

Nausea and vomiting after operations are due not so much to mere reflex activity as to the elimination of the anesthetic by the stomach and its irritant action. No matter how produced, such vomiting is of itself most depressing, mentally and physiologically, and is injurious in a large proportion of cases, and efforts should be made to prevent it. So long as it was regarded simply as a reflex act drugs were theoretically sufficient for its treatment, but with the appreciation of its actual causation it will be seen that the irritating material should be removed. This may be done with the minimum of discomfort and the maximum of advantage by means of the stomach tube. Lavage, therefore, constitutes the most rational and effective treatment in cases of postoperative vomiting.

That the anesthetic reaches the stomach by way of the circulation and is excreted by the gastric mucosa has been proved by the studies of Türck. He showed that the same is also true of morphine. He showed, moreover, that the stronger anesthetics disturb the metabolism of the cells and that toxic products are thereby produced which, being reabsorbed, cause an auto-intoxication reducing vital resistance of the blood serum and the tissues. Thus during anesthesia there occurs an atony of the stomach walls with the escape of the anesthetic into the stomach, which, acting as an irritant, leads to an increased amount of toxin production. The discoloration of the gastric mucosa and the capillary hemorrhage which take place, as shown postmortem in cases where persistent vomiting is a feature, illustrate the disturbing effect of the stronger anesthetics upon the stomach itself. This furnishes, then, the reason for washing out the stomach immediately after stopping the anesthetic and before the patient leaves the operating table. It cannot be said that by this measure postoperative vomiting will be abolished, but its frequency will be materially lessened.

Lavage may also be practised to great advantage not merely immediately after the operation, but during the ensuing twenty-four hours, or later should vomiting recur or come on late. On the other hand, where time has not been afforded in which to suitably prepare a patient for operation, it is advantageous to wash out the stomach before administering the anesthetic as well as after. This is recommended as a general measure, and without special reference to those cases where operation is directed to the stomach itself or to the intestinal tract, where it has become an established part of the preparation to carefully cleanse these viscera.

Several points in the performance of lavage will be of great service to patient and operator. It should be performed quickly in order to reduce the length of the discomfort, and the water used should be warm, at least 110° F. If the throat be previously sprayed with weak cocaine solution (2 per cent.), or if a cocaine lozenge be dissolved in the mouth, the tube can be introduced with less gagging and difficulty. The lubricant should be flavored with wintergreen or some other aromatic.

Where vomiting continues in spite of lavage it is advantageous to give a full dose of chloral with a little starch-water in the rectum; 2 or 3 Gm. of chloral, with as much sodium bromide, to which, in case of severe pain, a little opiate may be added, may be profitably used in cases where the patient is restless and where sleep is fitful or perhaps impossible. This will be more beneficial than drugs administered by the mouth. It is seldom rejected, and is very soothing.

Extreme restlessness is undesirable from every point of view. In some cases when it comes on early it is an evidence of insufficient oxygenation and may be combated by the administration of oxygen gas. It frequently accompanies shock and constitutes one of its most disturbing features. It may be combated by a subcutaneous dose of morphine or heroine, or chloral in doses of 2 Gm., with as much sodium bromide, thrown into the rectum with salt solution. The effect may not be as prompt, but it is often much better. Restlessness is not always a symptom of pain, but is occasionally an uncontrollable reflex nervous phenomenon.

After operations physiological rest of the operated part is necessary for the process of prompt repair. After abdominal operations, especially when restlessness and vomiting are combined, much harm may be done if the patient cannot keep the parts quiet.

Pain will often accompany restlessness, and frequently accentuate it, especially when patients have not yet fully returned to consciousness. It may be relieved by warm or cold applications. In some cases an ice-bag may be used as soon as the patient is placed in bed—for example, after breaking up an ankylosis. In mild cases the use of chloral in the rectum, as above, with an opiate added, may be sufficient. When pain is severe hypodermics of morphine or heroine should be given. Secretion should not be disturbed by such drugs as these, yet as between them or permitting patients to suffer intensely, my opinion is that opium should be given judiciously, providing it prove sufficient. In extreme cases morphine seems to be the only medicament upon which complete reliance can be placed. When the opiates seem to produce nausea the difficulties are heightened. It may be decided in some cases to push the opiate to the point of narcotism, preferring to keep the patient in this semistupefied condition for two or three days and until the series of early dangers have been passed. Opiates should be given with great discretion lest the opium habit be encouraged if not formed.

Lately there has come into use a remedy which has little or no unpleasant after-effects, and upon which a good deal of reliance can be placed, namely, aspirin, which may be given in 1 Gm. doses, repeated as necessary. If it be combined with phenacetin, in doses of half that amount, the combination will be more effective than either alone. This will often prove a serviceable substitute for opiates in any form.

After operation upon the lower bowel, or in any part of the pelvis, patients may complain of pain, sometimes severe, referred to the rectum. Relief may be obtained by throwing into the rectum, through a flexible tube, one-half to one pint of warm linseed oil. This will often take the place of an anodyne or a suppository.

The next question is one of catharsis. If the alimentary canal have been properly emptied, as it should have been before the operation, the bowels may be allowed to rest for the ensuing forty-eight hours. At the expiration of that time the lower bowel should be emptied. Whether this be done with laxatives administered by the mouth or by enema will depend on the character of the case and the reliability of the stomach. When vomiting is distressing little can be accomplished from above. In most cases the first effort is to be made by the administration of a thorough colon wash, or by the use of an enema, which may perhaps best consist of ox-gall, glycerin, and a saturated solution of Epsom salt. If this be thrown up high, and retained a while, it will in all probability be effective. Should the operation have been one upon the rectum extra care will be needed for the patient’s comfort, and just preceding the stool a small amount olive oil should be administered through a tube. Many patients will complain of gaseous distention or other discomfort, due apparently to fermentation, and partly perhaps to the air which they have swallowed during the act of vomiting, or because of nausea. No matter how produced it will afford relief to get rid of this gas, and while this may be partly accomplished by an enema, it will be more thoroughly effected by a mercurial, given by the mouth, to be followed by a saline laxative. In order that flatus may escape without effort, a rectal tube may be inserted, which later may be utilized for the administration of an enema. Save in rare instances it is a mistake to allow accumulation of fecal matter, as the stercoremia thus favored may easily lead into a more profound form of poisoning by its interference with elimination and vital resistance.

Attention should be also given to the bladder and to the urine. Renal insufficiency is one of the great dangers pertaining to the use of anesthetics. This may be combated by 2 Gr. doses of sparteine sulphate every three hours (McGuire).

Many patients are unable to void urine after operations, particularly after those upon the female genitalia, and the use of a catheter is often necessary. This should be used with antiseptic precautions, both as to the patient, the instrument, and the operator’s hands. Much of this difficulty can be avoided by injecting 20 Cc. of a 2 per cent. sterilized boroglycerin solution through a catheter in the evening after the operation. Its action is usually prompt, and in five to ten minutes the patient spontaneously empties the bladder without unpleasant after-effects.

After abdominal and pelvic operations the patient should not be allowed to urinate, but should be systematically catheterized. The bladder should never be allowed to become distended. The amount and character of urine passed should be carefully noted. In serious cases the amount of solids eliminated should be estimated, in order that it may be kept up to the necessary standard. In fact, efficient and sufficient elimination is more necessary after the prolonged administration of an anesthetic than after almost any other event. When sufficient fluid to keep up the standard cannot be administered by the stomach, it should be introduced into the rectum or given beneath the skin. Two or three enemas of salt solution should be administered each day, and in urgent cases the normal solution should be thrown beneath the skin, and this should be repeated as often and as long as may be necessary. When the patient begins to show evidence of what is vaguely described as uremia, i. e., the toxemia of renal insufficiency, not only should warm water be used in these ways, but hot-air bed baths should be given twice a day if necessary, in order that some of the work of the kidneys may be assumed by the skin. Hot-air baths stimulate the kidneys as well, and these measures will prove more effective than most of the diuretics, although digitalis and pilocarpine by the skin may be of assistance.

Patients frequently complain of excessive dryness in the mouth. This may be relieved by occasionally dropping beneath the tongue one-half of an ordinary hypodermic tablet of ¹⁄₁₀ Gr. pilocarpine; also by mouth-washes which contain a little glycerin, and by keeping the lips moistened with glycerin. Excessive sweating can sometimes be relieved by giving a hot-air bed bath or a hot mustard foot bath, as the extra action of the skin thus induced checks the spontaneous drain.

Delirium and acute mania occasionally supervene after operations. It should first be made clear that these are not due to any antiseptic or drug. Iodoform is less frequently used than formerly. Children and aged people become delirious with less provocation than do those in middle life. Such delirium is generally an expression of a toxemia, and, in addition to such other measures as may be necessary, calls for control and restraint and more active elimination, as in so-called uremia. In proportion to the degree of mania must be the restraint prescribed. A restraining sheet or a strait-jacket may be sometimes needed. When these conditions arise in surgical patients more harm will come from the violation of the principle of physiological rest than from the drugs which may be needed to secure it. The milder measures should be first used, abstaining as far as possible from opiates, which are probably the least desirable of all, but which may be occasionally demanded. Chloral, the bromides, cannabis indica, alone or in combination, may be made to render more valuable service. Hyoscine, in doses of ¹⁄₁₀₀ to ¹⁄₅₀ Gr. beneath the skin, will often control when other remedies fail; it may prove invaluable. When delirium tremens complicates a case it may be treated as suggested in the chapter on Various Intoxications.

Part V. SURGICAL AFFECTIONS OF THE TISSUES AND TISSUE SYSTEMS. — CHAPTER XXVI. CYSTS AND TUMORS. — GENERAL CONSIDERATIONS. — TREATMENT OF TUMORS. — CLASSIFICATION OF TUMORS.

A tumor is a new formation, not of inflammatory origin, characterized by more or less histological conformity to the tissue in which it has originated, and having no physiological function.

By the above definition it is intended to separate the new-growths from a distinctive class of neoplasms which are of inflammatory (i. e., of infectious) origin, to which the generic term of infectious granulomas has been given. (See Part II.)

Exceedingly vague notions have prevailed concerning the nature and origin of tumors, and, while the clinical observations of writers in the past will never lose their value, the ideas which have prevailed concerning their pathology constitute interesting reading in a historical sense, but are now of small value. Accurate notions scarcely prevailed until Virchow demonstrated that tumor cells nowise differ from cell types which are met either in embryonic or in adult tissues. Tumors, like all other parts of the body, are built up of cells, and the points concerning which we need most light regard the influences which determine cell overproduction in these characteristic forms. Concerning the views that have prevailed, this is scarcely the place in which to offer an epitome. I shall therefore take up but few of the explanations which have been offered to account for tumor growth, and will emphasize that, according to our present light, there is no explanation sufficient to cover all cases, but that it is now one cause and now another which may determine this peculiar form of cell activity.

Irritation and Trauma.

—The effort is often made to explain the presence of tumors upon the hypothesis or the known fact of some previous injury. Frequently tumors appear in sites where there have been previous traumatisms, but this sequence of events by no means proves a definite relation of cause and effect. On the other hand, there are forms of irritation which are often followed by tumor formations. Probably no woman escapes without one or more bumps or bruises upon the breast, yet they do not produce tumors in more than a trifling proportion of cases. Per contra, upon the lower lip of inveterate clay-pipe smokers and the scrotum of chimney-sweepers there develop certain forms of malignant ulcer (epithelioma) which so often and so significantly follow upon the irritation thus produced that it is impossible to avoid conviction that one is the cause of the other. Should events prove the parasitic nature of any of these growths they will also prove that the irritation causes surface lesions through which infection easily occurs. In regard to the relative frequency with which cancer in some form follows trauma we should not forget the well-known fact that traumatism usually diminishes tissue resistance. If cancer be an expression of infection, as many (including the writer) believe, the possible relation between trauma and malignant disease may be better appreciated.

Inflammation.

—This refers to inflammation in the sense in which it has been used in the past, implying a variable condition, sometimes including and sometimes excluding infection, the term covering a confused mixture of irritation, hyperemia, and infection. In so far as it concerns inflammation as considered in the present work it should not be here included, since inflammation (i. e., infection) produces neoplasms of a class considered in Part II and is distinctly ruled out from present consideration (i. e., the infectious granulomas).

If inflammation in the former sense be more than hyperemia it may be regarded as predisposing to cell activity, but not necessarily to tumor formation as distinguished from hypertrophy of a given part or tissue. If it refer to irritation, this has been acknowledged as a factor in the etiology of tumors, but as an uncertain one. Cancer of the gall-bladder or liver, which occasionally results from the irritation of a gallstone, or the cancer of the breast that follows eczema of the nipple, may be regarded in this light as additional illustrations if it is preferred to interpret them in this way. If by inflammation be meant the infectious granulomas, they have already been considered. As the term “inflammation” can scarcely mean anything except hyperemia, irritation, or infection, we seem to have completely ruled it out from consideration as by itself an active cause leading to tumor formation.

The Embryonal Hypothesis of Cohnheim.

—This in its ingenuity and in its applicability is a fascinating explanation, which is undoubtedly sufficient for at least a certain number of instances. According to Cohnheim, only one causal factor for tumors exists—i. e., anomalous embryonic arrangement. He regards them as entirely of embryonal origin, no matter how late in life they may develop and appear. Briefly summarizing his views, they are to the effect that in the early stages of embryonal development there are produced more cells than are necessary for the construction of a certain part, so that a number of them remain superfluous. While these may remain very small, they possess, on account of their embryonal nature, a potent proliferating power. This superfluous cell material may be distributed uniformly, in which case it will develop whole system arrangements, like supernumerary fingers, etc., or it may remain by itself in one place, and will then develop a tumor. In the latter case the tumor may appear early or not until late in life, according to the time at which the cell collection receives the necessary stimulus, or because of its suppression by resistance of surrounding structures. It may be an irritation or an injury, such as above alluded to, which shall give it this stimulus; as, for example, it is reasonable to think that certain nevi and other congenital conditions which develop later into cancers do so in accordance with this view. Surgeons generally find little fault with Cohnheim’s hypothesis, except that as yet they decline to see in it an explanation for all cases. Nevertheless for dermoid and teratomatous, and for all heteroblastic tumors, it seems to afford the only tenable explanation. Thus chondromas of the parotid and of the testicle are most easily explained in this way, and that cartilaginous islands occur in the shafts of adult bones is well known.

Heredity.

—In regard to heredity being a factor in the etiology of neoplasms there is reason to believe that a favorable tissue disposition may be inherited, but there is nothing to show that it permits the actual transmission of the disease.

Parasitic Theory.

—The parasitic theory of tumor formation has only within a few years taken definite form and shape, as a result of evolution from vague suggestions and scattered observations. It implies that tumors, and they are mainly of the malignant type, are due to irritation produced by extrinsic agencies, parasites of some kind, which, introduced from without, act as do bacteria in the now well-known infectious granulomas. While this theory, perhaps, does not afford an absolutely satisfactory explanation of all the phenomena of malignancy, it nevertheless comes nearer to it than does any other hypothesis now before the profession, the arguments in favor of it being scientific and positive, and those against consisting mainly of mere negations. Summed up these arguments may be stated as follows:

1. Comparative Pathology.

—The argument from comparative pathology begins with the lower forms of life. Tumors in trees and plants are well known to vegetable pathologists and botanists as of frequent occurrence. They vary in size from the most trifling galls to those large woody masses known as xylomas, which are essentially tree cancers, since they tend to the destruction of the tree. These are known to be invariably due to extrinsic agencies, such as insects, fungi, etc. As water freezing in the bark of a tree may crack it open and thus leave opportunity for subsequent infection, so may injuries upon the body surface make trifling lesions which predispose to subsequent infection and cancer in man and animals. Exclude parasites from such traumatic lesions on plants and there will be no xylomas.

PLATE XIV

Adenocarcinoma with Young Parasites. (Parasites blue. Plimmer’s method.)

This plate is introduced to illustrate the presence of parasites, whose minute and actual character is not yet positively determined, but whose existence is undeniable.

From Gaylord’s paper in the Third Annual Report of the New York State Pathological Laboratory of the University of Buffalo.

PLATE XV

Rapidly Growing Carcinoma of Breast.

The parasites herein demonstrated are still subjects of careful and minute study. It would therefore seem premature to make detailed statements concerning their exact nature.

From Gaylord’s paper in the Third Annual Report of the New York State Pathological Laboratory of the University of Buffalo.

PLATE XVI

Fig. 1. Parasites, at one time called Russell’s Bodies, at Periphery of Epithelioma of Tonsil. (Oil immersion.)

Fig. 2. Same in Lymph Node before Epithelial Invasion. (From N. Y. State Path. Lab. Rep.)

Fig. 3. Papillary Adenocarcinoma of Ovary, showing Intracellular Ameboid Forms of Parasites. (From N. Y. State Path. Lab. Rep.)

2. The Analogy Afforded by the Infectious Granulomas.

—These are universally conceded to be of parasitic origin, while their clinical course and behavior in every respect make many of them almost as malignant as the true cancers become.

3. Metastasis.

—This is in every other disease considered to be one of the most significant expressions of infection, yet until recently few of those who have willingly accorded to metastasis its now common interpretation in tuberculosis have been willing to give it the same dignity as a factor in the spread of cancer and an important explanation of its nature. Why should every other disease characterized by metastasis be everywhere viewed as parasitic, and cancer, in which occur some of its most positive expressions, be denied? Metastasis has the force and significance of an inoculation experiment performed under favorable circumstances.

4. Evidence of Local Infectivity.

—The involvement of a part which has lain in contact with a cancerous lesion, as about the mouth or the vulva, and in many other ways and places of which medical literature is now full, and the instances of cancer following the knife wound, especially following the track of the trocar used for tapping a case of cancerous ascites, stamp the disease as having an infectivity which cannot be explained on any inherent property of its own.

5. Microscopic Appearances.

—While it is true that but few observers have been able to agree upon a definite cancer parasite, it is also true that many of the best observers have seen, described, and figured bodies that do not belong in the cells of a cancerous growth except they are there in the roll of active agents, and the appearances which have been described by Pfeiffer, Plimmer, Gaylord, Calkins, and others are not to be explained away as mere artefacts, but must be given a place in our estimation which they would attain of themselves, as exciting suspicion, were there no other facts corroborating the views that they are in some way actively connected with the production of the disease. (See Plates XIV, XV, XVI.)

6. Inoculation Experiments.

—No feasible plan has been devised for practising inoculation experiments upon human beings. It is known, however, that the disease may be transmitted in some cases among animals of the same species, and the transfer has been made in a few instances from man to the lower animals. In the Gratwick Laboratory (Buffalo) the disease has been thus transmitted through hundreds of mice, and has thus afforded the best means of studying it in its varied phases, albeit in small animals, ever yet enjoyed. But cancer does occur in animals and has proved to be capable of inoculation, and, therefore, has responded to one of the severest tests of the value of the theory. Moreover the facts cited above (under 4) are essentially successful auto-inoculation.

7. Clinical Observations.

—Add to the features already mentioned above those impressions which come from accurate observation and correlation of the phenomena attending many cases of cancer, and a plausibility is thus lent to the parasitic theory which it can never gain from study in the dead-house or through the microscope. The resemblance between it and other known infections, the local and general alterations of tissues and fluids, the chemical changes by which the cachexia of the disease is brought about—these with other features all conspire to give the keen observer of cases of cancer an impression of parasitism or infectiousness which nothing can efface. Add to these its endemic, sometimes almost epidemic occurrence, its apparent transmission by contact, and the fact that it is but little influenced either by nutrition or drugs, and the argument is still strengthened. As against these arguments little has been advanced save denials or negations.

In thus upholding the parasitic theory, the writer would not wish to be understood as claiming either that the parasite has yet been discovered or its nature positively made out, nor that it is a question of one organism alone; rather, on the contrary, he feels that it is probably a question of several agents, probably of protozoan character, perhaps too small to be recognized with the lenses of today, perhaps belonging to some as yet unstudied class of organisms, making themselves known, however, as do the hypothetical parasites of syphilis and scarlatina, by their effects. To accept the parasitic view is to reconcile many discrepancies of earlier times and to give an entity to the disease by which, and until something better be found, we may be more safely guided in its management.

The parasitic theory lends plausibility to the statement which the writer wishes to emphasize, that cancer, like many of the other infectious diseases, is at first a local condition, that it is not transmitted by inheritance, and that there is a time in the history of every cancer when, if it could be recognized sufficiently early, and if it were also accessible and thoroughly removed, it could be cured.

Nomenclature.

—The nomenclature of tumors has been much confused, and if some new terms are introduced it is perhaps better than to cling to some which have prevailed in the past. Various systems have been followed of naming them according to their supposed nature or their evident tendency, or according to some purely arbitrary classification; thus there is the distinction into homologous and heterologous or heteroplastic, according as they are similar to or variant from that tissue in which they seem to originate; or they have been referred to as benign and malignant according to the disposition which they evince; and these terms are in sufficiently frequent use to demand acceptance. The distinction between benign and malignant is convenient and in some respects accurate, implying little in regard to histological structure, but much in regard to their effect upon the individual.

So far as method of classification goes, the anatomical (i. e., the histological) has proved far the most satisfactory, and is that which is now generally adopted. It is the basis for the classification followed in the ensuing pages. But even here it is impossible to maintain abrupt or always accurate distinctions, because tumors are frequently of mixed type, and it is required, if desired to express their composition by their names, to sometimes combine words in an awkward fashion.

By common consent that tissue which predominates furnishes the concluding portion of the compound term, while by prefixing other terms we endeavor to imply the composite character of the neoplasm.

Thus we have osteochondroma, fibromyoma, myofibroma, etc., and it is necessary often to reduplicate terms in order to be accurate in description. While this complicates phraseology, it nevertheless furnishes to the reader a reliable clue as to the general character of such a growth; and if one reads, for instance, of a myxochondrosarcoma, he promptly infers therefrom that thereby is meant a tumor essentially a sarcoma, in which both myxomatous degeneration and cartilaginous formation have taken place.

In the same way the prefix cysto is frequently used to imply a combination of originally solid tumor which had undergone cystic changes in whole or in part.

The old term cele is frequently used as a suffix, implying neoplastic changes in an organ, or at least the formation there of a tumor. Thus we have bronchocele, hydrocele, and cystocele. Again, certain terms are used in a different sense from that originally intended. Thus the term sarcoma has a definite significance, whereas originally it had little meaning and was applied inadequately and indiscriminately. Old terms also, like fungus hematodes, are now used rather in a descriptive sense, because for any such tumor we can find, on accurate examination, a proper term taken from descriptive pathology. Therefore the student of today should read the works of the older writers, especially concerning neoplasms, with a certain amount of intelligence, as well as of apology for the inaccuracy and misnomers of the past.

The results of treatment of tumors leave much still to be desired, particularly when dealing with those of malignant nature. So far as purely internal treatment is concerned, we have not yet discovered drugs which with any certainty influence cell growth to the extent of making them reliable or effective. In the past, and even at present, numerous remedies have been advocated as having more or less power in this direction. Of them all it is probable that arsenic in some form is more efficacious than any other. This is true in the case of the disease elsewhere spoken of as malignant lymphoma, or Hodgkin’s disease, which partakes much of the character of some of the other neoplasms. But to say that arsenic alone or any other known remedy can be relied upon at all times is making a bold assertion.

Operable Tumors.

—The treatment of operable tumors is essentially surgical (i. e., operative), although to a large extent results are based upon the essential character of individual cases. But it can be stated that to be successful in the removal of any tumor its complete extirpation is imperative. Even the most benign growths will return if only partially removed. This is true even of innocent cysts, which will be often reformed if a portion of the cyst wall be allowed to remain. Complete extirpation is ordinarily a simple measure when tumors are encapsulated, as are often many of the innocent tumors. On the other hand, the performance of some of these operations is made difficult and hazardous by the location of the tumor, as in many large uterine fibroids, tumors of the thyroid, etc. But when dealing with malignant tumors the secret of success is to extirpate them, sacrificing everything which may appear to be involved unless, like a large bloodvessel or important organ, it be essential to the life of the part or of the individual. These statements are made when speaking of tumors in a general way. More specific directions will be given when dealing with particular forms or in the chapters on Special and Regional Surgery.

Following custom in large degree, yet being guided by undeniable facts concerning histological structure, tumors will be classified and considered as follows:

• 1. Cysts.
• 2. Dermoids.
• 3. Teratomas.
• 4. Tumors of connective-tissue type.
• 5. Tumors of nerve elements.
• 6. Tumors derived from epithelium.

1. Cysts.

A cyst may be defined as a tumor containing one or more cavities filled with fluid or semifluid contents. This specifies nothing with regard to the location nor the character of the cyst wall nor the nature of the fluid contents. Following Sutton, I divide cysts into four groups:

• Retention cysts.
• Tubulo cysts.
• Hydroceles, or distention cysts.
• Gland cysts.

Retention Cysts.

—These imply a previously existing cavity whose outlet is obstructed and whose contents consequently accumulate, often to such a degree that the original character of both containing wall and contained fluid is entirely altered. When this occurs in glands or gland ducts there is usually complete atrophy of gland tissue, providing sufficient time have elapsed. Such cysts are due either to permanent or temporary arrest of flow. In hydronephrosis, for example, there is obstruction of the renal outlet and dilatation of its pelvis, with partial or complete atrophy of the kidney structure, until a cyst of enormous size may be present. When a similar condition obtains in the uterus, as by obstruction of the cervix, perhaps due to injury done during labor, we have a condition known as hydrometra, seen occasionally in women, often in the lower animals, and particularly in those having a bicornate uterus, causing a condition often mistaken for an enormously dilated Fallopian tube. Similarly, when the common bile-duct is obstructed, which may be due to impacted gallstones, to inflammatory lesions or tumors, there may be such backing up of bile in the gall-bladder as to produce the condition known as hydrocholecyst.

Under any of these circumstances pyogenic bacteria may produce infection which will be more or less promptly followed by suppuration; and then, instead of hydronephrosis, ydrometra, hydrosalpinx, etc., we have pyonephrosis, pyometra, and pyosalpinx.

Tubulo Cysts.

—These are cystic dilatations of certain functionless ducts and obsolete canals which no longer serve a useful purpose. They comprise:

1. Cysts of the Vitello-intestinal Duct.

—Cysts originating from this functionless duct occupy the umbilical region, sometimes projecting externally, sometimes internally. They are usually lined with mucous membrane furnished with villi and columnar epithelium. Such a cyst may be confounded with an umbilical hernia. These cysts occasionally open at the umbilicus and discharge irritating material, sometimes fecal matter. Cystic dilatation of the portion of the duct originally connected with the ileum is also sometimes seen.

2. Allantoic Cysts.

—These are connected with the urachus, which should ordinarily be found as a fibrous cord, but which occasionally persists in a pervious condition, in whole or in part. At birth it is often traversed by a narrow canal lined with epithelium continuous with that of the bladder. The urachus lies outside the peritoneum, and may be dilated at any point between its two extremities. When the entire urachus is pervious urine is discharged from the navel.

3. Cysts Connected with Remains of the Wolffian Body.

—The Wolffian body, or the mesonephros, is intimately related with the development of the kidney, the ovary, and the testis. In the two latter locations glandular elements may be met, persisting in adult life.

In the male the tubules persist as excretory ducts from the testis, but in the female they persist, in a vestigial condition, as the parovarium and Gärtner’s ducts. The ovary proper consists of the oöphoron and the paroöphoron, the former being the egg-bearing portion, the latter receiving the tubules from the adjoining structure known as the parovarium. The paroöphoron gives rise to cysts which burrow deeply between the layers of the broad ligament, make their way alongside the uterus, and raise the peritoneum. It is a peculiarity of these cysts that their inner walls often become papillomatous, and may even develop such a crop of warty outgrowths that these make their way through the cyst wall and protrude into the abdominal cavity, where they sometimes become detached and are dropped as loose bodies into the peritoneal sac. The condition is also often accompanied by warty growths upon the peritoneal surfaces. These need give rise to no alarm, because they usually disappear spontaneously with removal of the tumor. Paroöphoritic cysts are to be distinguished from parovarian cysts, which develop from the parovarium, this latter consisting of a number of tubules situated between the layers of the mesosalpinx, composed of an outer series known as Kobelt’s, an inner set, about a dozen in number, known as the vertical tubules, with a straight tube, running at right angles to these through the broad ligament to the vagina, known as Gärtner’s duct, which is homologous with the vas deferens in the male. Cystic dilatation of Kobelt’s tubes is often seen, these cysts being very small and having no clinical importance. Cysts arising from the vertical tubules are usually transparent until they attain considerable size, when their walls thicken. Their contained fluid is not harmful, and after rupture of such cysts internally the fluid is absorbed. Such cysts may rupture and refill several times. As between the paroöphorous and parovarian cysts the latter are easily enucleated, carry the ovary upon one side, and have the Fallopian tube stretched over them without communication.

The internal sections of Gärtner’s duct are more often involved in animals than in women, but excellent illustrations of cystic dilatation of its various portions have been observed, usually in the walls of the vagina.

Corresponding to the above-mentioned conditions in the female there are in the male, as the result of changes in the Wolffian body, two conditions—encysted hydrocele of the testicle, and general cystic degeneration of the same. Like the ovary, the testicle is a complex organ with remnants of the mesonephros persisting among its ducts, while only a few of the Wolffian tubules remain. True encysted hydroceles arise sometimes in the efferent tubes of the testis and sometimes in Kobelt’s tubes (the same structures which in the female give rise to parovarian cysts), the two conditions, therefore, being analogous and homologous. These cysts, though closely associated with the testis, lie outside its tunica vaginalis. Their contained fluid is usually clear or of a milky whiteness, due to fat globules. Sometimes it contains spermatozoa. Another variety is cystic dilatation of one or more of Kobelt’s tubules, which is often described as involving the hydatid of Morgagni.

General cystic disease of the testis, known also as adenomatous degeneration, was formerly referred to as hydatid disease of the same organ. The multiple cysts appear to originate in the remnant of the mesonephros still persisting, known as the paradidymis. The cavities are lined with epithelium, and papillomatous intracystic formation is not uncommon. These tumors have been called by a number of improper names, such as “cystic sarcoma,” etc.

Hydroceles.

—The term hydrocele has covered numerous conditions. At present, when no other locality is designated, hydrocele of the tunica vaginalis is understood. (The term implies a collection of watery fluid in a previously existing serous cavity.) This is the most common form.

Possibility of its formation depends upon the prolongation of the peritoneal cavity which takes place in advance of or along with the descending testicle, and which in many of the lower animals remains connected with the general cavity throughout life. In men only is it expected to close, even before birth. When the portion which extends along the spermatic cord is not completely obliterated there is encysted hydrocele of the cord, or funicular hydrocele, which is not common. The common form of hydrocele is constituted by serous effusion into the tunica vaginalis, and occurs usually without recognizable exciting cause. It will be treated more fully in its appropriate place.

The corresponding process of peritoneum in the female is known as the canal of Nuck; and, when persistent, this also becomes distended with fluid and forms a cyst known as hydrocele of the canal of Nuck, occupying the inguinal canal.

In many of the lower animals the ovaries are contained within a serous sac derived from the peritoneum, which is so connected with the opening of the Fallopian tubes that when the ova escape from the ovary they enter these tubes and pass to the uterus without entering the general peritoneal cavity. This ovarian sac is subject to serous distention, and constitutes a condition called by Sutton an ovarian hydrocele. An homologous condition occurs sometimes in the human female, by pathological adhesion, and such cysts may attain large size. They project from, and are intimately connected with, the posterior layer of the broad ligament.

Hydroceles of the Neck.

—Hydroceles of the neck, so called, are cystic collections of congenital origin found in the cervical region, due to dilatation of ducts or clefts which should have disappeared at or before birth. The forms of cyst to which the name “hydrocele of the neck” are usually limited are recognizable at or soon after birth, and constitute fluctuating tumors, often extending beneath the clavicle into the axilla or down upon the thorax. They may occupy the entire lateral region of the neck, and may be unilateral or bilateral—may be single or multilocular, and may even intercommunicate.

They originate always beneath the deep fascia. Some of these cysts are undoubtedly due to dilatation of lymph spaces. This is particularly true of the multilocular forms. There is noted in many of them a tendency toward spontaneous recovery, but many again require operative measures for their eradication. Occasionally their walls are extremely vascular, even to the degree meriting the term nevoid.

Some of these cysts are considered by Sutton to be essentially examples of the laryngeal saccules which are met with as diverticula from the laryngeal mucous membrane, which undermine the deep cervical fasciæ of certain monkeys. These air chambers, which are normal in the monkey, communicate with the larynx through the thyrohyoid membrane, and occasionally run down beneath the upper border of the thorax. Many of the cysts having this resemblance are closely related to the hyoid bone and to the larynx, and there is much to substantiate the view thus quoted.

Glandular Cysts.

—Ranula is an altogether too comprehensive term which has long been used in surgery, alluding to cysts in the floor of the mouth, and not indicating minutely their character nor their exact location. At present this term should either be restricted in signification or be eliminated. If used, it should be confined to retention cysts due to obstruction of the submaxillary or sublingual ducts. Such obstruction is often caused by salivary calculi impacted in the duct orifices. In other instances it is due to cohesion of the margins of the outlet. A similar condition in the parotid duct is known, but is less common. Aside from this, certain other cysts originate from minute beginnings in and about the floor of the mouth, being due to dilatation of the mucous glands, particularly one near the tip of the tongue, sometimes known as Nuhn’s gland. Dermoid cysts in this locality are not uncommon. Formerly cysts of the floor of the mouth were described as ranula.

Pancreatic cysts correspond in large degree to salivary cysts, the pancreatic duct becoming dilated by retention when its orifice is obscured; and, indeed, the condition has been referred to as pancreatic ranula. Sometimes the canal is dilated in distinct portions, so that the condition resembles a string of cysts; at other times it is the terminal portion which is most enlarged. Such cysts attain large size and contain mainly mucoid material. Examples have been reported showing that they have attained a capacity of two gallons.

In the mesentery there sometimes develop cysts which are known as chyle cysts, whose sacs appear to be formed of separate mesenteric layers, their cavity being occupied by fluid identical with chyle. Such tumors also sometimes attain great size.

In the eyelids one occasionally meets with cystic dilatations of the lacrymal ducts. These are known as dacryopic cysts or dacryops. Fistulas result when they are opened through the skin, and if meddled with at all they should be radically extirpated.[13]

Pseudocysts.

—In his elaborate work on tumors Sutton has made a distinct classification of pseudocysts, which lack some of the characteristics of genuine cysts, yet, nevertheless, are entitled to consideration in this place. Among these are included intestinal diverticula and vesical diverticula, in either of which instances hernial protrusions of the mucous membrane through the outer coating of the bowel or of the bladder occur, thus forming pouches. These are common in the bowel, rare in the bladder; especially in the former locality they are often multiple. This condition is often referred to as sacculation, and sacculation of the bladder may even be confounded with true urachus cyst. They are of little consequence so long as foreign materials, such as feces, urinary calculi, etc., do not lodge in them. But they occasionally cause serious trouble. Diverticula have been mistaken for appendices, while diverticula from the bladder have been encountered in hernia operations.

Pharyngeal diverticula give rise to rare but most interesting tumors. It is well known that the branchial clefts, which in early fetal life connect with the pharynx, are sometimes not completely closed, and that a portion of one may persist abnormally, giving rise to a condition known as the pouch of Rathke. There may also occur sacculation of the pharyngeal wall where it joins the esophagus, or hernial protrusions, especially in Rosenmüller’s fossa.

Cystic dilatation of Rathke’s pouch occurs near the upper part of the pharynx, and may attain the size of a marble. Hernial pouches are seldom mistaken for cysts, and are of importance mainly because of the fact that food or other foreign material gathers and lodges in them. Most of the other cystic abnormalities of the pharynx pertain to dermoids, and will be considered shortly. In a general way, these pharyngeal tumors have been grouped as pharyngoceles.

Similarly in the esophagus and trachea hernial protrusions occur, and lesions closely resembling retention cysts may be seen.

Synovial cysts (i. e., those containing synovial fluid) may arise (1) by protrusion of synovial sheaths, (2) by distention of bursæ in the vicinity of joints, or (3) by hernial protrusions of joint membranes. They are often met with in connection with the larger joints, more particularly about the knee. In this way tumors as large as goose-eggs may be formed, while their location may be so shifted that they present themselves in perplexing ways. To that form produced by hernial protrusion of the lining of a tendon sheath has been given the name ganglion.

The simple ganglion is frequently seen on the back of the wrist, and, while it is always connected with the tendon sheath, it undoubtedly often connects with the synovial membrane of the carpal joints. The compound ganglion, so called, is a much more serious and extensive affair, being one which has prolongations in two or more directions, and containing peculiar bodies, known as melon-seed bodies, which appear to be fibrinous concretions worn round and smooth by attrition. These are present sometimes in enormous numbers. (See Tuberculosis of Synovial Structures, Chapter IX.)

Bursæ are normal in many well-known situations in the body, but may undergo cystic dilatation and become annoying tumors. In many other places, under the influence of friction or mechanical irritation, there develop bursæ which are known as adventitious. These are sometimes subtendinous, and may communicate alike with joint sheaths and tendon sheaths. These are true cysts of new formation not developed from a pre-existing cavity.

They are largely the effect of peculiar occupation, as in housemaids and carpet-layers there are formed frequently prepatellar bursæ, while miners get them upon the elbow, porters upon the shoulder, plasterers upon the forearm, etc. In the same way, by the pressure of ill-fitting boots, an adventitious bursa is developed over the expanded head of the first metacarpal bone, thus forming a condition known as bunion.

Neural Cysts.

—This term has been applied by Sutton to pseudocystic dilatation of certain cavities found in the brain and central nervous system. Hydrocephalus is in one sense a pseudocyst of this variety. Corresponding to it in fetal life is hydramnios. Hydrocele or cystic dilatation of the fourth ventricle is well known. Cranial meningoceles, which are hernial protrusions of brain membranes, are also pseudocysts, to be included in this category. They will be considered in Chapter XXXVI. Cephalhematoma may be also included in the same way. Spina bifida, a condition which will be described in Chapter XXXVIII, is, nevertheless, practically a cyst of congenital origin involving the spinal meninges. One form of spina bifida is constituted by cystic dilatation of the central canal of the spinal cord, and produces syringomyelocele. These conditions will be treated more fully in their appropriate places.

Sutton has rendered a great service by showing that the brain and spinal cord are evolved from a segment of the primary intestines, and that the intestinal canal and the neural canal communicate in fetal life at their lower terminations; while it has been shown by several that in the earlier forms of mammalian life they were also connected by their anterior terminations. It is in this way that certain complex tumors of the sacral and coccygeal region are to be explained. So also is the collection of lymphoid tissue in the vault of the pharynx, known as Luschka’s tonsil, and in the coccygeal region, known as Luschka’s gland, it being a curious and instructive fact that lymphoid tissue of this character is always met with in the neighborhood of obsolete canals.

Hydatid Cysts.

—These cysts are the indirect product of the eggs of the Tænia echinococcus, a form of tape-worm which infests the alimentary canal of dogs. The eggs reach in some direct or indirect way the food or water taken into the human stomach and are there hatched; the young animals migrate through vessel walls and are deposited in some tissue or organ where the cyst later develops. These cysts have a thick, elastic wall, with a lining containing cells, involuntary muscle fibers, and a water-vascular system. After such a cyst has attained the size of an inch or more, small vesicles, or “brood capsules,” begin to develop, which present at one point a retractable head, with scolices so arranged in crown form as to produce sucking disks. According to the date at which the cyst is opened appearances will differ. Sometimes a large cavity will be filled with multiple “daughter cysts,” and sometimes these will have disappeared, so that the cyst fluid contains nothing distinctive. After having ceased to develop, hydatids frequently undergo atrophy and even become calcified; the characteristic hooklets are the last of the distinctive features to disappear.

These growths may be rapid, even to the point of producing necrosis and rupture, or may be very slow and persist almost unchanged for years. The disease is uncommon among the native-born population of the United States, and most of its examples are seen in emigrants. It is exceedingly prevalent in Iceland and in New Zealand. It occurs most often in the liver, but is frequently met with in these countries in the lungs, the brain and spinal canal, and the bones, but may be encountered in any part of the body. When located near the intestinal tract or the air tract the cysts are more liable to penetration by ordinary germs of sepsis, and then may suppurate. It is not infrequent to have conversion of an hydatid cyst into an abscess. Before or after such change it may undergo rupture, spontaneous or traumatic, and this, according to the nature and amount of its contents, and the location of the opening, will promptly produce more or less grave symptoms. While spontaneous recovery has, in rare instances, followed rupture, it has perhaps more often led to fatal result. At all events, it will produce serious and perhaps distressing symptoms.

The only radical treatment for hydatid cysts is extirpation. When this is not possible the cyst may be opened and the margins of the opening attached to those of the skin wound. After being evacuated it should be packed and drained, and then may be expected to slowly contract, perhaps even to the point of obliteration. The contents of such a cyst should not be allowed to escape into any of the body cavities, since their sterility can not be always relied upon.

Cystic Degeneration.

—Hematocele is an expression meaning a tumor composed originally of effused blood which has undergone chemical and other changes, which consist of lamination and thickening of its exterior portion and fluidification of the interior, until in course of time such an internal blood clot may be converted into a distinct and plainly walled cyst. This condition may be seen in two locations—namely, in the pelvis and between the cranium and the brain, or in the brain. The hemoglobin gradually disappears, and the contents of these cysts are translucent or even watery in appearance. Hematoceles may form where there has been internal hemorrhage in certain locations which has failed to absorb, and where no pyogenic infection has occurred.

Pseudocystic changes occur in other tumors and in other parts of the body as the result of mucoid and colloid liquefactions. In the midst even of apparently dense and entirely defined tumor masses changes of this kind occur, and lead to formation of cavities containing fluid of variable consistence, causing the tumor when divided to present the appearance of the geodes or quartz rocks, containing cavities lined with quartz crystals. The occurrence of such cystic changes is indicated, in naming such a tumor, by prefixing the term cysto-, as cystosarcoma, cystofibroma, etc.

2. Dermoids.

Dermoids are cysts or tumors containing tissues and appendages which are developed from the epiblast, and which occur when skin and mucous membrane are not normally found. The simplest form of dermoid is a cyst whose interior is lined with modified skin, containing sebaceous glands and hair follicles, from which often numerous long hairs are produced. Even sweat glands may be present. Its cavity is occupied by mixed material, pultaceous in character, made up of sebum, cholesterine, and growing hairs which are often rolled into balls. The sebum is the product of the glands contained in the cyst wall.

A complex form of so-called dermoid cyst is met with in which there are unstriped muscle fiber, teeth, mammary glands, etc. These belong rather to the class of teratomas, as they contain more or less tissue not of epiblastic origin.

A dermoid tumor is one lacking cystic characteristics, made up of tissue largely developed from the epiblast, with more or less tissue of mesoblastic origin. Such a tumor may contain much connective tissue, fat, fetal hyaline cartilage, and nerve tissue, while from its exterior long hair may grow, and teeth project from its surface or be embedded within its substance. Such tumors are generally found in the pharynx and about the rectum.

The explanation of dermoids and teratomas may be gleaned from embryology, and rests upon the arrangement of the different blastodermic layers of the developing ovum, and upon the facts already alluded to in explaining Cohnheim’s hypothesis of the origin of tumors. Strictly speaking, a dermoid should contain only that which may be developed from the epiblastic layer. It is well known that teeth and hair, as well as sebaceous material, are epiblastic products. Consequently such material may be found within a dermoid and needs no further explanation than an epiblastic inclusion, according to Cohnheim’s views. But so soon as such a tumor contains bone, muscle, etc. (i. e., tissues of mesoblastic origin), we should drop the term dermoid and consider it a teratoma. Such is the distinction between these two terms. According to Wilm’s researches, any tumor of this sort which contains epithelial products as teeth or hair is sure to contain also mesoblastic elements, and thus to belong to the latter. The term epidermoids has been applied to the former.

The most prominent characteristics of dermoid cysts are: (1) Skin, which may be thick or thin, lined with papillæ, containing more or less pigment, its deeper layers possessing a quantity of fat. (2) Hair, which next to skin is the most constant structure found in dermoids; this may be present in trifling amount or in long coils or balls. It is of interest that in dermoids found in animals covered with wool we find the same character of hairy structure, while in birds dermoids contain feathers rather than hairs. (3) Sebaceous glands and their peculiar secretion are invariably found. These may be of large size, and sebaceous retention cysts may be seen in the walls of dermoids. Sometimes horny matter or tissue is found in these, indicating the same relation between horn and sebaceous structures, as we see upon the external skin in other instances. So, too, material resembling the texture of finger-nails is occasionally found projecting into the cavity.

The fluid or semifluid contents of these cysts consist usually of sebaceous material, cholesterin, epithelial debris, etc. Sometimes it is thick, sometimes thin—and occasionally consists almost entirely of mucus.

It is not uncommon to find structures in ovarian dermoids closely analogous to, or actually resembling, mammary glands. These may be mere nipple-like processes of skin, or completely developed mammæ, well formed, but without ducts or gland tissue, may occupy such a cyst. These really are pseudomammæ, because they have no ducts. Nevertheless, glandular tissue is not always absent. This resemblance proceeds even farther, in that in some of these ovarian mammæ changes occur analogous to those which take place in normal breasts.

The epiblast seems to have the power of developing mammary glands or supernumerary mammæ in many locations—in fact, upon any part of the body surface. About the thorax they are common; upon the abdomen they are rarely observed; and they have been found even upon the labia.

Sweat glands are infrequent in dermoids. Teeth are quite common. These may vary in number from two or three up to several hundred—may be embedded in definite sockets or simply sprout from the cyst wall. Occasionally bone material, lodging such teeth and crudely resembling a jaw, will be found.

Dermoids containing mucous membrane are found, especially in connection with the ovary and with the postanal gut (i. e., the original communication between the spinal and alimentary canals).

It is curious that under these circumstances mucous membrane is sometimes furnished with hair, as it normally is in the stomach or other cavities of some of the lower animals. Mucous glands and retention cysts of these glands are also found in ovarian dermoids. This will be more readily understood if the mutability of skin and mucous membrane be not forgotten. The transition from one to the other is not difficult, and we find all intermediate stages between the two extremes—if not in man, at least in animals. This will account for the fact that skin-covered dermoid tumors are found in certain parts of the alimentary canal, and particularly in the pharynx. These tumors grow also from the mucous membrane of the bowel, of the rectum, or even of the small intestine.

Sutton has made a division of dermoids into three classes:

• 1. Sequestration;
• 2. Tubulodermoids;
• 3. Ovarian.

1. Sequestration Dermoids.

—Sequestration dermoids occur chiefly in situations where during embryonic life coalescence takes place between two surfaces possessing an epiblastic covering, although sometimes this coalescence practically occurs late in life and by implantation.

Dermoids of the trunk occur particularly where opposite halves of the body wall coalesce—that is, in the midline of the trunk and head. Dermoid cysts are rarely found in connection with spina bifida, and certain tumors spoken of as spina bifida undoubtedly are dermoids. Anteriorly dermoids occur frequently in the scrotum, and occasionally in the testicle. At the umbilicus they are rarely found—usually as pedunculated tumors projecting externally. In the midline of the thorax and neck they are most common opposite the manubrium, dropping down behind it to invade the anterior mediastinum. Near the hyoid bone they occur relatively frequently; about the head they are met with most commonly at the angles of the orbits—more so at the outer than at the inner angle. Dermoid cysts are known to oculists as growing upon the iris or springing from the conjunctiva. About the ear they are not infrequent; in the roof of the mouth, especially if this be incomplete, we frequently find cysts of epiblastic origin.

Sequestration dermoid cysts are also undoubtedly found in connection with the dura mater, in the scalp, most commonly at the anterior fontanelle, at the root of the nose, and at the external occipital protuberance, where they may be confounded with sebaceous cysts or with meningoceles. In order that a dermoid of the dura may communicate with the skin there must of course be osseous defect.

Sequestration dermoids upon the limbs have been mostly reported as sebaceous cysts. They are rare, and usually associated with antecedent injury, by which epiblastic structures are driven in and implanted in such a way that as they develop they give rise to these peculiar tumors. These are what Sutton calls implantation dermoids. They are found upon the fingers and elsewhere.

2. Tubulodermoids.

—These are largely connected with obsolete canals and ducts. It is a great service which Sutton has rendered in proving, apparently beyond the possibility of doubt, that the central canal of the nervous system is really of intestinal origin, and may be regarded as a disused segment of the primary alimentary canal. He has also shown how it behaves occasionally as do other functionless ducts, and that cysts and dermoids in connection with it are to be thus explained. He and others have also shown the anterior as well as the posterior communication of these canals, and the pituitary body are to be regarded in this light as the same formation of lymphoid tissue around an obsolete canal which we see in Luschka’s tonsil close by, and in Luschka’s gland at the other extreme of the canal.

Fig. 72

Solid dermoid escaping from pelvis. (Original.)

Fig. 73

Congenital dermoid cyst of pelvis. (Ahlfeld.)

 

The primary alimentary canal was a continuous tube lined with a continuous layer of columnar epithelium. That portion connected with the yolk sac develops into the intestine, the balance into the central nervous canal. Portions of this canal are in postnatal life absolutely obsolete; others persist in a rudimentary condition. Dermoid cysts and dermoid tumors develop in connection with each of these. In some there is a large central cavity; others are almost absolutely solid. Thus we find dermoids in the coccygeal region, which have been variously regarded as sarcomas, adenomas, etc., which are really of origin as stated above and should be considered simply as dermoid tumors. Most of these project outwardly; some of them arise and develop within the pelvis. Dermoid cysts and tumors are also met with in connection with the rectum—sometimes between the rectum and the bladder, and between the rectum and the spine. Dermoid tumors are also found in connection with the pituitary body. These sometimes develop within the cranium, or, again, protrude perhaps into the orbit, perhaps into the pharynx.

Thyroid dermoids are tumors of great interest. They develop sometimes about the craniopharyngeal canal, which may be detected as a small canal in the macerated sphenoid bone of a fetus, and which before birth is filled with fibrous tissue. It connects with a recess in the middle line and at the base of the skull, presenting in the pharynx, which is often referred to as the bursa pharyngea. It is around this recess that the lymphoid tissue known as the “pharyngeal tonsil” develops. It may be thus expected that the roof of the pharynx should be the occasional site of dermoids. It is from the pharynx or the floor of the mouth that in vertebrates the thyroid body arises. In higher forms it becomes dissociated from the pharynx and shifts its position. The thyroid body is developed around the thyroid duct, which first appears as the thyrohyoid duct, which later becomes divided, that portion in relation with the tongue becoming the thyrolingual duct, the remaining portion persisting as the thyroid duct. These are present about once in every ten subjects, according to Sutton, the canal when persistent being lined with epithelium. When the extremities of these ducts become occluded retention cysts may form. In the same way dermoids of the tongue are formed, similar to those occurring on the scalp. These are frequently mistaken for sebaceous cysts. They may be unilateral, central, or even bilateral. The lingual duct is also of interest, because it would appear that certain cases of epithelioma of the tongue arise along this duct, and perforating malignant ulcer of the tongue is thus produced. Dermoid tumors of the lingual or thyroid ducts resemble in structure the thyroid body. The thyroid duct may also be detected in many adults running from the isthmus of the thyroid body to the posterior aspect of the hyoid bone, and surrounded by muscle tissue. Sometimes the space usually occupied by this duct is represented by a series of detached bodies known as accessory thyroids. These are not infrequently the seat of cysts, sometimes of considerable size. (The accessory thyroids often enlarge when the main thyroid has been extirpated for disease.) Thus cysts in close relation to the hyoid bone are common. Some of them grow slowly, while others grow rapidly and contain much fluid. Many of them are unilateral, and are often mistaken for enlargements of one lobe of the thyroid. Cysts growing from accessory thyroids are often filled with papillomatous masses, and are occasionally the seat of malignant degeneration.

In the omphalomesenteric duct or its remains, especially in relation with the umbilicus, we often meet with small cysts or tumors in infants and young children. When the duct is persistent it presents normal intestinal structure, and, like the appendix, possesses much adenoid or lymphoid tissue.

Another and very important form of tubulodermoids develops in connection with the branchial clefts of the neck. Congenital fistulas of the neck have been long known, but only comparatively recently understood. Of the branchial clefts it is well known that the first alone should persist, as the Eustachian tube. Occasionally, however, they fail to become obliterated, and then we have congenital tumors or cysts, which may, perhaps, not develop to appreciable size until somewhat late in life; or there may be fistulous passages opening either into the pharynx or externally, forming canals varying in length from half an inch to two inches, secreting a little fluid because lined with epithelium. When these become inflamed an abscess results. When they open externally the opening is often marked by a little tag of skin containing a fragment of yellow cartilage. These are often referred to as cervical auricles. They open along the line of the sternomastoid muscle. The internal openings of these fistulas frequently form diverticula from the pharynx or esophagus. Thus it will be seen that dermoid cysts about the neck are principally relics of openings or ducts, which are normal in embryonic life, but which should have been obliterated at or long before birth. Congenital fistulas, however, may be met with in the middle line of the neck, which are not to be confounded with branchial fistulas, but rather with the ducts previously described.

3. Ovarian Dermoids and Teratomas.

—These may be unilocular or multilocular cysts, usually the latter. They are lined with epithelium, and contain mostly mucoid fluid, the inner coat being practically identical with mucous membrane. Occasionally, however, the skin is furnished with hair, sebaceous glands, teeth, and even nipples. The multilocular cysts are practically an aggregation of those just described. They are surrounded by dense capsules, often attain great dimensions, and are made up of primary cysts resembling large cavities in a honeycomb-like mass, which itself is occupied by secondary cysts, and belong rather to the class of mucous retention cysts, these being occupied by still smaller ones, which are histologically indistinguishable from distended ovarian follicles. In these large tumors we find in some cases hair, in others teeth, and in others sebaceous glands, etc., the dermoid constituents being scattered throughout. As Wilms has shown, in almost every tumor of this character a projection may be found whose summit is covered with epiblastic elements, which when cut in serial transverse sections will show in its deeper portion other epithelial collections representing a feeble attempt to develop a nervous system, or lung tissue, while mesoblastic elements, like connective tissue, cartilage, and bone, appear scattered throughout, as though a very crude effort had been made to reproduce an atypical embryo.

3. Teratomas.

So far the endeavor has been to limit the term dermoid to tumors which are essentially of epiblastic formation, their location being explained on the inclusion theory of Cohnheim. There is also a still more complicated type of tumor, composed of tissues of both epiblastic and mesoblastic origin, perhaps even hypoblastic. Their consideration belongs to that department of pathology known as teratology, which is supposed to deal especially with monsters. Strictly speaking a teratoma refers to an irregular tumor or mass containing tissues and fragments of viscera of a suppressed fetus which is attached to an otherwise normal individual. Nevertheless the term is often applied to growths which are the result of luxuriant mesoblastic development in which neither form nor member of a suppressed fetus is present.

The presence of supernumerary members is largely connected with what is called dichotomy, alluding thereby to cleavage either at the anterior or posterior end of the developing embryo. When the whole embryonic axis divides twins may be produced, but should cleavage be partial we may have a monster with two heads if it be anterior, or one with three or more limbs if it be posterior. Children born with these deformities are usually called monsters, and the study of such cases belongs entirely to teratology. But in certain tumors small portions of a suppressed fetus may develop, as, for instance, from the posterior portion of the sacrum, or within the abdomen or thorax, or upon the neck or face, which on dissection may contain a few vertebrae or processes resembling fingers associated perhaps with a structure resembling intestine or liver. This should be called a teratoma. Such tumors possess for the pathologist the greatest value. In surgery, however, they are rare, and there are scarcely two cases alike. The question of operation will often arise, as it does with supernumerary limbs, and each case should be studied upon its own merits. Sometimes they are amenable to extirpation.

Embryonal Adenosarcoma.

—Embryonal adenosarcoma is a term given to certain teratomatous tumors peculiar to renal and adrenal structure, which present peculiar characteristics in the mixture of elements which enter into their composition. At various times these tumors have been called adenoma, sarcoma, rhabdomyoma, congenital cystic kidney, etc. They have been also likened to the thyroid. They comprise a group of neoplasms, always congenital in origin, which usually appear early in life, but occasionally occur in advanced adult life. One of the most marked specimens of this kind the writer removed from a man over fifty years of age. Most of the specimens, however, described in literature pertain to the young. On minute examination they often present a strange, mixed picture of voluntary muscle elements intermingled with epithelium arranged to imitate acinous glands, with cystic dilatations of the true kidney tissue. They often attain enormous size, and undergo such proliferation of mesoblastic elements as to resemble sarcoma. Their occurrence is to be explained only on the principles of Cohnheim’s hypothesis. When the original Wolffian body is being differentiated from the elements about it a confusion of the same with the excretory tubular beginnings, which are to empty into the Wolffian duct, occurs. Thus we have the commencement of a mixed mass which presents itself as a more or less rapidly growing tumor, in which even cartilage or other mesoblastic structures may be met with. It is scarcely possible that any two specimens should yield exactly the same microscopic picture, much depending on whether one element or the other prevail. In a few of them there may occur also a mixture of adrenal elements. Sometimes the renal structure itself is more or less distinct, and rides, as it were, upon the surface of the tumor; at other times it is entirely mixed up with it. While the condition is usually limited to one side it may be a double affection, so that the second kidney becomes useless and the patient succumbs. The only treatment is extirpation.

Teratomatous tumors are sometimes found hanging in the pharynx, attached by a small pedicle, where they may be confounded with dermoids unless carefully examined after removal. Many instances of this type of tumor are found in animals. Here no false sentiment will prevent complete examination and preservation of the specimen. They are also encountered in the sacral and coccygeal regions.

4. Tumors of Connective-tissue Type.

Lipoma.

—Lipomas, or tumors composed of fat, are the most common of the neoplasms. Their normal type is the ordinary adipose tissue of the body, and may be divided into the encapsulated and the diffuse, the former of which are surrounded by fibrous tissue. The diffuse lipomas are those which have no capsule, and where the pathological collection of fat merges into that normally present—in other words, they are not circumscribed.

Subcutaneous Lipomas.

—Subcutaneous lipomas are perhaps the most common of all, and are usually irregularly lobulated and encapsulated, adherent rather to the skin than to the deeper tissues. Usually but one is found in an individual, though instances of multiple lipomas are not rare. They develop sometimes to enormous size, cases being on record where the tumor has even weighed one hundred pounds. They may be met with at any point on the surface of the body. The lobules often burrow between the muscles, and those found in the palm of the hand penetrate even beneath the palmar fasciæ. They are sometimes markedly pedunculated, and often hang by a small stem. The diffuse subcutaneous lipoma is most common about the neck, in the groin, and in the axilla.

Subserous Lipomas.

—Subserous lipomas are mostly retroperitoneal, and large tumors of this character, mistaken for ovarian, have been successfully removed by operation. They also occur in the hernial canals and spaces. They develop beneath the peritoneum covering the intestines, and in this location give rise occasionally to intussusception. Here in their pathological development they have the general form and significance of appendices epiploicæ.

Subsynovial Lipomas.

—Subsynovial lipomas occur about various joints and tendon sheaths; within the knee they assume a distinctive type which has been called lipoma arborescens, where they take on a dendritic appearance and arrangement. Submucous lipomas are rare. Intermuscular fatty tumors are occasionally met with, an interesting variety being that which develops between the masseter and buccinator muscles. Intramuscular forms rarely occur, as well as a variety known as parosteal, which arises in connection with the periosteum. Fatty tumors also occur within the spinal dura, as well as outside of it within the spinal canal, and more or less lipomatous alterations are common in connection with spina bifida.

Lipomas are ordinarily easy of recognition, save when deeply located. The subcutaneous forms are intimately related with the overlying skin, and have a dough-like consistence which is usually pathognomonic. Tumors, suspected to be fatty, in the middle line of the back or cranium are always to be viewed with suspicion, as they are often connected with congenital meningeal protrusions.

An encapsulated lipoma when thoroughly removed will not return.

Mixed forms of fibrous and fatty neoplasm are occasionally seen, and are referred to as lipoma fibromatosum or fibroma lipomatosum, according as one or the other tissue predominates. These growths are innocent in their character, but call for thorough extirpation. They frequently give rise to considerable discomfort or pain, and are called lipoma dolorosa.

Fibroma.

—Fibromas are tumors composed of fibrous tissue, which, when of pure type, are found to be not so common as was formerly supposed, the majority of tumors hitherto roughly grouped as fibromas containing either muscle tissue or sarcomatous elements, which takes them out of the category of pure fibroma. A typical fibroma is ordinarily dense, and is composed of wavy bundles of fibrous tissue whose cells are long and slender and closely packed together, the mass being permeated by distinct bloodvessels.

Fibroma occurs most commonly in the ovary, the uterus, the intestine, the gum (epulis), in nerve sheaths, and in the skin in the form of so-called painful subcutaneous tubercles and molluscum fibrosum. There is also a fibrous tumor of the skin, known as keloid, sustaining to fibroma the same relation that exists between exostosis and osteoma.

Painful subcutaneous tubercle is a sample of pure fibroma in the shape of a small, flattened, pea-like tumor which never attains great size. It is situated loosely in the subcutaneous structure and may form a visible prominence. Insignificant as it would thus appear, it becomes the seat of exasperating pain, particularly when touched or handled, which may radiate to considerable distances. The etiology of these growths is unknown.

In the ovary, the uterus, the intestine, and the larynx true fibrous tumors are pathological curiosities rather than common lesions.

Fig. 74

Keloid of external ear: a, dense tissue of skin; b, fibrous connective tissue; c, epidermis. (Klebs.)

Epulis.

—Epulis means any tumor growing upon the gum. The term was formerly applied in an indistinct and too comprehensive way, although it is still retained in literature. But pure fibromas do spring from the fibroösseous structure of the gum and alveolar process. They are covered with the gingival mucous membrane and seem to spring from the periodontal membrane. They seldom attain large size, and then only by neglect. By the pressure of such tumors teeth may be separated and distortion of the mouth produced. They should be promptly extirpated.

Keloid.

—Keloid is a fibrous neoplasm arising mainly in cicatricial tissue, which is essentially fibroid in structure. It is a neoplasm which often follows the general outline of the scar in which it grows, consists in elevation of the surface, ordinarily quite smooth, sometimes of a delicate pink from the dilated vessels which it contains. Keloid is the bête noir of surgeons, as it frequently complicates and disfigures scars which have at first been satisfactory, and since it indicates a condition which it is discouraging to deal with, because when it is removed there is usually recurrence of growth within a few months after cicatrization. It often occurs in stitch-hole scars and upon the site of extensive burns, and may be observed after puncture of the ears for ear-rings, and has also been observed in scars left by smallpox, acne, etc. It is more prevalent in the colored race than in the white. In negroes multiple keloid tumors are often seen, occasionally in large numbers. Their explanation is unknown, and it may be that some trifling injury has preceded each individual tumor (Fig. 74).

The treatment of keloid will be considered in the chapter on the Surgical Diseases of the Skin.

Desmoids.

—This term has been applied to tumors of a certain clinical type which arise from the fibrous structures, usually of the abdominal wall, and produce neoplasms like the fibromas of other parts of the body. The use of the term should be restricted to those tumors which proceed primarily only from muscles, tendons, and aponeuroses, or perhaps from ligamentous and periosteal tissues. These tumors are usually single, attain sometimes considerable size, grow slowly, rarely involve other structures, and not infrequently develop to such an extent as to encroach upon either pelvis or the abdomen, or both. They have been known to attain to the weight even of ten pounds or more. They are usually more or less encapsulated, and are firm and dense in structure. Under the microscope they have the general appearance of cellular fibroma. Sarcomatous elements may be met, while they occasionally undergo cystic degeneration. Their occurrence may be explained, at least in some instances, on the embryological theory of Cohnheim.

Fig. 75

Multiple enchondromas.

The treatment of desmoids consists in their complete extirpation. They should not be allowed to attain large size because their removal may entail a serious weakening of the abdominal wall. There should be such plastic rearrangement of abdominal protecting membranes as to reduce the resulting weakening to a minimum.

Psammoma.

—Psammoma is a term applied to a form of hard fibroma met with in the dura mater, in which there has occurred a petrefaction of some of the cells—i. e., a deposition of calcareous salts, which gives it a gritty or sandy appearance.

Chondroma.

—The true chondroma is a tumor composed of hyaline cartilage. It occurs in the long bones, usually in relation with epiphyseal cartilages, and is often noted during the earlier years of life. While it is usually a solitary tumor, multiple chondromas are often seen, especially upon the hands. These tumors are often encapsulated and form deep hollows, in which they rest. Unless pressing upon nerve trunks they are painless and slow of growth. They are exceedingly dense and hard, and ordinarily immovable. Mucoid softening (i. e., cystic degeneration) is common, and the softened areas may give rise to fluctuation. There may be coincident calcification or ossification in any of these growths. It is noted as a curious circumstance by Sutton that their tissue resembles histologically the bluish, translucent, epiphyseal cartilage seen in progressive rickets.

To the small local hypertrophies of cartilage which are seen especially about joints, about the laryngeal cartilages, and the triangular cartilage of the nose, are given the term ecchondroses. They are most common in the knee in connection with rheumatoid arthritis, and occur as prominences along the margins of the joint cartilage. They may project to such an extent as to be detached by accident, after which they become movable and floating bodies in the joints. Many of the floating cartilages or bodies found in joints are detached ecchondroses, which may be smoothed off by attrition, and may be found singly or multiple, even several hundred existing in one joint.

Chondromatous changes as occurring in sarcomatous tumors have been alluded to. It seems to be easy for connective tissue to form hyaline cartilage, and mixed tumors may thus be seen in connection either with sarcoma, fibroma, or other forms.

Treatment.

—The treatment of chondroma is solely operative. Unless the integrity of a member or a limb be compromised, such a tumor can usually be shelled out from its location, but requires that the matrix be completely extirpated; all of which may call for the use of powerful bone instruments. At other times amputation is the only measure which may relieve from deformity, pain, and disability. The ecchondroses occurring within joints necessitate incision and evacuation, with the most rigid aseptic precautions, with or without drainage. When practised according to modern technique this is almost invariably successful. In former times many lives were lost because of septic infection.

Osteoma.

—Under the head of nomenclature I have already endeavored to distinguish as between exostosis, or irregular bone outgrowth, and osteoma, as a distinct tumor which is composed of bone tissue, with the subvariety odontoma, or tumors of dental origin and structure. Osteoma is regarded by some as ossifying chondroma, for it is nearly always found near epiphyseal lines, and is always covered by hyaline cartilage when thus found. Nevertheless it is not invariably such. We speak of compact or ivory osteoma and of a cancellous form. The former is identical with the compact tissue of the shafts of long bones, and may occur anywhere, but is most common about the cranium, at the frontal sinus, the external meatus, and the mastoid process. Osteomas growing into the frontal sinus of oxen form large, lobulated, bony masses, sometimes weighing several pounds, and as dense as ivory. Some of these tumors growing into the cranial cavity have been regarded as ossified brains. Osteomas in connection with the external auditory meatus may partially obscure this channel and cause deafness. They constitute ivory-like growths, which sometimes defy the finest steel instruments with which the surgeon can supply himself.

Fig. 76

Double osteoma of the skull. (Musée Dupuytren.)

Cancellous osteomas grow in the cranium as well as in the long bones, and, like the compact forms, only occasion pain by pressure upon nerve trunks.

Exostoses.

—Exostoses are classed by Sutton as—

1. Those formed by ossification of tendons and their attachments. There should be excluded from this group such natural or evolutionary processes as the supracondyloid process, the third trochanter of the femur, etc. Over or around such exostoses bursæ will form to mitigate as much as possible the effect of friction. Such an outgrowth is known as an exostosis bursa; it is most frequently seen on the inside of the femur immediately above the knee.

2. Subungual exostoses, occurring usually beneath the nail of the big toe.

3. Exostoses due to calcification of inflammatory exudations, including the rare condition known as myositis ossificans.

PLATE XVII

FIG. 1

Round-cell Sarcoma. (Low power.)

FIG. 2

Spindle-cell Sarcoma. (Low power.)

When a true osteoma is once thoroughly removed there is no tendency to recurrence. Thorough removal, however, calls sometimes for serious and often mutilating operations, which may become dangerous when the growth involves the curve of a rib or a large portion of the skull. At other times amputation is rendered necessary. Special forms require special treatment.

Sarcoma.

—Formerly this name implied a fleshy tumor, and was made to cover many different conditions. Now sarcoma means a tumor composed of immature mesoblastic or embryonic tissue in which cells predominate over intercellular material. Sarcomas are sometimes encapsulated; they merge into and infiltrate the surrounding tissue and disseminate widely, and have usually these propensities and characteristics to such a degree as to constitute malignancy. For the laity sarcomas and carcinomas are together included in the comprehensive term of cancer; for the surgeon they constitute but one form of cancer. Sarcomas are classified, according to the shape of their cells and their disposition, into—

• A. Round-cell;
• B. Spindle-cell;
• C. Myeloid.

To these are added other varieties mentioned below.

Fig. 77

Osteoma of frontal sinus. (Neisser.)

Fig. 78

Recurring sarcoma of parotid. (Original.)

 

A. Round-cell Sarcoma.

—This is simple in construction, and consists of round cells containing very little intercellular substance. The nuclei of the tumor cells stain easily, the cells themselves varying in size in different cases. Bloodvessels lead up to the tumor, but in the interior appear rather as channels. These tumors have no lymphatics: they grow rapidly, infiltrate easily, recur quickly, and give rise to numerous metastatic or secondary deposits. They may affect any part of the human body. The size of the cells is supposed to be in some measure an index of their malignancy—the smaller the cell the more malignant the tumor. They appear at all periods of life. They are perhaps the most commonly seen of malignant tumors in animals. (See Plate XVII.)

Lymphosarcoma.

—This tumor is composed of cells similar to the previous form, but enclosed in a delicate meshwork resembling that of lymph nodes, hence the term lymphosarcoma. Lymphosarcomas are not to be confounded with enlargements nor with the specific granulomas involving these lymphatic structures.

B. Spindle-cell Sarcoma.

—In this form the cells have a spindle shape and run in all directions, so that sections will show them in various shapes and sizes. In some cases the cells are small and slender, in others large. The size of the cell is a measure of the malignancy of the tumor. (See Plate XVII.)

The largest of these spindle cells are frequently striated transversely like voluntary muscle fiber, and tumors composed of this form have been considered as tumors of striped muscle tissue, and are generally called rhabdomyoma. There is no tumor of striped muscle fiber, and the rhabdomyomas of writers generally should be considered as spindle-cell sarcoma, or may be dignified by the name myosarcoma. (See Rhabdomyoma, under Myoma.)

Alveolar Sarcoma.

—This is a rare form, in which the cells, contrary to the general rule of sarcomas, assume an alveolar arrangement strongly imitating that of epithelial cells in carcinoma. Almost invariably, however, on close examination it will be possible to distinguish a delicate reticulum between individual cells, which is never met with in cancer.

C. Myeloid, or Giant-cell Sarcoma.

—In this form the tissue resembles histologically the red marrow of young and growing bone, containing large numbers of multinuclear cells embedded in a matrix of spindle or round cells. These tumors usually occur in the long bones, and when freshly cut look like a piece of liver. They constitute most of the epulides or cases of epulis—i. e., spongy tumors springing from the gums. (See Plate XVIII., Fig. 2.)

Fig. 79

Sarcoma of femur following fracture—i. e., developing in callus. (Original.)

Giant or multinuclear cells should be present in considerable numbers to entitle a tumor to classification in this group. When round cells, spindle cells, or giant cells mingle in nearly equal proportion the tumor should be called a mixed-cell sarcoma.

D. Osteosarcoma.

—Osteosarcoma is something more than sarcoma of bone, which latter may spring from the fibrous or medullary elements. It is sarcoma of the specific bone-forming connective tissue, including the osteoblasts and osteoclasts; in other words, of the stroma of the bone. Under these circumstances real bone develops throughout the tumor, and it is essentially a bony neoplasm. In like manner there may be true osteofibroma. These tumors are to be distinguished, even clinically, from the medullary sarcomas, which develop within the bone and expand it, even to enormous proportions, the bony covering then being a mere shell.

E. Chondrosarcoma.

—Chondrosarcoma resembles osteosarcoma in that it is sarcoma of the stroma of cartilage, or of the specific tissue which produces cartilage. In it true cartilage (white fibrous) also is found throughout the tumor. Chondrofibroma is also possible. (See Plate XIX.)

F. Endothelioma.

—Endothelioma has been called various names, and its true character has been only lately determined. It is composed particularly of the endothelial cells which line the lymph spaces, and which have no peculiar secretion. It is met with most often in the skin (especially of the face), in the parotid region, in the genital glands, the bones, the lymph nodes, and dura.

PLATE XVIII

FIG. 1

Angiosarcoma. (Low power.)

FIG. 2

Giant-cell Sarcoma. (High power.)

PLATE XIX

FIG. 1

Chondrosarcoma. (Low power.)

FIG. 2

Osteosarcoma. (Low power.)

PLATE XX

Melanosarcoma of Skin. (Dry high power.)

The microscopic picture of these tumors varies greatly, the endothelial cells often shaping and grouping themselves so as to imitate epithelioma. In doubtful cases the primary location or origin of the growth should be ascertained.

Endotheliomas are mainly of rapid growth, and often show a high degree of malignancy. If thoroughly extirpated before metastasis has occurred, prognosis is fair; but metastases happen early because of the direct connection of the tumor with the lymph current.

Fig. 80

Endothelioma of the soft palate: a, dilated lymph space; b, endothelial cells with beginning cystic formation; c, completely formed cyst. (Volkmann.)

G. Angiosarcoma.

—Angiosarcoma is a sarcoma arising from the adventitia of the bloodvessels. It is characterized by its extraordinary vascularity, the ease with which hemorrhages into the structure of the tumor take place, and the frequency of pigmentation. Peritheliomas constitute a subvariety, met with especially in the kidneys, the bones, and the skin, and originate in the perithelial cells between the capillaries and the perivascular lymph spaces. They are more vascular than the angiosarcomas. The latter are common in the liver. In many cases the cells of these tumors simulate the columnar epithelium of adenocarcinoma. (See Plate XVIII, Fig. 1.)

H. Cylindroma.

—This is a term applied to tumors of the angiosarcomatous type in which hyaline changes have occurred, so that along the vessels appear cylindrical masses of altered cells. Similar appearances are noted in certain endotheliomas and are due to the same hyaline degeneration.

I. Melanosarcoma (better known as Melanoma).

—This refers to the deposition of pigment, rather than to type or shape of cell, the distinguishing feature of these growths being the presence both in the cells and in the intercellular substance of a variable quantity of blackish pigment. Of all the forms the melanotic growths are considered the most malignant. They invariably recur after removal, lead to secondary deposits at long distances, and present the most intractable and incurable forms of cancer. Deposition of pigment in carcinomas is most rare, if ever met with, and the growths of melanotic type should be relegated entirely to the class under consideration. The tumors most often develop from pigmented nevi of the skin, though primary melanoma of the deeper parts of the body is known. These will be treated more fully in the chapter on the Skin. (See Plate XX.)

This name has been variously applied by different writers to different growths. In order to avoid confusion it would be well, in using it, to be definite.

General Characteristics of Sarcomas and Endotheliomas.

—The vascular supply of sarcomas varies within wide limits. In nearly all instances it is of capillary character, the blood circulating rather through vessels without well-marked walls. While large vessels may be found about and in the periphery of these tumors, distinct vascular structure is usually absent from the more internal portions, which will explain the frequency of hemorrhage, its persistency after operation, and the ease with which large extravasations occur. True hematocele may thus take place within sarcomatous tumors, with the usual later cystic alterations, and thus in one way we have the condition known as cystosarcoma.

In attacking these growths the vascular and bloody area may be met just about their margins, the bloodvessels expanding as they arrive at the tumor, and sometimes bleeding extensively. Under most circumstances, however, this hemorrhage can be controlled by packing or by operating at a greater distance from the circumference of the growth.

Metastasis in sarcoma is common, dissemination occurring mainly along the veins, as these growths connect with the venous channels and permit of easy detachment of fragments, which are then carried along as emboli. These emboli pass naturally to the right side of the heart, and thence to the lungs, where it is most common to find secondary growths, except in areas emptying into the portal veins, in which case the liver will be the most common site. Sarcomas are destitute of lymphatics, and dissemination does not occur through these channels.

Infiltration is also a common phenomenon with these growths. This is generally seen in muscular tissue, particularly with growths proceeding from the periosteum and projecting into it.

Sarcomas, like other tumors, tend to grow along the lines of least resistance. Hence processes of these tumors will insinuate themselves into fissures and interspaces, and penetrate perhaps even into the cavities, from which it is hazardous or impossible to remove them. Thus, sarcomas springing from the head of a rib have been known to extend through an intervertebral foramen and give rise to an intraspinal tumor, causing fatal pressure.

Secondary changes are usually seen in sarcomas, the most frequent being hemorrhage. Myxomatous degeneration is also frequent, and gives rise to cystic conditions. Calcification is common, particularly in the slowly growing tumors which arise from bone. Upon the other hand, necrosis (i. e., ulceration) is common in growths which project upon the surface or into any of the open cavities of the body. Ulceration here is growth at a rate faster than nutrition will justify, and gangrene is to be regarded as a failure to supply sufficient blood. It may also mean infection, of which it is a usual expression.

Tumors of this character, which luxuriate upon reaching the surface, and bleed easily upon the slightest touch, were formerly known as fungus hematodes. The name may be preserved for the sake of convenience, but should be held to mean, in almost every instance, a rapidly growing round-cell sarcoma.

Sarcoma is common in the lower animals, particularly so in horses—most common in those of gray color. It is met with also in cows and various other domestic and undomesticated animals.

Myxoma.

—The myxomas are composed of mucous tissue, whose best-known normal representative is the Whartonian jelly of the umbilical cord. True myxoma should be distinguished from myxomatous degeneration, which occurs frequently in cartilage, fibrous tissue, and sarcoma, and which brings about a similar condition of affairs, though of essentially different origin. Myxomas appear under the following forms:

1. Polypi.

—These include many of those which grow in the nose. The pure form of nasal myoma proceeds from the mucous membrane of the nasal passages or sometimes from the accessory sinuses. But most of the so-called nasal polypi are due to edematous hypertrophies of the submucosa. The polypi usually hang as gelatinous tumors of grayish-yellow tint, being present sometimes singly, sometimes in clusters or in large numbers. Their principal effect is to produce nasal obstruction, with, perhaps, subsequent serious disorder, due to decomposition or to extension into the pharynx or other cavities. Similar growths also occur from the mucous membrane of the tympanum, and constitute the common variety of aural polypi.

2. Cutaneous Myxoma.

—Cutaneous myoma is not common. It presents usually as a sessile tumor, although about the perineum and labia the tumors may become pedunculated. It is often difficult to distinguish between a myoma of the skin and a sarcoma of the same which has undergone myxomatous degeneration, and which then should be called sarcoma myxomatodes. The latter tend to recur after removal; hence the importance of exact diagnosis.

3. Neuromyxoma.

Neuromyxoma is a similar condition involving the nerve trunks, and is dealt with under Neuroma.

Myxomas require complete removal, and, in the nose especially, cauterization or destruction of the surface from which they spring. When this is thoroughly done they do not recur; otherwise, they are likely to require subsequent operation.

Myoma.

—The true myoma is a tumor composed of unstriped or involuntary muscle fiber. Until recently it has been customary to divide the myomas into the leiomyomas in contradistinction to the rhabdomyomas, the latter being supposed to be tumors of voluntary muscle fiber. Myomas are met with only where involuntary muscle fiber is found—namely, in the uterus and adnexa, the vagina, the esophagus, alimentary canal, the prostate, the bladder, and the skin. They form encapsulated tumors composed of fusiform muscle cells with a rod-like nucleus, the size of the cells varying greatly in different specimens. The bundles of muscle fibers are much contorted, and it is often difficult in a single section to decide to just what class of cells they belong.

These tumors are most common in and about the uterus, and are referred to as intramural when developing in the true uterine tissue, and submucous and subserous when situated just beneath one or the other of the adjoining membranes. They differ in their rate of growth, are firm in composition, and are moderately vascular, sometimes containing areas of softening and becoming even cystic. In rare instances they become enormously vascular, and are then known as cavernous myomas. Aside from mucoid or colloid changes they occasionally undergo fatty metamorphosis or calcareous infiltration. The latter is possible to such an extent as to lead to a condition of uterine calculi.

Uterine myoma is liable to septic infection, which frequently follows exploration of the uterus or the changes incident to pregnancy or parturition. It then becomes a case for immediate operation. Uterine myomas do not occur before puberty, rarely before the age of thirty-five, and are most common between the thirty-fifth and forty-fifth years of life. They produce disaster not alone by their size, but by hemorrhage, by pressure on adjoining viscera (rectum, kidneys, etc.), and occasionally by torsion of a long pedicle.

Myomas are found in the esophagus, in the walls of the stomach, where they are frequently confounded with malignant tumors, in the prostate and wall of the bladder, and in connection with the skin. As soon as they give rise to inconvenience or to dangerous symptoms they are to be dealt with surgically, as no other treatment has proved of lasting benefit.

The rhabdomyomas deserve but brief description. The striated muscle fibers of which these tumors are composed have been often confused with spindle-shaped sarcoma cells. They are met with almost exclusively in the mixed tumors of the kidney under Teratomas.

Myoma or myofibroma is exceedingly likely to undergo sudden conversion into a form of growth entitling it to be called malignant myoma.

Angioma.

—Angiomas are tumors composed of bloodvessels, and group themselves under three headings, in accordance with the structure of the vascular system:

1. Capillary Angioma, or Nevus.

—Capillary angioma, or nevus, is the most common form of all, and is frequently seen in the skin and subcutaneous tissue. When the condition is spread over a relatively large area it gives rise to a discoloration known as port-wine mark, and called telangiectasis by the pathologists. The condition is often congenital or begins soon after birth. The color of the affected area determines whether the vessels belong to the venous or to the arterial system. These tumors may be found in all parts of the body, on the surface, on the submucous surfaces of the tongue, the inside of the mouth, the conjunctiva, and the vulva. The tendency is toward gradual increase in size; rarely, spontaneous contraction and obliteration occur.

2. Cavernous Tumors.

—These are similar in structure to the corpus cavernosum, and are called erectile tumors. They are common in connection with the skin, and are exaggerated forms of the variety first described, the vessels becoming not merely dilated but cavernous in arrangement. They occur occasionally in the tongue, in the voluntary muscles, and in the liver, and are noted very rarely in the mammæ, in the larynx, and subperitoneally.

A similar condition is met with in the so-called cavernous tumors which involve various organs, especially the thyroid and the liver. In these instances a part or the whole of the organ may be involved, and presents great increase in size and evidences of vascularity.

In cavernous growths of the thyroid are vessels, veins especially, the size of the thumb, while with the ear not touching the body of the patient a distinct venous murmur may be heard.

3. Arterial or Plexiform Angiomas.

—Arterial or plexiform angiomas, when of any particular size, are called cirsoid aneurysm or aneurysm by anastomosis. This form consists of arteries abnormal both in number, length, and diameter, tortuous in arrangement, occurring often in the scalp, but rarely in the perineum or genitalia, and seldom in other parts of the body. (See Aneurysm, Chapter XXIX.) These tumors are liable to rupture from external injury, and necessitate ligation of the main arterial trunks, with perhaps extirpation of the tumor mass.

Recognition of angiomas is not difficult unless they are deeply concealed. The effect of intermitting pressure, the emptying and refilling, and the distinction between arterial and venous growths by the result of alternating pressure and relaxation, either above or below the growth, with discoloration of the skin, and, in the larger growths, audible murmur, leave little doubt of the character of the growth.

When such growths are small they may be dealt with by electrolysis, the needles from both poles being introduced, or that from the negative, the positive being applied upon some neighboring portion of the body. The effect of the electric current is to determine coagulation of the blood in the tissues acted upon, and this is followed by organization of thrombus, conversion of vascular into cicatricial tissue, shrinkage, and possible eventual disappearance of the mass. Radical excision under an anesthetic should be made, dissecting out the mass, securing bleeding vessels, and reuniting the parts by sutures, with the expectation of securing primary union. This is the quickest and in many cases the least disfiguring method. Old methods of ligation of surrounding vessels or the subcutaneous ligature are now practically discarded. The injection methods as formerly practised, especially the use of iron salts in solution, are severely condemned, as death is liable to occur. With electrolysis and excision the surgeon has nearly all the measures which he will need to practise for the medical treatment of angiomas.

Fig. 81

Lymphangioma of lip; macrocheilia. (Neisser.)

Lymphangioma.

—Lymphangiomas are tumors composed of lymph vessels and bear resemblance to the tumors above considered. They may be divided into three varieties:

1. The Lymphatic Nevus.

—The lymphatic nevus is composed mostly of lymphatics nearly normal in size, and occasionally colored red by the presence of bloodvessels. When pricked, pure lymph or blood-stained lymph, will flow. They are usually small, and are noticed during childhood. They may occur anywhere upon the surface of the body or in the mouth, generally in connection with the tongue, where they may appear as large papillæ involving a portion or all of the dorsum. When the lymphatic structures of the tongue are thus enlarged and involved the condition is known as macroglossia, and consists of enlargement of the organ, sometimes to a degree not permitting its retention in the mouth, but leading to its constant protrusion (Fig. 81).

2. Cavernous Lymphangioma.

—Cavernous lymphangioma corresponds to cavernous angioma, and is a condition in which the lymph vessels become positively cavernous and sacculated.

3. Lymph Cysts.

—Lymph cysts are the still more aggravated form which lymphatic dilatation may attain, and are usually encapsulated, complicated with more or less tense tissue, and produce a condition of the parts, especially about the scrotum and labia, to which the term elephantiasis is often applied (Fig. 83).

The question of congenital occlusion or dilatation of lymph channels is one which has been made the subject of large separate monographs (especially by Busey). Numerous tumors, essentially of lymph-vascular origin, are found upon the lips, in the neck, and elsewhere, which grow slowly, are more or less elastic and spongy upon pressure, are frequently covered with skin, from which hair grows most luxuriantly, and in which pigment or papillomatous structures are dispersed. These tumors are called cavernous tumors, are of slow growth, and undergo spontaneous involution, but usually require surgical relief. They are often confounded with branchiogenic and other congenital cysts of the neck.

Treatment.

—The treatment for the smaller lymphatic tumors is simple, but here electricity is less to be relied upon and excision is more urgently demanded. Electrolysis will cause coagulation of blood, but not of lymph—at least not to nearly the same extent; consequently its usefulness is restricted to blood-vascular tumors. Excision, then, is the best remedy. When this is impracticable much can be done by galvanopuncture or ignipuncture, the cicatricial contraction following multiple punctures leading to reduction in size of the affected part. The enlargement of the tongue spoken of above as macroglossia may be treated by ignipuncture or by electrolysis, if necessary under an anesthetic, the effect of the electric current here being not to produce coagulation, but apparently absorption of fibrous tissue and changes which come slowly rather than by obliterative processes.

Fig. 82

Congenital lymphangioma. (Original.)

Fig. 83

Lymphangioma of lower extremity. (Original.)

 

5. Tumors of Nerve Elements.

Glioma.

—Glioma is a malignant tumor developing directly from actual nerve structure or that of the original nerve elements, and is clinically allied to the sarcomas. It arises from the neuroglia, and hence is confined to the central and peripheral nervous system, mainly the former. It is most common in the brain, the cord, and in connection with the optic nerve and fundus of the eye. It is often extremely vascular, the vessels being sacculated, and is usually met with in solitary form. When near the surface of the cortex such a tumor may appear like a great convolution (Virchow). In the basal portions of the brain it may attain considerable size. In the cord it is rare, usually limited to the cervical region. In the orbit and eye it may produce marked exophthalmos. It is more frequent in the young than in the aged.

Glioma is an exceedingly malignant form of tumor, and operation is rarely performed sufficiently early to more than prolong life. Dissemination by continuity is the rule rather than metastasis. It kills usually by its pressure effect on the nerve centres.

Neuroma.

—True neuromas spring from the structures of nerve trunks, which trunks may also be the site of other tumors, mainly fibromas and sarcomas, with which neuromas may be easily confounded. The most common nerve tumor is the neurofibroma, which grows from the structure of a nerve sheath, its long axis usually coinciding with that of the nerve trunk. Tumors of this class vary greatly in size, are often multiple, and in other instances affect nearly all the nerves in the body. They are extremely liable to myxomatous degeneration, which will account for many of the instances reported as myxoneuroma, etc. They attack cranial and spinal nerves alike, and no nerve or nerve root in the body is exempt. The sensory nerves appear more liable to attack than the motor. The nerve least often attacked is the optic. They are not rare upon the roots of the spinal nerves, in which location they may attain to such size as to press upon the cord and induce paraplegia. Multiple neuromas are often associated with molluscum fibrosum (q. v.). There is an instance on record in which 1600 of these tumors were found after careful dissection of the neuroskeleton, and another in which at least 2000 were found, 60 of them involving the pneumogastric trunks and their branches.

Fig. 84

Plexiform neuroma, dissected free from all adherent tissues. (Lexer.)

Fig. 85

Plexiform neuroma of chest wall in a young child. Illustrating its gross external resemblance to lymphangioma. (Lexer.)

 

Plexiform Neuroma.

—Plexiform neuroma is relatively rare. This is a type of nerve tumor in which all the branches of a given nerve which are distributed to a particular area become enlarged and elongated, the overlying skin being stretched and thin. Such a tumor seems like a loose bag containing a number of vermiform bodies, resembling the sensation given when palpating a varicocele. On section each of the affected nerves reveals a quantity of myxomatous tissue replacing the nerve sheath. They are in large measure congenital. The skin overlying a plexiform neuroma will frequently be found to be pigmented, variously altered in thickness, and covered with fine hair. These growths have been frequently mistaken for lymphangioma (Figs. 84 and 85).

Malignant Neuroma.

—Malignant neuroma (so called) will generally be found to be a true sarcoma of nerve structures, usually of the spindle-cell variety. Traumatic neuroma is often seen in amputation stumps, where the terminations of the divided nerves become bulbous, attaining the size of cherry stones, the tumors being composed of a mixture of connective tissues and nerve fiber, from which in time the true nerve structure usually recedes or vanishes. They form when suppuration has been profuse or healing long delayed, and when sufficient care has not been exercised to prevent entangling of the nerve ends in the scar of the wound. They give rise to much pain, and often necessitate re-amputation. The bulbous enlargement is the result of prolonged irritation in a nerve, and has been noted around various foreign bodies.

True neuroma is innocent in tendency, though often painful. It is the sarcoma of nerve tissue which produces signs of malignancy. A true neuroma which causes unendurable pain should, when accessible, be removed. It is sometimes possible to separate the tumor mass from the balance of the nerve trunk, and thus to remove it without excision of the nerve. At other times it is impossible to avoid division and ensuing paralysis. Divided nerve ends should be brought together by catgut suture, by which means it may be possible to avoid permanent loss of function. Nerve grafting is also resorted to for repairing such defects. Removal of painful neuromas due to injuries to the head has more than once been the means of curing traumatic epilepsy.

6. Tumors Derived from Epithelium.

These tumors consist of specific epithelial elements supported and more or less bound together by a vascular connective-tissue stroma. The only apparent exception to this statement is tumor of dental tissue. The teeth are positively modified and petrified or calcified epithelial products.

Odontoma.

—The odontomas are tumors composed of one or more of the dental tissues, arising either from tooth changes or teeth in process of development. They may be divided, according to Sutton, as follows:

1. Epithelial Odontomas.

—These are provided with a capsule, and present usually as a series of cysts separated by thin septa, containing mucoid fluid, while the growing portions have a reddish tint not unlike sarcoma. They are most frequent about the twentieth year of life, but may occur at any age. They probably arise from persistent remains of the epithelium of the original enamel organs.

2. Follicular Odontomas.

—These are often called “dentigerous cysts.” They arise in connection with permanent teeth, and especially with the molars, sometimes attaining great size and producing conspicuous deformity. The tumor consists of a wall representing the expanded tooth follicle, and a cavity containing viscid fluid, with some part of an imperfectly developed tooth, occasionally loose and more or less displaced in location. The cyst wall always contains calcareous material. These tumors rarely suppurate. They occur also in animals.

3. Fibrous Odontomas.

—These consist of condensed connective tissue in a developing tooth, presenting as a tumor with a firm outer wall and a loose inner texture, blending at the root of the tooth with the dental papilla and indistinguishable from it. The developing tooth thus becomes enclosed within the capsule before it protrudes from the gum. These tumors are most common in ruminants, being often multiple.

4. Cementoma.

—A tumor of fibrous character whose capsule has ossified or calcified, the developing tooth thus becoming embedded in a mass of dental cementum. These tumors occur most frequently in horses.

5. Compound Follicular Odontomas.

—These are tumors containing a number of masses of cementum resembling small teeth, or even amounting to well-formed but ill-shaped teeth composed of all three dental elements. In such a tumor teeth may be found in great numbers. They occur in the human subject as well as in animals.

6. Radicular Odontomas.

—These are tumors which arise after the crown of the tooth has been completed and while its roots are yet in process of formation. The crown, being unalterable enamel, does not enter into the composition of these growths, which then consists of dentine and cementum in varying proportions. They are rare in man, but frequent in other animals, and often multiple.

7. Composite Odontomas.

—These are hard tumors, bearing little or no resemblance in shape to normal teeth, occurring in the jaws, consisting of a conglomeration of enamel, dentine, and cementum, presenting abnormal growth of all the elements of the tooth germ. So far this tumor has only been found in man.

Little is said about the odontomas in general surgical literature. These tumors, as they grow, are often regarded as due to necrosed bone or to unerupted teeth, while fibrous odontomas have been often regarded as myeloid sarcomas. No tumor of the jaw, especially in young people, should lead to excision of the jaw until it has been demonstrated that the tumor is not one of the above forms. When diagnosticated as true odontoma its complete removal is all that is necessary.

Papilloma, or Fibro-epithelioma.

—The type of papilloma is this common wart, consisting of a central stem of fibrous tissue and bloodvessels covered by epithelial projections and proliferations. Papillomas are usually sessile and villous.

1. Warts.

[14]—These are sessile papillomas, most common on the skin, often seen on mucous surfaces, and occurring sometimes singly, often in crops. They are exceedingly common about the perineum, where skin and mucous membrane meet, and are regarded as due to the irritation of specific discharges. The papillomas occurring about the genitalia are known as condylomas. The growths in these instances are frequently so luxuriant and proliferative that they assume fungoid shape, and are called mulberry growths. Warts grow slowly or rapidly according to circumstances. Warty growths may attain enormous size and become vascular. Late in life they are frequently the starting points of epithelial ingrowths, and then become true epitheliomas—i. e., cancer. Warty growths sometimes line the buccal cavity and complicate cases of macroglossa. They occur also in the larynx, and when situated near the glottis may cause dyspnea and fatal obstruction to respiration. It is claimed by some that cutaneous warts will disappear with continued small internal dosage of Fowler’s solution. (See Plate XXI.)

Fig. 86

Papilloma of the bladder.

2. Villous Papillomas.

—These are met with most commonly in the bladder, occasionally in the pelvis of the kidney. They are identical with chorionic villi, and occur most often singly. It frequently happens that long, fine tufts are detached and carried away with the escaping urine. Another form of villous growth arises from the choroid plexuses of the lateral ventricles in the brain. These may grow and attain a size sufficient to produce disturbance (Fig. 86).

3. Intracystic Villous Growths.

—These are seen, for example, in mammary cysts. These, of course, are lined with epithelium, which acts here as it does in other localities, and proliferates more or less rapidly under unknown circumstances. In dealing with paroöphoritic cysts the presence of these growths has also been alluded to.

4. Ovarian Papilloma.

—There is a form of ovarian papilloma which partakes of the nature of a malignant tumor, in that separated particles seem to attach themselves to peritoneal surfaces, where they grow luxuriantly. Either this is an expression of parasitism or infectivity, or else of the implantation of tumors, which, to the writer’s mind, constitutes a strong argument for the parasitism of cancer. After abdominal section, with removal of the original focus, these growths often disappear. This affords a parallel to the instances of cure of tuberculous peritonitis after the same procedure.

PLATE XXI

Photographic Reproduction of Papilloma. Low power. (Gaylord.)

5. Cutaneous Horns.

—These are also epithelial outgrowths, and are met with in four varieties (Sutton):

(a) Sebaceous horns, quite common, arising by protrusion of contents of a sebaceous cyst through a rupture in its wall or through its duct, with consequent desiccation by exposure to the air, while fresh material is consequently added at the basis so long as sebaceous secretion continues. These growths soften when soaked in weak liquor potassæ.

(b) Warty horns, structurally identical with the above, but growing from warts instead of from sebaceous cysts. Both these forms are often found about the head. Cutaneous horns are also met with in ovarian dermoids. They are common in the lower animals and may attain large size.

(c) Horns growing from cicatrices, especially of bones, are rare, but a cornified condition of the cicatrix itself, with formation of scales resembling those from horns, is not uncommon.

(d) Nail horns are simply overgrown nails, occurring on the digits and toes of bedridden patients who never walk (Fig. 87).

Fig. 87

Nail horns. (Original.)

Treatment.

—All these forms of epithelial outgrowth call for radical removal, which implies complete extirpation of the membrane or tissue from which the growth occurs, after which, if effected, there is no recurrence. If some be left there is tendency to recedive.

Mucous Polyp.

—Similar papillary and often pedunculated epithelial tumors frequently hang or project from the mucous membrane—e. g., the rectum. The pedicle really projects from the submucosa. Between the layers of the overgrown mucosa are found altered glands. So long as the growth of these polyps is toward the exposed surface they are innocent and wellnigh harmless, unless they attain fair size; but so soon as they grow inward and the boundary of the submucosa is transgressed they assume malignant aspects at once. Such transformation is by no means rare, and constitutes a strong argument for their prompt removal.

Goitre; Struma.

—Pathologically the various enlargements of the thyroid known as goitre or struma constitute essential neoplasms. (See chapter on Regional Surgery of the Neck.) In this condition either the epithelial or the connective tissue may be primarily at fault.

1. Struma Parenchymatosa Nodosa.

—This includes also the colloid and the cystic varieties, and refers to an enormous overproduction of the epithelial elements (parenchyma) in distended alveoli, where they often undergo colloid softening. So marked are these changes in numerous instances that multiple cysts (minute or large) result. The collective volume of such altered tissue may be very large.

2. Struma Fibrosa.

—This presents itself in the way of dense enlargement of the thyroid, the stroma being the tissue now involved, even to the extent of causing much of the alveolar structure to disappear or become obliterated. In this condition calcification is common, and calcareous concretions or patches are often found.

Even benign tumors of the thyroid show occasionally a tendency to metastases. Cases are on record of benign goitre causing general metastases, and even of metastasis without noticeable thyroid enlargement. These occur most often in the bones, less frequently in the lungs and other organs. They are more common when the goitre has undergone colloid changes. The reasons for these changes are unknown.

In either form hemorrhages are common, with their resulting blood cysts or their solid residue, in which case pigment is usually found. Both forms are often accompanied by enlargement of the vessels, and sometimes these become enormously dilated and constitute an almost insuperable obstacle to successful removal. (See Thyroidectomy.)

Ovarian Cystoma.

—The cystomas of the ovarian region assume two types: (1) Glandular cystoma, and (2) papillary cystoma.

1. Glandular Cystoma.

—The glandular type produces the multilocular forms, with numerous small and large cavities, filled with fluid which varies in color and appearance within wide limits, having usually the consistency of mucus or thin pus, and containing a small number of cylindrical epithelial cells. The cyst wall may contain tubular glandlike structures reaching into the surrounding connective tissue.

2. Papillary Cystoma.

—The papillary type presents projections into cavities of papillomatous outgrowths from their walls, which are covered by cylindrical epithelium, which latter also lines the cavities. It is most common in the parovarium.

It is rare to find a pure type of either variety; both forms are usually blended. Malignant transformation, of the latter type especially, occurs easily and insidiously, and explains many disappointments in result.

Adenoma and Fibro-adenoma.

—Adenoma is a tumor whose type is the normal secreting gland, from which it differs in being an abnormal outgrowth or product, but particularly in that it has no power of producing the secretion peculiar to the gland tissue or type from which it grows. The adenomas occur for the most part as circumscribed tumors in the mammæ, parotid, thyroid, liver, and in the mucous membranes of the bowels and the uterus. They may be single or multiple; in the intestine they are usually multiple. In certain locations (e. g., the mammæ) they attain enormous dimensions, and in the ovary tumors of this character may be met with weighing forty or fifty pounds. The true adenoma shows no tendency to infection of neighboring lymphatics, and gives rise to no secondary deposit, and when it causes death it is usually because of size or pressure upon important organs. It displays a marked tendency to cystic alteration, while the relative proportion of epithelium and connective tissue or stroma varies within wide limits. In some cases, in which the former is small in amount, the preponderance of the latter has caused the use of the term adenosarcoma, which is really a misleading name.

The distinction between adenoma and true carcinoma is in some respects but slight, and this fact will account for the conversion which many innocent gland tumors seem to undergo from one into the other. As soon as the epithelial cells lose their regularity of disposition and collect in groups, or make their way outside of the acini into the tissues, then the change from the benign to the malignant tumor has begun, and the entire clinical aspect of the case has altered. This change may be the result of external irritation, of such tissue changes as pregnancy and lactation, or of the undefined changes which advancing years seem to produce. (See Plate XXII, Fig. 2.)

Adenoma occurs in the breast as cystic adenoma or fibro-adenoma. The former often attains large size, is encapsulated, the acini are much dilated, while from the walls of the epithelium-lined cavities frequently project papillomatous processes, forming what are called intracystic growths. Cystic adenomas grow slowly, produce atrophy of mammary tissue by pressure, occur after puberty until the menopause, and rarely give rise to pain until they become large. As they grow they distort the breast until it may become pendulous. When the growth of connective tissue, peculiar to the tumor in that it is rich in nuclei, forms well-marked partitions between alveoli, the growth is called pericanalicular adenofibroma, which may assume a tubular or an acinose type. When the alveoli and ducts are themselves invaded by ingrowth of this tissue, then we have the intracanalicular adenofibroma, which constitutes a growth sometimes bordering on the malignant. When the arrangement of epithelial cells in the acini and ducts becomes irregular and atypical, then malignant transformation has begun.

PLATE XXII

FIG. 1

Fibromyoma of Uterus. (Low power.)

FIG. 2

Fibro-adenoma of Breast. (Low power.)

PLATE XXIII

FIG. 1

Epithelial Pearl Formation in Squamous Epithelioma. (Middle power.)

FIG. 2

Malignant Adenoma of Rectum. (Middle power.)

Fibro-adenoma occurs also in the breast as a small tumor, encapsulated, usually superficially placed, movable in its site, often multiple; most common between the twentieth and thirtieth years of life; often painful, especially during menstruation; tender upon pressure. Both forms may occur in young men. A form of fibro-adenoma in which fibrous tissue is greatly in excess, which never attains great size, is common in the breasts of unmarried women. It gives rise to much pain and distress, but is clinically not malignant. (See Plate XXII, Fig. 2.)

Adenoma occurs frequently in sebaceous glands as:

1. Sebaceous Cysts.

—Sebaceous cysts are generally known as wens. These tumors commonly begin as retention cysts, the ducts of the sebaceous glands becoming occluded. But in many cases there is no occlusion of the ducts, and their secretion may be easily expressed. They occur wherever sebaceous glands abound, but especially upon the scalp. They are usually multiple, vary greatly in size, are easily movable over the bone, and are intimately related to the skin, while the duct orifice is frequently recognized by a black spot, after removing which sebum can be expressed. These cyst-adenomas are encapsulated, and can be easily shelled out of their matrices, save when inflamed, in which case they are often astonishingly adherent. Their contents consist of pultaceous debris resembling old epithelial scales, fat, cholesterin, etc. The contents of these cysts are very prone to decompose, and they become as offensive as anything with which the surgeon has to deal. Putrefaction may be independent of inflammation or coincident with it. When irritated these gland cysts become inflamed and may suppurate, suppuration being tantamount to cure by spontaneous processes. They may also ulcerate, without suppurating, and form foul-smelling ulcers, or give rise to cutaneous horns.

Fig. 88

Multiple atheromatous cysts (wens). (Lexer.)

2. Sebaceous Adenomas.

—These arise from the sebaceous glands, which are lobulated, like those about the nose and ear. Adenomas from this source are extremely liable to ulceration, may undergo calcification, and are often mistaken for epithelioma because of the fungous ulcerations to which they give rise.

3. Adenocarcinoma.

—Sutton has also described an adenocarcinoma of the peculiar sebaceous glands named after Tyson. These are found particularly at the base of the prepuce, this form of tumor being rare. Adenomas arising from the mucous glands, which are usually transformed into cysts, are also known, as well as other gland tumors springing from the glands of Bartholin, Cowper, etc. (See Plate XXIII, Fig. 2, and Plate XXIV.)

Pituitary adenomas are either analogous to struma or belong to the mixed tumors of dermoid or teratomatous type.

Prostatic adenoma is in large degree fibromyoma of that body, with more or less hypertrophy of its glandular structures. Minute cystic alterations may occur also, as well as growth resembling intracanalicular fibro-adenoma.

Adenoma is occasionally observed in the salivary glands, where it is usually encapsulated, and may undergo cystic changes. It has been observed in the liver and pancreas. In the former its pseudo-ducts often contain inspissated material of bile-green tint.

The lesions of the kidney referred to as cystadenoma are now grouped among the teratomas, and are described under that heading. They present interesting examples of mixed tumors.

In the testis, as in the ovary, epithelial tumors frequently present themselves, but they partake less often of the type of pure adenoma, and incline rather to that already described under Ovarian Cystoma. Even in the paradidymis tumors of this same character are found, with cystic or even papillary alterations.

In the mucous membrane of the stomach and bowels adenoma usually presents as an ovoid tumor, attaining such size as to give rise to mechanical obstruction either by pressure or by traction. Adenoma of the pyloric region is a repetition in structure of the pyloric glands. In the rectum it presents usually as a polypoid outgrowth, often seen in young children. Such tumors are generally small, and when solitary they often hang by a distinct stalk.

Similar polypoid tumors present in the cervical canal of the uterus, where are also found sessile and racemose tumors, all of which are structural repetitions of the glands met with in the cervix uteri. Adenoma of the uterine cavity is seldom seen; it is also rare in the Fallopian tube, but occasionally presents as a dendritic outgrowth from the mucous membrane distending the tube.

Epithelioma.

—Epithelioma is common, especially where there is transition from one kind of epithelium to another, and, of all other localities, particularly where skin and mucous membrane meet—e. g., the lips, the vulva, and the anus. Epithelioma differs from papilloma in that the former is no longer limited by basement membrane, but passes beyond it into the underlying connective tissue and presents down—rather than up—growth. Characteristic of epithelioma are the so-called cell nests or pearly bodies, where there seems to be a tendency to globular arrangement of cells with such condensation or alteration that they lose their ability to take stains, and appear as a more or less lustrous mass, showing off by contrast among the standard surrounding tissue. On this account they are often called pearly bodies. Recognition of these is tantamount to diagnosis of epithelium. (See Plate XXIII.)

This form of neoplasm is essentially the same, no matter what its clinical varieties. These comprise a wart-like growth or nodule, which quickly becomes an ulcer with elevated edges, ulceration being due to necrosis of cells farthest from the periphery; or, again, the disease may start as an ulcerated fissure, ulceration and infiltration keeping pace, in which case there is a sharply defined ulcer with undermined edges. A third variety, often seen upon the lips, comprises a projecting mass, with more or less horny surface. In nearly all of these, however, the characteristic cell nests with their onion-like arrangements of cells will be found.

Epithelioma, especially when exposed to the air or to surface irritation, quickly ulcerates and tends to involve all the surrounding tissues, while occasionally the distinctive cells proliferate so rapidly as to give the ulcer more or less of a bursal or a cauliflower-like arrangement. From such a surface there is a constant discharge of foul-smelling detritus or of sloughs. Even bone cannot resist its progressive invasion and slowly disintegrates before the advancing mass. Cartilage is resistant, and usually preserves its integrity. In other words, the tendency of epithelioma is toward constant encroachment and infiltration, and toward a fatal termination from hemorrhage by ulceration, from septic infection, exhaustion, or other accidents. The wart-like forms run the slowest course of all, but even here the malignant tendency is most evident.

Lymph-node Infection.

—A striking characteristic of epitheliomas is the invasion of the adjoining lymph nodes, which attain a size disproportionate and bearing no necessary relation to that of the primary growth. This constitutes one of the most serious complications of the condition. This lymphatic invasion partakes of the malignant character of the disease, and from every focus of this character infiltration and destruction proceed. Infected nodes also show an early tendency to central degeneration and to spurious cyst formation. When the overlying skin becomes involved we have extensive sloughing and the conversion into large malignant ulcers. Dissemination to a distance (i. e., metastasis) is rare in epithelioma—much more so than in carcinoma. (See Plate XXV, Fig. 2.)

About the mouth epithelioma is not common before the thirty-fifth year, though I have seen it on the lip of a twenty-year-old woman. It is vastly more common in men than in women, and more frequent on the lower than the upper lip. In the tongue it seldom occurs before the fortieth year. It seems to be more common both on the lip and tongue in men with bad teeth and in confirmed smokers, thus giving rise to the view often held that it is purely a matter of irritation. It may, however, be due to contact infection should it be regarded as of parasitic origin. In one-fifth of the cases of epithelioma of the tongue there are preceding lesions, usually described as leukoplakia or ichthyosis of the tongue—conditions characterized by epithelial reduplication and the formation of dense plaques or scales. These lesions are usually regarded as precancerous conditions. (See Plate XXVI.)

PLATE XXIV

FIG. 1

Primary Papillary Adenocarcinoma of the Kidney. (One-half original size.) (Gaylord.)

FIG. 2

Section of the Primary Growth. (Gaylord.)

PLATE XXV

FIG. 1

Carcinoma developing in a Thrombus in the Portal Vein. (Middle power.) (Gaylord.)

FIG. 2

Metastasis of Squamous Epithelioma in a Lymph Node. Pearl Formation. (Middle Power.)

PLATE XXVI

FIG. 1

Epithelioma of Tongue. Enlarged three diameters.

FIG. 2

Paget’s Disease of the Nipple. Enlarged two diameters.

Photographs from hardened unstained specimens.

The disease often starts near the stump of a carious tooth, in which case infiltration and erosion begin promptly and progress rapidly. Epithelioma of the tongue has been known to follow along the obliterated track of the thyrolingual duct, and in this way to bring about a perforating ulcer.

Epithelioma of the esophagus is a common cause of stricture of this passage-way. It leads to ulceration, and usually to perforation into the trachea or some other cavity or passage (i. e., a bloodvessel). In the larynx the disease is well known, and gives rise to intense and finally fatal symptoms, but has been dealt with successfully by radical operations for extirpation of the entire organ. (See Chapter XLI.)

Fig. 89

Epithelioma of forehead and eyelid. (Neisser.)

Fig. 90

Epithelioma of lip. (Neisser.)

 

Occurring upon the scrotum, epithelioma has been called chimney-sweeper’s cancer, or soot-warts, and has been ascribed to the irritation of foreign material. Ulceration and infection of the inguinal nodes usually proceed rapidly and disastrously. It is believed also that tar and paraffin may produce similar irritation, and paraffin cancer has been described by various writers. It usually occurs upon the scrotum.

The skin lesions which precede the formation of paraffin cancer resemble those seen in chimney-sweeper’s cancer. The skin becomes dry, thickened, parchment-like, while the openings of the sebaceous glands become obstructed by the tar or other material, producing acne-like lesions. Warty outgrowths then occur, and these become the seat of malignant ulceration. In chimney-sweeper’s cancer the scrotum is usually first affected in a chronic dermatitis, to which warty outgrowths succeed, these enlarging and growing downward as ulceration takes place.

About the external genitalia epithelioma is not uncommon, particularly in and about the prepuce. Such a degree of phimosis as leads to retention of smegma is certainly a predisposing cause, not only in man but in the lower animals. Epithelioma of the vulva has been described under the name esthiomène, and requires to be recognized and dealt with promptly if the surgeon should attempt a radical cure. In the vagina and about the cervix uteri it is common, a large proportion of cases of cancer of the uterus being essentially epitheliomas of the cervix.

In and about scars and upon granulating ulcers epithelioma is quite common. One danger to which a chronic ulcer is always exposed is that of epitheliomatous transformation. These growths also attack lupus scars, or even any tissues actively involved in the lupoid process. This is particularly true between the fortieth and sixtieth years of life.

Among the viscera the gall-bladder is probably more often involved in distinct epitheliomatous changes than any other. It presents as a uniform thickening, and causes augmentation in size, so that a distinct tumor projects from beneath the liver. In this location dessemination is rare.

Epithelioma is to be regarded as having an essential malignant tendency. Its treatment demands early removal of diseased parts and complete extirpation of involved lymph nodes. It is only the small and incipient growths which should be attacked by such destructive agencies as cancer pastes or the electrolytic current.

Rodent Ulcers.

—Under the name of rodent ulcers, lupus exedens, noli-me-tangere, etc., writers, mostly English, have described a variety of epithelioma, met especially upon the face, to which a separate classification has usually been assigned. Until recently it has been generally regarded as a local ulceration, distinct from cancer. In some text-books it is described as lupus exedens. It is preceded usually by a nodular condition of the skin, vascular, breaking down into a regular ulceration, but little elevated, the base of the ulcer deeply excavated, with a striking disproportion between ulceration and new-growth. In this particular variety infiltration seems to be continuously in advance of the rodent process, the former being excessive, the latter but slight. This variety of epithelioma rarely produces lymphatic involvement; the discharge is slight, the pain complained of inconsiderable. Occasionally it entirely alters its aspect, and may present features of the conventional epitheliomatous type.

Fig. 91

Fig. 92

Rodent ulcer. (Original.)

The development of cancer in lupus areas is now of sufficiently frequent occurrence to demand attention. Whether the epithelium which gives rise to it is to be accounted for by Cohnheim’s hypothesis, as having been cut off in the course of healing and become a cell rest to subsequently undergo malignant degeneration, is not yet settled. It has been suggested that curettage might cause fragments of epidermis to be loosened and then entangled in the cicatrix, and thus be responsible for subsequent malignant changes. When lupus thus degenerates it assumes usually the papillomatous form, which rarely involves lymph nodes, while the change which follows x-ray treatment often succeeds a hyperkeratosis and rapidly involves gland structure.

Rodent ulcer allies itself with the type of tubular epithelioma springing from the outer sheath of the hair follicle, sending out cylindrical processes which freely blend with one another. It is to be regarded as an equally malignant type of ulceration with other cancerous ulcers, and demands the same thorough and radical measures for its relief as do other forms of epithelioma. It is perhaps the most favorable one with which to deal, because of the usual freedom from involvement of deep lymphatics. No distinctive measures are necessary for its relief—only those which are thorough.

Carcinoma.

—Carcinoma is a tumor springing from preëxisting gland tissue, which it more or less closely resembles in type, save that the structural similarity is incomplete, the epithelial cells now collecting in irregular clusters, or filling the acini and obstructing the ducts, or bursting beyond the basement membrane and invading the surrounding tissues. They frequently so fill the ducts as to appear in columnar arrangement when seen under the microscope, and this has given rise to the use of a term so vague as to have no place in pathology—i. e., cylindroma. Carcinomas may arise from any of the secreting glands, but more commonly from some than from others. They have no capsules. They infiltrate the surrounding tissues, usually involve the lymphatics early, are liable to spread to the superficial tissues and to ulcerate, and to undergo various degenerative changes. Nearly all cancerous tumors abound in lymphatics, which will explain the rapidity with which the lymph nodes become infected, as well as the tendency to dissemination, which is characteristic of these growths. Dissemination leads to so-called secondary or metastatic growths, which may make their appearance in any organ or tissue, even in the bones, where they give rise to changes of texture that make spontaneous fracture easy. It is characteristic of carcinoma that the metastatic tumors which it may produce will reproduce almost perfectly the type of the primary tumor whence the embolic fragments which have produced them spring. The amount of dissemination varies exceedingly: it may even become so marked and widespread as to produce a condition analogous to that met with in miliary tuberculosis—miliary carcinosis. A similar condition, much more rare, is seen in dissemination of sarcoma, and is known as miliary sarcomatosis. A constantly spreading cancerous infiltration of the superficial tissues, which is noted most often after mammary cancer, is described under the form of cancer en cuirasse, or jacket or corset cancer. Instances will be seen in which this infiltration of the surrounding structures has extended nearly or even completely around the thorax. It gives rise to a brawny induration which is unyielding, and is studded here and there by nodules that tend to ulcerate, to fungate, and to bleed easily. It is perhaps the most hopeless form of cancerous disease.

The older writers have constituted two or three clinically distinct forms of carcinoma, based mainly upon the relative hardness or softness of the tumor and the invaded tissues. The term scirrhus is thus applied to a tumor in which connective tissue preponderates and epithelial cells are relatively deficient. On the other hand, the term encephaloid has been applied to a tumor in which the connective tissue seems barely sufficient to hold the mass together, while the epithelial cells are in vast preponderance. These are all tumors of the round epithelial-cell type, and these distinctions are of clinical interest, yet have no great pathological import, save that in a general way the greater the proportion of epithelial elements the sooner will life be terminated by destructive processes. In other words, the more the tumor may partake of the encephaloid type the worse the prognosis or the shorter the probable duration of life. Again, these tumors pursue a varying clinical course. In those tumors, particularly of the scirrhus type, where the connective tissue largely preponderates, there is often an eventual reduction in the size of the part involved, and such reduction of vascularity and of nutritive activity that the rate of growth is thereby perceptibly checked. The so-called atrophying cancers of the breast are the best examples of this type of cancerous disease. Here the volume of the gland is diminished rather than augmented, and the disease may last for a number of years. It is questionable whether it is well to operate.

The so-called colloid forms of cancer are simply the expression of pathological changes occurring in growths of more distinct type. Thus colloid softening may occur in any tumor in which cancer cells predominate, and the so-called colloid cancers of the peritoneum, the ovary, etc., are either examples of such alterations or are possibly endotheliomas arising in these locations. The term villous cancer, with other terms like it, should be expunged from all scientific literature, unless these terms are used in purely adjective and clinical sense, for they imply nothing accurate as to histological structure, and are often misleading and inaccurate.

Carcinoma is most common in the following regions:

In the breast it appears particularly in two forms:

• 1. Acinous Cancer; and
• 2. Duct Cancer.

1. Acinous Carcinoma.

—Acinous carcinoma is usually of the scirrhus type. It may arise at any portion of the breast, and if anywhere near the nipple it will cause retraction of that prominence, which is always pathognomonic; elsewhere it leads to puckering and adhesion of the overlying skin. These tumors infiltrate widely, especially along the connective-tissue stroma and the fibrous tissue which intersperses the fat of the breast. They are usually firm and sometimes exceedingly dense. A form of scirrhus known as atrophying scirrhus consists largely of strands of fibrous tissue, injected here and there with epithelial cells. It is the slowest in growing of all the forms of cancer, and by its contraction tends to reduce rather than augment the size of the mamma.

Acinous cancer is rare before the age of thirty, most common between forty and fifty. It occurs in women in all conditions of life, married and single, but is rarely noted in the male breast. The most dangerous form is that which appears during lactation. Ordinarily its progress is slow. As it augments in volume it infiltrates the surrounding tissues, becomes adherent to the pectoral fascia, infiltrates the muscle fibers, and finally attaches itself to the periosteum of the ribs. The infiltrated tissues tend to shrink rather than to increase in volume. Lymphatic injection occurs early in this form, and is a pathognomonic sign. It occurs mostly in the axillary lymphatic nodes, but may often be detected in the neck above the clavicle. When the skin is involved there is a tendency toward ulceration and fungoid condition. This is preceded by the purplish appearance of the tense skin. (See Plate XXVII.)

Fig. 93

“Pig-skin” appearance of cancerous breast.

Pain is an uncertain and variable feature. It is important to emphasize this fact, as many of these conditions have been lightly regarded because of freedom from pain. Pain is not a constant phenomenon in cancer. On the other hand, it is sometimes intense, either localized or radiating and referred to distant points. Pain is particularly noticed in cases which assume the form of cancer en cuirasse. Secondary deposits in viscera frequently occur, particularly in the abdominal organs and the lungs; but any organ may be the seat of secondary infection, and this is found occasionally in the bone-marrow, not alone of the sternum or ribs, but of distant bones, and is called marrow injection. As the result of cancerous affection of serous membranes effusions of fluid frequently take place, as in the pleura, peritoneum, and pericardium, and this fluid is often blood-stained.

In consequence of pressure upon the venous trunks in the axilla there is often a swelling of the arm upon the affected side, dropsical in character, known as lymphatic edema. The arm grows heavy, the patient loses control of it, and the skin may become so distended by effusion as to cause the limb to resemble a cast. This is due not alone to pressure upon the veins but to involvement of the lymphatics, and upon careful examination positive dilatation of the lymphatic vessels may be noted. Pain is a usual accompaniment of this form of edema.

2. Duct Carcinoma.

—This appears especially about the time of the menopause, when glandular structure has disappeared and only ducts remain. It is common, without reference to cancer in these instances, to find cystic dilatation of numerous ducts, which vary in size from a mustard seed to that of a cherry. These are referred to by Sutton and others as involution cysts. They are filled with mucoid material and have a bluish tint. They occur usually upon the under surface of the gland. Such cystic breasts are common, and when appearing in diffused form may be easily mistaken for cancer. Pain is not frequent. This condition is certainly a precancerous stage, since the dilated ducts are often the starting points of cancer, and occasionally of papillomatous or villous outgrowths from their walls.

Duct cancer implies the form which arises in these dilated ducts, most commonly in the terminal branches, appearing ordinarily as a single tumor, but sometimes as a mass of separate nodules. Intracystic and intracanalicular growths of this character are often found. When assuming the truly cancerous phases they may be spoken of as duct cancers, otherwise as duct papillomas. They have generally been referred to as intracanalicular fibromas. Duct cancers are less tense than the preceding variety, and when situated near the surface often discolor the skin. It is from these cases that there is seen a more or less abundant discharge of fluid resembling bloody milk. These tumors grow slowly, lymphatic involvement is late, and in general they present the least malignant forms of breast cancer.

PLATE XXVII

FIG. 1

Scirrhus Carcinoma of Breast. (Middle power.)

FIG. 2

Soft Infiltration Carcinoma of Breast, showing Stroma. (Mallory’s connective-tissue stain.)

Carcinoma of sebaceous glands is by all means most common in those specialized glands named after Tyson, occurring about the prepuce. They give rise to the usual forms of cancer in this locality.

Carcinoma in the prostate is not common, and is usually confined to old men. Infiltration proceeds around the base of the bladder at the same time and binds the pelvic viscera together. The pelvic lymphatics become early infected and dissemination is frequent. (See Prostatic Hypertrophy.)

Fig. 94

Recurring carcinoma of male breast. (Original.)

Carcinoma in the salivary glands is not common; it is more frequent in the parotid region, occurring at middle life, growing rapidly, infiltrating surrounding parts, and tending to ulceration.

Carcinoma of the liver varies in its arrangement and appearance. Sometimes it appears in the form of nodules; at other times, as a more diffuse malignant infiltration by cells relatively abundant in number, so that the clinical aspects of the case conform rather to the encephaloid or medullary type.

Carcinoma of the kidney was formerly described as encephaloid, meaning thereby simply a malignant tumor of soft structure. It is probable that a large proportion of these tumors were sarcomas. Nevertheless, true carcinoma of the kidney is possible.

Carcinoma of the ovary may originate as such, or be the result of a transformation from an ovarian cystoma (see above). No better illustration can be offered of the infectivity of cancer cells (be the secret of this infectivity what it may) than the rapid dissemination of cancer throughout the peritoneal cavity, which sometimes follows the removal of an apparently non-malignant tumor which is undergoing this change.

On the other hand, in the testicle such tumors are common—more so than sarcomas. It is likely that many of them arise from the paradidymis.

Carcinoma of the stomach is a frequent disease. It involves the tubular glands, especially in the pyloric region, and conforms to them in type. After involving the mucosa it spreads to the entire coats of the stomach and infiltrates adjacent structures, while the mesenteric lymphatics are usually early and notably involved. Were it possible to recognize this involvement early in the course of the disease diagnosis of pyloric cancer and operative interference would be much more common and hopeful. Secondary involvement is generally in the adjoining viscera, but may be seen at a distance. Miliary carcinosis has been noted after pyloric cancer. This form usually occurs between the fortieth and sixtieth years of life, the duration of the disease not being long.

In the intestine, and particularly in the rectum, carcinoma proceeds also from the mucous glands, and tends constantly to extend at its periphery and involve the entire lumen of the bowel. It seems to be inseparable from a tendency to contraction of the gut and consequent annular stricture. Ulceration, favored by surface irritation and infection, occurs almost always early. Above the rectum it usually occurs in the neighborhood of the sigmoid flexure. Cripps has observed that when cancer of the rectum spreads downward and involves the anus, it loses its typical glandular character and assumes the type of epithelioma, or squamous-cell cancer. In these cases the pelvic and mesenteric lymphatics are infiltrated and metastatic affections are common.

Carcinoma may appear in any portion of the uterus, but is more common in the lower than in the upper half. It assumes the type of the cervical glands, spreads rapidly, infiltrates widely, ulcerates early, and disseminates frequently. By extension of ulceration the formation of urinary and of fecal fistulæ is common. Pyosalpinx and hydrosalpinx are also favored, while the spread of the disease is, in fact, more common when it involves the cervix than when it involves the uterine fundus.

Malignant Chorion Epithelioma.

—This has also been called deciduoma malignum, a malignant growth of chorionic epithelium. Inasmuch as this tumor also includes a syncytial layer it has been known as syncytioma. Such tumors usually contain elements derived from both layers of the chorion. They follow pregnancy, generally within a few months, and are often preceded or accompanied by a hydatidiform mole. This growth constitutes a malignant neoplasm. It pertains to ulcerating uterine growths characterized by early extensive metastasis, which prove fatal. It has been shown that similar growths occur not only in the uterus but also in the testicle, and thus the scope of the term has been much enlarged. In its biology it resembles the sarcoma; in its histology, the carcinoma. It is more malignant than any other known growth. (See Plate XXVIII.)

Occurring within the uterus its most important clinical feature is a tendency to frequent and alarming hemorrhage. When occurring about the testicle this trouble rapidly becomes fungoid, bleeding easily and excessively, the lungs being among the first organs to show metastasis, which takes place through the blood as well as the lymphatic vessels, for the cells of these growths seem to penetrate the capillaries. By the time a diagnosis is made a case is likely to be too far advanced to admit of radical treatment. If scrapings could be examined early, shreds of syncytioma would be found, and it might be possible that a complete hysterectomy would be of use.

Metastatic nodules consist mostly of round, dark masses presenting a more or less pronounced fibrous structure. These are generally found in the lungs and cerebrum, where the vessels are large and the tissues soft. There is usually a sharp contrast between such a tumor and the surrounding tissues. The time which elapses between delivery and the appearance of the growth is from three to ten weeks. The tumor rapidly spreads to the upper portion of the vagina. The trouble probably begins some time before delivery.

The latest tendency among pathologists is to refer a growth of this kind to the teratomas. In women this tumor is particularly a teratoid growth, some cells of the fecundated ovum giving rise to neoplasms, while the ovum itself thus derived may misdevelop into a hydatidiform mole. The tumor may be properly regarded as consisting in effect of fetal cells; it is built up of these cells, without bloodvessels and connective tissue, and so belongs to a class by itself. Occurring in women it is almost always a consequence of pregnancy; occurring in the testicle or in the ovary it should be regarded as proceeding from ectodermal cells. For their treatment the earliest and most radical measures only will suffice.

Suprarenal Epithelioma; Hypernephroma.

—Grawitz has distinctly established the right of these tumors to separate consideration, for he first determined their origin and identity. Hypernephroma is a tumor, found mainly in the kidney, composed of adrenal rests, or bits of accessory suprarenal tissue imprisoned within the renal capsule. Their minute structure is often that of the adrenals, with a tendency toward the type of perithelioma. They have hitherto been considered examples of sarcoma of the kidney, but are to be abruptly distinguished from it in most instances. Tumors of this character have also been found within the capsule of the liver and along the spermatic artery. In the kidney the tumor portion is usually distinct from the renal tissue; it is often enclosed within a sort of capsule, and rarely connects with the pelvis. Hence, though exceedingly liable to hemorrhages, blood rarely escapes by the ureter. Hypernephroma is delicate in structure, and its vessels give way readily. After this has happened a true hematoma may result. (See Plate XXVIII.)

Similar neoplasms form in the adrenals themselves. These tumors vary in degree of malignancy, some of them scarcely deserving the designation malignant. They may be met at any age, but are more common in adult life. Before removal they are not to be differentiated from other tumors of the kidney. Their cells manifest this peculiarity in that they contain a notable percentage of glycogen. It should also be added that even in true sarcoma of the kidney proliferating adrenal elements may be found.

PLATE XXVIII

FIG. 1

Hypernephroma Renalis. (Medium magnification.)

FIG. 2

Chorion Epithelioma.

GENERAL DIAGNOSTIC FEATURES OF MALIGNANT GROWTHS.

The following tables are here inserted, trusting that they may aid the young practitioner in distinguishing in a general way between benign and malignant tumors, and even in making a diagnosis between sarcoma and carcinoma. I have also inserted a table differentiating the clinical appearances of epithelioma and of lupus. In these tables comprehensiveness has not been aimed at, rather simplicity, while it is not denied that cases are met with in which diagnosis may be exceedingly difficult, and in which the common signs herein mentioned may be found either absent or misleading:

Table I.—Differentiation between Benign and Malignant Growths.

Table II.—Diagnosis between Sarcoma and Carcinoma.

Differential diagnosis between epithelioma and ulcerating gumma will be found in Chapter X.

Table III.—Diagnosis between Epithelioma and Tuberculosis (Lupus).

GENERAL CONSIDERATIONS CONCERNING CANCER.

Cancer is one of the most fatal of diseases, yet has no symptomatology of its own. It produces no symptoms which may not be produced by other affections, and this lack of pathognomonic features constitutes one of the great difficulties in diagnosis. It may disturb every function of the part involved. Experimenters have sought in vain for a distinctive feature by which the disease can be recognized; neither in the blood nor in the various organic tissues have such changes been found that can be explained only on the hypothesis of cancer. The pain which it is supposed to cause is often lacking, and is extremely variable and uncertain. The cachexia of its terminal stages is not characteristic, no matter how pronounced, and may be explained by a variety of conditions, all of which may accompany the disease. The search for the suspected parasites cannot be made with such certainty as to lead to any definite conclusions. It is known by a complex of clinical conditions or by microscopic sections of tissues already removed.

When the disease is superficial it is easily recognized, but when deep-seated, recognition comes later.[15]

[15] Since the discovery of Spirochæta pallida in syphilis, Mulzer and Loewenthal have found spiral organisms on the surface of ulcerating tumors. Borrel also found spirochætæ in conjunction with helminthia in two enclosed mouse tumors, and also in a large tumor sent from Ehrlich’s laboratory. None of these authors attributed any significance to the presence of these organisms, but recently, through the publication of Gaylord, in the Journal of Infectious Diseases, who has found a characteristic small spiral organism in nine out of ten primary mouse tumors, and in all of the transplanted mouse tumors of three distinct strains in the New York State Cancer Laboratory, the subject has attracted new interest.

Fig. 95

Rat with primary cystosarcoma of thyroid; cage infection in previously healthy animal kept in cage formerly occupied by rat with same condition. (Gaylord and Clowes, Jour. Amer. Med. Assoc., January 5, 1907.)

Fig. 96

Rat with tumor produced by transplantation from that represented in Fig. 95. (Gaylord and Clowes, loc. cit.)

Gaylord’s organism is best demonstrated by the Levaditi silver method, but can be seen by experienced observers in the living fresh state. It measures from 2.5 to 7.8 microns in length, and the individuals have from four to thirteen closely packed abrupt turns. The organism measures 0.6 micron in diameter. Thus far it has been impossible to stain it with any of the aniline stains, which characteristic appears to distinguish it from the organism described by Borrel and Loewenthal. Calkins has also found this organism in a spontaneous mouse tumor in New York. The distribution of the organism in the growing periphery of the tumors, when considered in the light of Fischer’s work with Scarlet-R, would make it appear not impossible that the organism bears an etiological relation to the tumors in which it occurs.

In the light of the well-authenticated cases of cage infection and the evidence of immunity now definitely determined, the way should be prepared for the discovery of the organism or organisms of cancer. At present this organism would appear strongly in evidence as its cause.

The microscopic picture may explain considerable in regard to the future as well as the past. For instance, in a case of sarcoma the presence of small, round cells, and especially of pigment, bespeaks a degree of malignancy which probably nothing yet known can baffle. A chemical examination of the tumor after removal may make the surgeon alert regarding the future of the case, according to the amount of glycogen contained within the mass, since the glycogen content is in direct proportion to its malignancy. For a while some reliance was placed upon the percentage of urea elimination, but this is influenced by so many factors as to have proved unreliable.

The relations which cancer bears to other diseases are of considerable interest. Those between cancer and trauma have been discussed; tuberculosis perhaps is the condition which, next to pure local irritation, predisposes to cancerous invasion. The transformation of tuberculous into cancerous lesions can be best appreciated where it can be most readily inspected, i. e., on the skin, and it is well known that lupus lesions frequently undergo this change. This is also true of large ulcers, which may undergo a direct transformation into epithelioma, or pass through the intermediate stage of tuberculous infection. Cancer in tuberculous lymph nodes is also a matter of interest. Again, cancers and tuberculous lesions may exist side by side in the same organ, as in the lung or the brain. Distinct sarcomatous nodules have been found in infiltrated lungs and alongside of tuberculous cavities, while cancer of the face will not infrequently be found associated with tuberculosis of the cervical lymphatics. Lubarsch has claimed that 4 to 5 per cent. of tuberculous patients suffer also from cancer, and that about 20 per cent. of cancer patients suffer from tuberculosis.

The method of death in cancerous patients is as free from distinctive characteristics as the course of the disease. It is usually associated with two prominent features, malnutrition and some terminal infection. At the last there is usually some toxemia, which renders the closing hours free from actual pain, while if the toxemia be profound patients may linger unconscious for several days.

GENERAL REMARKS ON THE TREATMENT OF CANCER.

Accepting the views expressed when discussing the nature of the cancerous process, the following may be assumed to be true: Cancer begins as a local disease. There is therefore a period in its history when if it be recognized in time, if it be or can be made accessible, and if it be thoroughly removed, it can be frequently cured. The “ifs” in the foregoing statement afford such insuperable obstacles in so many cases that the difficulties in the way of treatment are very great. It has been said that, “The resources of surgery are rarely successful when practised upon the dying.” It happens too often that these cases are not submitted to the surgeon until long after the favorable period above indicated is past. This is explained by the difficulties of diagnosis, by the inaccessibility of many primary cancers, and by the unwillingness of patients to submit to the knife. Nevertheless the best time to treat a cancer is when its existence is first suspected, and the best way is the most radical, i. e., by thorough extirpation.

While such extirpation should include a wide area of apparently healthy tissue and of the entire organ which seems to be involved, for instance, in the case of the liver, this last may be impossible; and yet by removal of a considerable area of healthy liver around a cancerous gall-bladder the writer has seen complete and apparent final recovery follow. The principal direction is to be thorough.

That cancer so often returns after operative attack is largely due to the fact that the general practitioner, under whose observation most of these cases first come, is slow to recognize the malady, and timid to advise radical methods.

It has been recognized that in cancer the internal administration of arsenic has been beneficial. In order to obtain the best results from its use, it must be pushed to the physiological limit and in preparations of the most active and reliable kind.[16]

Treatment by Toxins of Erysipelas.

—A number of years ago Fehleisen, calling attention to the fact that cancers had seemed to improve or possibly even disappear after an attack of erysipelas, suggested deliberate infection of the surface of such a growth from a case of erysipelas. In this procedure he met with some success, but there were numerous objections to it, one being the impossibility of controlling the spread of the infection thus produced. Coley, of New York, then undertook a much more systematic study of the relation between the two diseases, and devised a method of injecting the toxins produced by the streptococci of erysipelas and of reinforcing them, if necessary, by those of the bacillus prodigiosus. The intent of this treatment is to produce reasonable reaction in the hope of mitigating the rapidity of the growth, checking its progress, or even causing its disappearance. It has been on trial now for several years, and while in a few cases of sarcoma, especially in the hands of its originator, the treatment has apparently been of service, it has proved disappointing in the majority of instances.

Liquid Air.

—The application of liquid air to superficial malignant growths has proved successful in a number of instances, but inasmuch as this is practicable in only one or two of the largest cities of the country, it is not a measure which need be discussed here at length. The liquid seems to act as an almost painless escharotic, and its use produces sloughing, or a drying up under a scab, which after a day or two will loosen and be easily detached.

Radium.

—This remarkable element has aroused within the past few years an amount of scientific interest and experimentation with which there is little else to compare. The enormous expense of a preparation of any great activity, and the rather bewildering contradictory statements which have been made by those who use the weaker preparations, have caused it to occupy a doubtful position in any list of reliable therapeutic agencies. It is undeniable that certain rodent ulcers, tuberculous lesions of the skin, and a few carcinomatous lesions have been much improved or apparently cured by its use. It is ordinarily used in glass or aluminum tubes or capsules, which are applied upon the surface of the growth to be treated. It has also been used sprinkled upon a plaster whose surface has been prepared with Canada balsam, and thus directly applied. Again, it has been enclosed in a capsule to which a strong silk thread has been fastened so that the former may be swallowed, retained in the stomach for a few hours, and then withdrawn. These last means of using it are of questionable value. Of still less value are the suggestions to dissolve it in water or to administer water in which a receptacle containing radium has been allowed to stand. There is much of interest and perhaps something of value in radiotherapy, but nothing as yet of positive value in the hands of the profession generally.

Ultraviolet Light

, or, as it is often named after its promoter, Finsen light, has proved of value in many cases of lupus, and in some cases of superficial epithelioma. Its effects, however, can scarcely be made to penetrate into the deeper tissues, and in its use it is even necessary to make pressure upon the part treated with quartz compressors, because ordinary glass shuts out a great proportion of these rays from whatever source may produce them, and because it is necessary to create a temporary anemia of the lesions, as the fluids of the body have the same effect as does glass. For these reasons the method, which is of but limited value, can be made serviceable in but a small proportion of cases.

X-ray Therapy.

—The Röntgen or cathode rays have played a large part during the last few years in the therapy of cancer. Such varying statements have been made concerning their value as to keep them still on trial and nothing very positive can be said regarding their efficacy. It may be said, however, that the nearer the malignant growth is to the surface of the body the more promptly can their effects be produced. The superficial growths, especially of the epitheliomatous variety, often yield readily to their use; the deeper the lesion the more vague the effect, both in character and permanence. It has been the writer’s experience that they furnish the best method of relieving pain, in a large number of these growths, short of the anodyne effects produced by powerful drugs, which are in every other respect undesirable. He holds that no one can predicate with certainty what may be their effect in any given instance, but that they are worthy a trial in every inoperable, painful, or otherwise hopeless case. Occasionally improvement follows their use, while in the next, apparently a similar case, one may be doomed to great disappointment. There are as yet no indications by which the cases which are most amenable can be easily recognized. Even in cases of extensive and disseminated abdominal cancer marvellous improvement may follow, but never a cure. It is indeed questionable whether deep cancer can ever be really cured by these means. As against their undoubted and unchallenged value in some instances, certain disadvantages are met in the difficulty of selecting a proper vacuum tube, the frequency and duration of exposure, the distance, etc. Dermatitis, sometimes mild, sometimes severe, has too often followed the injudicious use especially of a “high” tube, and more painful, irritable, or intractable ulcers are seldom seen than some following so-called “x-ray burns” of the skin. Moreover this is not the worst of these cases, for efforts intended for the best have been in repeated instances turned into a travesty by the development on surfaces thus burned of epithelioma, necessitating later mutilating operation. A well-known American surgeon suffered amputation of one hand and nearly all of the other as a penalty for inattention to the destructive effects of too prolonged exposure of his hands. It has, therefore, impressed itself upon the writer that the x-rays should not be indiscriminately employed. Nevertheless in skilled hands and used with great discretion they can be made a powerful instrument for good in many cases, especially for the relief of pain. They should never be regarded as a substitute for operation if operation be feasible, but they may often be employed to advantage after operating, in serious cases, where there is reason to fear recurrence.

The efficiency of the x-rays is apparently enhanced by the simultaneous administration of thyroid extract; although the explanation for this improvement is not known, it is, however, of enough importance to be borne in mind. The extract should be given in 5-grain doses three or four times a day. All the remarks above made may pertain as well to the employment of cathode rays in non-malignant affections, i. e., tuberculous lesions, neuralgia, etc.

Miscellaneous Measures.

—A large number of suggestions concerning the treatment of cancer have emanated from various sources and from men of widely different views. Beaston, of Glasgow, being impressed by the physiological relationships and sympathies between the ovaries and the mammary glands, has suggested the benefit of the removal of the ovaries in hopeless cases of mammary cancer, holding that the nutrition of the mamma being thus influenced there would be more or less subsidence of pathological activity. He has reported instances in which, apparently, this measure had the desired effect; nevertheless it has not found general favor.

Based upon views concerning the hyperacidity of the blood and tissues in the cancerous condition, it is believed that there is a pronounced indication for the internal use of alkalies; and the hypodermic injection of 5 minims of a 1 per cent. solution of a chemically pure soap has been recommended by Webb, on the theory that it promotes the separation of cholesterin from the living cell. He would increase the dose until 60 minims are given at one time, every other day. A 20 per cent. solution of Chian turpentine, dissolved in sterile oil, has also been recommended to be used in the same way. These are recent suggestions of unknown value.

In the general management of cancer patients, two things should be kept in mind: (1) That they are entitled to relief from suffering in the least harmful way in which it may be offered, and (2) there comes a time in the history of many of these cases when all other considerations may be set aside in favor of comfort and tranquillity. Opium and other “drugs that enslave” have their disadvantages, but these cannot outweigh the benefit which they may confer in the last stages of cancer. The terminal pains of malignant disease should he assuaged at any necessary cost of other considerations.

But while all this is going on elimination must not be neglected. Opiates are peculiarly liable to diminish secretions and peristaltic activity. The skin, the kidneys, and the bowels should be kept active by measures which serve this purpose, and if it be desirable to prolong life, nutrition should be regulated and frequently administered, but it is absolutely necessary to maintain elimination.

The latest suggestion, viz., to treat cancer by injections of pancreatic ferments (trypsin and amylopsin), seems to the writer to be based upon erroneous notions concerning the nature and causation of the disease, and to hold out only specious hope of self-justification.

CHAPTER XXVII. THE SKIN. — DERMATITIS CALORICA. — BURNS AND SCALDS. — FROSTBITE. — DERMATITIS OF RADIO-ACTIVE ORIGIN. — ACUTE INFECTIONS OF THE SKIN. — CHRONIC INFECTIONS OF THE SKIN. — CYSTS OF THE SKIN. — HYPERTROPHIES AND BENIGN TUMORS OF THE SKIN. — SKIN APPENDAGES; HAIR AND NAILS. — TATTOO MARKS.

It is proposed here to treat only of those diseases of the skin which may complicate surgical cases or call for surgical treatment.

Dermatitis may be produced by chemicals, caustics, and various irritants; the former, for instance, by the use of strong antiseptics upon sensitive skins, and the latter as when fecal matter or urine is poured over unprotected skin or allowed to remain in contact with it. Ammoniacal urine will prove irritating, as will also that of diabetes. When carbolic acid was in general use it gave rise to great trouble upon the hands of many surgeons, while iodine, iodoform, and other such remedies, as well as the stronger mercurial preparations, will cause local symptoms similar to those produced by poison ivy.

This may be prevented, when the condition has occurred, by applying soothing lotions or mild astringents, with anodynes, in dry dusting powder or in ointment form. Cocaine in small amounts, or preferably orthoform with menthol, may be employed in either of these ways. When an acid discharge is expected the skin should be protected with an ointment or with collodion or rubber cement; the latter by drying will leave a thin film upon the surface. Thus around a fecal fistula the skin will be irritated and more or less macerated, and should always be thus protected when possible.

Between sixty and seventy drugs are known to produce distinct forms of dermatitis, such as copaiba, cubebs, the various preparations of iodine, bromine, and arsenic, some of the aniline preparations, quinine, etc.; while the various antitoxic serums, especially that of diphtheria, will sometimes produce a skin disturbance. In these cases it is only necessary to recognize the source of the trouble and remove the cause by stopping the drug. Should dermatitis produce such restlessness as to interfere with the physiological rest necessary for a wound or fracture an opiate should be administered.

Dermatitis calorica means the varying degrees of irritation which may be set up by extremes of heat and cold, continuous or alternate, as in so-called chilblains. These are often seen upon the feet, but occur upon the hands and even the face, i. e., in places most exposed and least supplied with blood. The lesion occurs in patches, often with livid discoloration, and causes sensations varying from discomfort to acute pain, almost always aggravated by warmth; while the skin appears inflamed, though to the touch it usually seems cool.

Treatment.

—Chilblains occur most frequently in the anemic and those with uric-acid diathesis, but may be met at any time. The constitutional treatment should not be overlooked. Much pertains to good care of the feet, especially after exposure. After wetting or chilling they should be dried and then rubbed with boric-acid talcum powder, containing 1 or 2 per cent. of menthol; this may be dusted upon the feet, before going outdoors, upon return, and when there is discomfort.

It will often give relief to immerse the feet in warm water containing sufficient tincture of iodine to give it a mahogany color; or the feet may be simply dipped in this and then allowed to dry without using a towel. The use of hydrogen dioxide diluted two or three times has been highly commended. If this proportion of dioxide be added to four or five parts of hot saturated solution of sodium bicarbonate the efficacy of the measure will be much enhanced. In extreme cases frequent use of the following formula will probably give more relief than anything else: Carbolic acid 1 part, ichthyol and tincture calendula each 4 parts, and glycerin 16 parts. With this the skin may be kept constantly moistened.

The expressions of dermatitis produced by heat may vary from an efflorescent rash to complete destruction, and will be treated of under the following head:

The term “burn” is applied to lesions produced by flame or dry heat, while moist heat (i. e., boiling materials or steam) causes injuries known as “scalds.” Between the two there is but little essential difference, except that with the latter there is usually loosening of the hair of the part, and sometimes much loosening of the epidermis as well, so that it is easily detached in more or less large patches. Whether heat is relatively feeble but prolonged, or higher in degree and of shorter duration, the results of dry heat are about the same. Some differences will exist according to whether the part is exposed to actual flame or to hot or melted material, sufficiently hot perhaps to cause complete charring or carbonization of a part.

Fig. 97

Burn by electric current from “live wire” carrying 1200 volts. (Original.)

Similar injuries are produced by concentrated caustics, acids, or alkalies, while such materials as phosphorus or sulphur produce deep burns. The burn produced by lightning is rarely deep, although it may be extensive (Fig. 97). Persons coming in contact with live wires sustain burns which partake much of the nature of the electric discharge, and are sometimes of a character to deserve the term “brush-burn.” Formerly burns were divided by Dupuytren into six or seven degrees, but this classification is too cumbersome and artificial to be acceptable. Morton’s classification is now everywhere accepted, by which they are divided into three degrees: (1) Dermatitis without vesication. (2) Vesication even to the formation of bullæ. (3) Destruction of the skin, with or without that of the deeper parts, which may include actual carbonization of a limb.

Burns may vary within the widest imaginable limits. To an extensive burn of the surface may be added the features produced by inhalation of smoke, steam, or flame; accordingly the eyes and the mucous membrane of the nose and mouth suffer, the parts becoming chemotic and disfigured, so as to make the individual unrecognizable. Burns constitute one of the most painful and distressing injuries known to the surgeon, particularly when the area is large and the case is complicated by injuries which necessitate more or less prolonged rest in bed. When the body is burned completely around it is difficult to ensure rest without the use of anodynes.

Shock is a marked feature of every serious case of burn or scald, and albumin quickly appears in the urine in these cases. Ulceration of the duodenum may follow extensive injuries of this kind, and is occasionally the cause of death. It is to be attributed to a toxic action produced by absorption of putrid material connected with the surface sloughing process. A temporary diabetes is sometimes noted. Laryngitis, bronchitis, and pneumonia may occur from inhalation of steam or smoke, while the inhalation of flame may bring about a rapid edema of the glottis, which may necessitate tracheotomy as an early and emergency measure. It is generally stated that a burn of the second degree, which even involves half of the surface of the body, may prove fatal; while this is not invariably the case, it is too frequently true, and may afford aid in prognosis.

Burns of the second degree are always followed by exudation with formation of blebs, usually within a few hours. In the more serious cases the exudate may be bloody. Burns of the third degree are necessarily followed by more or less gangrene, and this fact affords the reason for the radical treatment recommended.

Treatment.

—By the time the surgeon is called to treat a burn the first indications are usually relief of pain, and perhaps stimulation for shock. The circumstances attending such injury generally leave the patient in an excited mental condition, and for several obvious reasons it would be well to use sufficient anodyne to tranquillize and give comfort. An excellent application in emergency cases is a saturated solution of sodium bicarbonate, or it may be dusted over the affected surface.

The unpleasant visceral complications that follow burns are due to absorption of decomposing fluids or tissues, so retained or so in contact with readily absorbing surfaces as to produce a more or less violent degree of toxemia. In this way are to be explained delirium, convulsions, or coma, as well as the ulcerative and toxic intestinal symptoms which constitute the distressing complications.[17] For this reason the radical method of prevention is the best; hence whenever there is any prospect of sloughing, or when even the epidermis is so burned as to make it appear that it will soon separate, the best method of treatment is to anesthetize the patient and then with a stiff brush and antiseptic soap scrub the part and remove everything that is at all loose, if necessary even using a wire brush, scissors, or a razor. Beneath every sloughing area toxic absorption will go on, and it will be far better to have fresh raw and bleeding surfaces than those which cover sources of danger; the resultant scar will not be any greater, while the subsequent course of the case will be favorably influenced. Exquisitely tender surfaces thus have their sensibility blunted, and the comfort of the patient is greatly enhanced by thorough cleansing and sterilization; moreover, dressings will not need to be so frequently changed. A soothing, antiseptic ointment should be applied; there are few better than the ordinary ointment of zinc oxide, to which may be added bismuth subnitrate and orthoform.[18] Treatment of this kind would probably not need to be repeated, and the duration of the trouble would be reduced to one-quarter or one-third of the time which would otherwise be required. When actual carbonization has occurred amputation is generally necessary. Diluted solutions of ichthyol have proved satisfactory, and the dressings should be covered with some impermeable material, so as to exclude the air. Another advantage is that the amount of subsequent discharge is limited, and thus there is less need for frequent change of dressings. In extreme cases there is no method which gives so much comfort and certainty as continuous immersion in warm water; to this may be added common salt or some other antiseptic, but the water alone is sufficient, if changed frequently. In burns covering a great part of the body this treatment is the most serviceable. It should be employed until the sloughs have separated and surfaces are granulating and ready for skin grafting. This implies, of course, immersion of the entire body in a bath-tub, the body lying on a sheet fastened to the sides of the tub. The advantage of brewers’ yeast dressing, when sloughs are present, has been previously emphasized in the chapter on Ulcers and Ulceration.

The disfigurement caused by a superficial burn will fade after a few months. In cases where the skin has sloughed there is a tendency to cicatricial contraction as soon as granulations begin to form, and the tendency then is to the formation of disfiguring scars. About the limbs the flexor muscles will always overcome the extensors, and bridle-like deformities will be formed at flexures of the joints. These are to be prevented so far as possible by two measures—proper splinting and early skin grafting. About the face splints cannot be used, but one of the grafting methods should be used.

Fig. 98

Epithelioma following ulcer due to burn. (Lexer.)

A tendency in the scars of old burns is to formation of keloid (see below) and epithelioma. The writer has seen epitheliomatous ulcers covering at least an area of a square foot, which had formed upon the sites of burns received years previously. In one case of this kind it was necessary to remove the entire upper extremity; even then the disease recurred and finally destroyed the patient (Fig. 98).

Burns produced by caustic acids or alkalies call for appropriate chemical antidotes at first and later essentially the same treatment as that already mentioned. In cases of severe burn there is danger of neglecting the ordinary rules of general treatment, which consist in maintaining elimination and nutrition.

Effects similar to those produced by heat are caused also by cold, varying from a superficial dermatitis with its surface irritation, its possible vesication, and, later, desquamation, to complete freezing of an extremity or a part (e. g., the nose, or the ear), which may be followed by gangrene. Portions which are not frozen beyond the point of restoration of vitality undergo a marked reaction and become swollen and discolored, save in rare instances where they shrivel. Gangrene is not so immediate a process as in a severe burn, as it takes a number of hours, sometimes days, for the establishment of the so-called line of demarcation, by which the dead tissue is separated from the living. On one side of this line putrefaction goes on rapidly, as in moist gangrene from any cause; on the other side there is active circulatory disturbance, with phagocytosis, by which the line becomes more marked; no portion of tissue on the distal side of this dead line can be saved. The location of the lesion and the exigencies of the case will indicate where amputation should be made. (See chapter on Gangrene.)

Treatment.

—A rapid restoration of warmth to the part is most undesirable. The thawing-out process in a case of severe freezing should be begun in cold or ice-cold water. Crude petroleum at a temperature of 60° F. has been recommended as a substitute for cold water, and immersion may be continuous for several hours. A rubbing with alcohol and water may be substituted for the cold water, and then a gradual restoration to the ordinary temperature of the air. Unless this treatment be skilfully managed there may be such a rapid reaction as to be painful and even injurious. By the time there is any active exudation, or putrefaction has begun, an absorbent dry dressing and suitable antiseptics may be used.

The common expression of this form of skin affection is called a burn. This is something more than its name implies, for it is understood that the active factors are the ultraviolet rays, or the rays beyond the color region of the spectrum; that it is not due to the heat rays is shown by the intense burning that is frequently seen in the Arctic regions. In the skin of the young and tender, sunburn is sometimes followed by vesication and desquamation; ordinarily it simply produces the latter. Any soothing ointment or solution is usually sufficient for the treatment of sunburn, which should, however, include avoidance of the exciting cause.

Fig. 99

“X-ray burn,” result of nine exposures in nine days. Extensive necrosis and sloughing, with an intractable ulcer. (From collection of Dr. G. W. Wende.)

Much more intense actinic effects are produced by the x-rays, leading sometimes to complete destruction of the skin. These phenomena are usually called x-ray dermatitis. They vary from local discomfort, with itching, loss of hair on hairy surfaces, and partial anesthesia, with later a glossy appearance, to edema of the cellular tissue, by which anatomical outlines are effaced. The natural color of the skin, owing to pigmentation, appears dark. If the exciting cause be stopped before or as soon as this stage is reached complete recovery is possible, save that hair does not always grow from the surface which has lost it. The x-ray treatment should be pushed up to this stage. Careful management is now necessary, especially should any surface irritation like chafing occur. That x-ray burn, so called, may result from x-ray exposure made some time previously seems to be established by a case reported to me by Dr. L. L. McArthur, of Chicago, where he had to do skin grafting upon a lesion of this kind which did not appear until fifteen months after the last exposure.

The stage of danger is characterized by extreme itching with multiform eruptions in successive crops, desquamation, formation of minute vesicles, and ulcers; or the process may be more acute and the skin begin to slough. Small lesions will become confluent, and large excavations may be formed. The sloughing process is usually slow, and by it are produced ulcers characterized by extreme pain and discomfort and a lack of tendency to heal.

These ulcers are exquisitely sensitive and applications intended for relief are of themselves most distressing. Everything about such an ulcer seems sluggish, while small areas which have apparently healed break down again; healthy scabs are not formed and granulations are extremely indolent.

Treatment.

—In the treatment of these lesions, so long as they are mild, the surgeon should confine himself to soothing applications and rest; at the same time discontinuance of x-ray exposures and even avoidance of light seem to be essential. Any operator threatened with such trouble should wear thick rubber gloves during all his work. The local treatment of this lesion is not essentially different from that described in the chapter on Ulcers and Ulceration, but the surfaces are often so erethistic as to demand either anodyne applications, containing such remedies as orthoform, anesthesin, or even cocaine, or else they need radical treatment with a sharp spoon.

Sloughing surfaces should be treated with brewers’ yeast until the surface has become healthy. Picric acid in solution has been recommended, a saturated solution being diluted seven or eight times before using.

The writer has rarely seen any more distressing or obstinate lesions than presented in some of these cases. In speaking of epithelioma it has been stated that some of these ulcers are prone to thus degenerate. It seems an extreme contradiction in physics that the agent used so frequently in the treatment of superficial cancers should, when used to excess, produce lesions which themselves become cancerous. It has been the writer’s privilege to witness amputation of all of one hand and a large part of the other, in the case of a well-known colleague, who carried the x-ray treatment to excess, and until he suffered to this extent. Careful and discriminating judgment is therefore necessary in the management of vacuum tubes.

Since radium has come into use it has been found to exercise a deleterious effect upon the skin. The radium emanations are known to influence living cells and tissues, and their inhibiting effect upon the growth of larvae has been well established. The prohibitive price of radium preparations will make these lesions rare. After exposure there appears an erythema followed by an active dermatitis, which so closely resembles lesions above described, in their early stages, that one description will suffice for both. Moreover, the treatment of a radium burn differs in no essential respects from that of an x-ray burn.

Furuncle or Boil.

—A furuncle is a phlegmon having its origin in a hair follicle and involving a small area of skin and subcutaneous tissue. The infection is produced by one of the ordinary pyogenic organisms, which have easy access to the base of the follicles. Sometimes these organisms are of unusual virulence, but ordinarily there is a local condition which favors the infection, while it may be encouraged by a general diathetic condition, such as diabetes. The lesion is usually single, but may be multiple. Boils appear sometimes in groups or in crops, and when the condition has become chronic it is called furunculosis, which may be local or general. A boil commences as a tender papule, which rapidly enlarges into a conical swelling, sometimes of considerable size. Around it there is an area of dusky discoloration, while the apex becomes quite dark. Pus, travelling in the direction of least resistance, comes more or less readily to the surface, the apex of the boil yielding and pus finally escaping, if not evacuated by incision, usually with a small amount of necrotic tissue, which may be sufficiently large to justify the term “core.” With the escape of pus the throbbing pain is much relieved. A furuncle arising in tissues where swelling is not easily treated, as in the nose, the external meatus, and also in the axilla and the perineum, will produce an abnormal amount of pain.

Treatment.

—The domestic treatment of boils consists of poultices, usually made of hot flaxseed. These are always nauseous applications, and tend to favor the development of similar trouble in adjoining follicles. An equally comforting application can be made with a piece of spongiopiline, or a compress, saturated in an antiseptic solution, and covered with rubber tissues, outside of which, if necessary, a hot-water bottle may be applied. Inasmuch as it is tension which produces pain, early incision, which can be made under a little freezing spray, or with cocaine, will give the greatest relief. This may be practised even before pus has appeared. After such incisions the same moist applications may be applied. Incisions should be made as soon as pus is shown to be present. The appearance of a whitish point at the apex of the furuncle will always indicate the presence of pus beneath.

General furunculosis has almost always an underlying diathesis as a cause, and this should be sought out and treated according to its nature. In the absence of recognized constitutional conditions the writer has never found anything equal to aromatic sulphuric acid, given in 10 or 12-drop doses, with tincture of arnica in teaspoonful doses, to be freely diluted with water.

Carbuncle.

—This differs from a furuncle in the extent of the local infection, involvement of subcutaneous tissue, and the amount of necrosis which it produces. It is in most instances a more serious affair, life often being destroyed by the extent of the resulting necrosis and the amount of toxins produced. It begins as a local process, but always with constitutional disturbance, and sometimes even with a chill. The affected surface rapidly assumes a brawny hardness, and the infiltration is often extensive; pain is severe and throbbing; the surface becomes more dusky in appearance, numerous pustules appear, development of all the features of a serious carbuncle usually taking place in a few days. Later it begins to soften and the skin gives way at several points, at each of which a small drop of pus is discharged, while after removing this there may be seen white necrotic tissue beneath. The sloughing process extends deeply, generally to the deep fascia, and this itself occasionally succumbs. A person may have a distinct carbuncular lesion where the area primarily involved is not much larger than that of a five-cent piece; on the other hand, in debilitated or dissipated subjects, a lesion of this kind may become as large as a dinner plate, while the sloughing process may expose the underlying bone. This is often the case on the back of the neck and trunk. A carbuncle may occur in any part of the body, but is usually seen on the back; when upon a limb it generally involves the extensor surface. It is especially serious and dangerous when occurring upon the face, as septic thrombosis may readily extend to a cranial sinus and rapidly kill. It was formerly believed that carbuncles of the lip always terminated fatally; while this is not necessarily true it will indicate the seriousness of the condition (Figs. 100 and 101).

Fig. 100

Carbuncle of the neck. (Lexer.)

Treatment.

—There are few lesions where both constitutional and local treatment need to be more judiciously combined. Many of these patients are diabetic, and then it assumes malignant tendencies. Others are syphilitics or alcoholics, whom dissipation has reduced to a condition of serious malnutrition. The urine should always be examined for sugar and albumin, and whatever indications it may afford carefully followed. Septic intoxication and infection may so rapidly depress the already weakened patient as to call for stimulants and tonics, and pain may be so severe as to justify the use of anodynes.

The local treatment should consist of soothing applications until the extent of the plastic exudate has declared itself, after which it should be more radical. It is better, therefore, to excise under an anesthetic, the area which ordinarily would require days or weeks to slough. The most satisfactory treatment is the radical. The knife, the scissors, and the sharp spoon constitute the best means of combating this disease. In other respects the treatment was discussed when dealing with septic infection. Nothing will so hasten the sloughing and cleaning up process as brewers’ yeast. The writer’s custom is to make a thorough excision of the affected area and treat the part with yeast for some days. About the lip and face the sharp spoon should take the place of the knife, but even there, if the case be attacked early, tissue can be saved and disfigurement reduced to a minimum. The method used by some of injecting 5 per cent. carbolic solution is less satisfactory, although the measure above recommended is a rather severe operation and usually requires complete anesthesia.

Fig. 101

Anthrax carbuncle of forearm. (Lexer.)

Tuberculosis.

—Most of the skin lesions formerly described as scrofulous are now known to be expressions of tuberculosis. So, also, are some of the papillomatous growths and the chronic ulcers, which do not assume distinctive form.

Lupus vulgaris is perhaps the most common of these cutaneous lesions, especially in certain parts of the world. It is seen more often among the young than the old. The lesions begin with a papule, which becomes the well-known lupus, smaller nodules coalescing and forming eventually a brownish-red patch, whose borders are somewhat elevated and scaly. This lesion usually goes on to ulceration, particularly in those parts of the body where it is kept moist or frequently irritated. It is in these lesions that a healing or cicatrizing tendency is seen at one point and progressive ulceration in another. Ulceration does not always occur, but the papule just described sometimes undergoes spontaneous absorption, the tissue atrophying, losing its peculiar skin functions, and the scar being depressed and scaly.

Lupus vulgaris is to be distinguished from lupus exedens, referred to under Epithelioma. It is often mistaken for the latter, and a differential diagnostic table has already been given. (See p. 293.)

Verruca necrogenica, as it used to be called, is now known as verrucose tuberculosis. It consists of cutaneous warts, surrounded by an erythematous zone or patch, which tend to break down, and covered with scabs, intermixed with pustules. The lesion rarely proceeds to complete ulceration. It occurs especially upon the hands and exposed parts of those who handle cadavers or carcasses. The lesion is usually slow and sometimes disappears spontaneously.

On or about the mucocutaneous borders of individuals suffering from tuberculosis there appear small ulcers, secreting a thin, puruloid material. These are seen especially about the nose, the mouth, the anus, and the vulva. These lesions should be regarded as local infections from a constitutional source. They are often sensitive, show little tendency to heal, and are sources of danger to others. They should receive radical treatment.

Under the term scrofuloderm are included a variety of subcutaneous tuberculous nodules which spread and involve the skin. They begin in the superficial lymph nodes. The overlying skin becomes bluish and gives way, while an ulcer remains which discharges more or less puruloid material. The edges of these ulcers are frequently undermined for a considerable distance. These are ordinarily chronic lesions, which sometimes undergo a spontaneous recovery, leaving disfiguring and discolored scars, usually irregular and more or less striped or banded.

Some of the scrofuloderms are included under the erythema induratum of Bazin, lesions which appear mostly on the calves of the legs of young women, consisting of deep-seated nodules, which break down into deep ulcers, having elevated and overhanging edges. Again, there is the so-called lichen scrofulosorum, i. e., a papular eruption seen in the young, especially those who show other evidences of tuberculosis. It consists of rounded groups of papules, usually on the sides of the trunk, at first bright in color, new papules appearing as the old ones fade. In addition there is the pustular scrofuloderm, which crusts over, heals, and leaves small cicatrices.

In all of these lesions the tubercle bacilli can be usually demonstrated. There are other skin lesions in which no bacilli can be demonstrated, which are supposed to be due to the toxins generated in tuberculous foci elsewhere. Hallopeau suggests calling all tuberculous skin lesions tuberculides and to group them as follows: (a) Those in which bacilli are present, bacillary tuberculides, and (b) those arising from tuberculous toxins, toxic tuberculides.

Fig. 102

Lupus of skin (hypertrophicus et exulcerans). Finally healed by excision and plastic operation. (Lexer.)

Fig. 103

Lupus vulgaris. (Hardaway.)

 

Among the latter he describes what he calls folliculitis, i. e., small papules, firm, at first red, then elevated, becoming nodules, appearing on the extremities, and gradually producing crater-form ulcers covered with black crusts, leaving small pock-like scars. This condition is chronic, lasting years. In these patients the skin is furfurated, showing a sluggish circulation.

Treatment.

—Inasmuch as tuberculous skin lesions tend to spread and to recur, they need radical treatment—i. e. the sharp spoon, the scissors, and caustic. Ordinarily it is best to scrape the affected surface, to trim away all unhealthy edges, and then to apply a strong caustic for a brief space of time, thereby sterilizing it and searing the mouths of the absorbents which may have been opened by the scraping. Treatment for two or three days with brewers’ yeast will usually suffice to put the surface in a healthy condition, after which it may be skin-grafted or treated by any of the ordinary plastic methods.

Rhinoscleroma.

—The bacillus of rhinoscleroma was described in the chapter on Inflammation, under the heading Pyogenic Organisms. It is a specific infection, primarily of the skin, which appears invariably upon the nose. It begins either in the skin or mucous membrane, or both, and having once thoroughly invaded the tissues grows in all directions. It shows no tendency to heal, but gives to the tissues a distinctive brawny induration. From the nose it extends to the palate, pharynx, and antrum, making steady encroachment upon the parts which it affects, distorting the features, obstructing respiration, and often causing pain by pressure on the sensory nerves. Its first appearance is characterized by nodules, frequently covered with dilated bloodvessels. Unless it can be seen and recognized early it is a wellnigh hopeless condition with which to contend. Extirpation of the affected tissue is the only satisfactory method of dealing with it. It is a different disease from rhinophyma described elsewhere. (See Figs. 7 and 8, p. 55.)

Mycosis Fungoides.

—This form of skin infection, of somewhat uncertain origin, is met in shape of fungoid nodules, and likely to involve the upper part of the body; they tend to increase in number and size, to infiltrate, often to ulcerate, sometimes to disappear by spontaneous absorption, but in severe cases cause death, either by malnutrition or sepsis. Tumors are thus formed which attain the size of a child’s head. As soon as surface infection or ulceration begins the breaking-down process is rapid; there is early involvement of the lymph nodes, and the general health begins to suffer. The tendency in almost every case is to fatal termination. Cases may run from a few months to fifteen years, however, before this stage is reached. By some authors the disease is considered as a peculiar form of sarcoma. It is, however, generally regarded as a granuloma, whose specific organism has not been ascertained.

Fig. 104

Ulcerating gumma of skin, cicatrizing in certain areas. (Lexer.)

Actinomycosis, Syphilis, Leprosy, and Glanders

should be included among the chronic infections of the skin, and have been described.

Radesyge.

—Radesyge is a granulomatous involvement of the skin, peculiar to certain parts of Europe, particularly Norway, which has been by some considered to be an expression of leprosy, by others to be a disease by itself. It is generally held that the lesions which have passed under this name are really expressions of cutaneous syphilis.

Framboesia; Yaws.

—This is an endemic tropical disease, of which we see our nearest specimens in the West Indies, and involves especially the negro and Oriental races. It begins with an eruption, papules maturing in fungoid form, being met with most often at mucocutaneous borders, but appearing anywhere upon the surface. It is specific and inoculable, having a period of incubation of about two weeks, and becoming generalized in from fifteen to twenty weeks. The papules increase in size, become covered with yellow crusts, which fall off and expose a rough surface which discharges an offensive puruloid material. After remaining in this condition for an indefinite time the lesions spontaneously improve and may disappear, leaving only pigmented spots to mark their previous sites. Beyond local cleanliness and antiseptic applications the lesions require but little treatment. If anything more is attempted it should be thorough and effected with the cautery or the sharp spoon.

Mycetoma.

—Mycetoma is more commonly known as Madura foot, or sometimes the fungus foot of India. It prevails especially in Southern India and about Madras, and is apparently confined to that part of the globe. Nevertheless it has been reported from Algiers and from South America. It is a specific infection of the foot, beginning in the skin; it rarely occurs on the hands, the scrotum, etc. It leads to the formation of an infectious granuloma, which gradually destroys the texture and identity of the tissues, and finally demands amputation or ablation of the part.

Russian bacteriologists have discovered parasites resembling the protozoa which they have found in the granulations and ulcerations of the Delhi boil. They were also occasionally seen in the leukocytes. By these observers these parasites have been regarded as active agents and have been given the name ovoplasma orientale.

Oriental Boil.-This also is a slow infection of the skin, met with especially in Southern India, where it is known as the Biskra button and the Aleppo or Delhi boil.[19] It appears mainly on the unprotected parts of the body at first as a papule and then a nodule, which enlarges, ulcerates, usually tends to heal spontaneously, and leaves an ineffaceable scar. It is practically a granuloma of the skin, is auto-inoculable, and is best treated by complete excision.

Guinea Worm, or Filaria Medinensis.

—This worm is about one line in diameter and two or three feet long, and is found generally throughout the tropics. The embryo is taken into the intestines with drinking water and migrates to the skin, beneath which it develops. The male worm has never been discovered. What is known of the evidence of its presence pertains only to the female. When fully developed it can be felt in a coil beneath the skin. It produces local inflammation, a vesicle forms, and the head of the worm then protrudes. When it is exposed it can be frequently extracted by gentle traction, removing as much each day as protrudes. Christie has suggested to destroy the worm by electrolysis, and others inject into the vesicle some antiseptic, by which the worm is killed, it being afterward absorbed without difficulty (Fig. 105).

Fig. 105

Guinea-worm bleb just cut off. (Bryant.)

Blastomycetic Dermatitis.

—This is a true protozoan infection of the skin, first described by Wernicke in 1892, which has now become quite generally recognized and described. The parasite is a very small, spheroid protozoan, and is found in the skin elements, as well as in the pus and debris discharged from the lesions. It has been successfully cultivated and inoculated. It is classed among the yeast fungi. It produces lesions very much like some of those met with in syphilis, tuberculosis, and mycosis fungoides. Indeed it may be necessary to use the microscope in order to complete the diagnosis, which is best accomplished by teasing a small portion of tissue on the slide in liquor potassæ (Hardaway).

The lesions begin usually as small papules, which may later coalesce and become covered with a fine scab. Around these there develop thickened borders, with fungus-like projections. Between the little elevations pus may form, or an exudate occur in sufficient quantity to dry into a large-sized crust. Here, as in lupus, cicatrization may be going on at interior points while the lesion is encroaching around the margin. The affection is slow, and the ulcer may attain a size of several inches in diameter.

The treatment consists in radical measures, i. e., strong caustics, curetting or complete extirpation with the knife, which may be followed by more or less plastic work, as required.

Coccidioidal Granuloma.

—Under this name is described a rare form of granulomatous lesion of the skin, whose exciting cause is not one of the ordinary bacteria, but a form of mold—one of the varieties of oidium. The clinical manifestations of this lesion resemble those of blastomycetic dermatitis, save that in the latter the primary focus of infection is always found in the skin and remains there localized, whereas coccidioidal granulomas may occur as well in the deeper tissues or viscera as upon the skin; in fact, the skin lesions of the latter may be described as oidiomycosis in distinction from blastomycosis. It produces miliary skin nodules which closely resemble tuberculous lesions, and may even caseate or assume an acute type and break down rapidly. The lesions are progressive, with a tendency to dissemination, both by the lymph and the blood currents. The lymph nodes are usually early affected and often suppurate.

Cysticercus, or Tænia Solium

, may be found in the subcutaneous tissue in the shape of small nodules, covered by unaffected skin. When young these tumors are tense and elastic, but are subject to calcareous changes. They occur frequently on the back.

Echinococcus Cysts

are also found in the skin, where they may attain a size which will make them fluctuate. The treatment for all such lesions is complete eradication.

Trophoneuroses.

Perforating Ulcer of the Foot.

—This has already been alluded to in the chapter on Ulcers and Ulceration. The lesion apparently begins as a thickening or callosity, usually beneath the head of the first metatarsal bone, at a point where much pressure is made, owing to the natural position of the foot. Beneath the thickened skin there develops an adventitious bursa, in which, or in the skin itself, the first degeneration may take place. The result is a deep ulcer, with overhanging borders, and a thin, often foul discharge. The lesion is not painful, and patients are less likely to spare the foot. It is usually associated with some central spinal disease, or with a peripheral neuritis. It is more common in those patients who have had disease leading to loss of sensation in the foot.

The treatment consists in excision of the ulcer down to healthy tissues, with careful protection. Skin grafting is often found successful.

Ainhum.

—Ainhum is essentially a disease of the negro and of tropical climates. It usually begins in the little toe or little finger, and goes on to spontaneous amputation, the result of an anemia caused by the formation of a sclerotic ring, which encircles the digit and shuts off the blood supply. It is an annular scleroderma, or keloid, which produces the disturbance.

The most common cysts of the skin are the sebaceous, known also as steatomas, which result from obstruction of the ducts of sebaceous follicles, and accumulation therein of sebaceous secretion. They are found where these glands abound, and may attain the size of a hen’s egg or larger. They are frequently infected and suppurate, or their contents may undergo slow change and lose their original characteristics by the time they are evacuated. Peculiar changes occur in rare instances, since they may calcify, or their bases serve even for the development of cutaneous horns, while in the other direction they not infrequently undergo malignant degeneration. In some of these cysts a small opening can be found, through which, on pressure, fatty or butter-like contents can be exposed. When their contents begin to putrefy the odor becomes offensive.

Another variety of the skin cyst is the so-called atheromatous, which is more allied to the cutaneous dermoid, and whose contents are often nearly pure cholesterin. Sometimes they contain hair or other epithelial products. They occur usually in the scalp. These are essentially inclusion cysts and purely epiblastic products. When infected their contents putrefy and smell badly. (See Fig. 88, p. 285.)

Treatment.

—The treatment for any cysts of the skin consists in extirpation of the sac. It is sufficient to split them thoroughly with a sharp, curved bistoury, and then, on either side, to seize the edge of the divided sac with forceps and enucleate it. All this can be done under local anesthesia. The cavity should be thoroughly disinfected and not too tightly closed.

Under the name Cock’s peculiar tumor some English writers have alluded to the offensive ulcerated surface, with raised edges, which is left after the contents of these cysts have undergone putrefaction and escaped by breaking down of the surface. Such a lesion is on the border-land between mere ulceration and malignancy.

Corns.

—Clavi, or corns, vary in density. A soft corn differs from a hard one only in that it is located where it is softened by moisture of the parts. A hard corn is a reduplication or callosity, conical in shape, representing great hypertrophy, with condensation of surface epithelium. Beneath old lesions of this kind will frequently be found small cysts, while nerve fibers become entangled, and these little lesions are sometimes exceedingly sensitive. They frequently become inflamed, the process proceeding to suppuration or ulceration.

Bunions.

—When beneath such an indurated area of skin there forms an adventitious bursa, or a natural one becomes involved, the lesion is called a bunion. These are more frequent over the joints of the toes, where they sometimes cause intense discomfort. The bursæ sometimes connect with the joint cavity, and should one suppurate the other necessarily becomes involved. An infection of either of these lesions causes local and possibly fatal disturbance. I have seen death from pyemia follow infection of a bursa beneath a soft corn (Fig. 106).

Fig. 106

Distorted foot, from pressure and bunion. (Erichsen.)

These lesions are not met with among the savage races or those who go barefooted. They are essentially products of the footwear affected in modern society. Were shoes made to fit the natural foot and not to constrain it in abnormal positions, corns and bunions would be practically unknown.

Treatment.

—Preventive treatment is the most important and pertains to properly adapted footwear. Unfortunately the treatment of these minor lesions is too frequently left to charlatans and so-called chiropodists, who may give temporary relief in many instances, but have no knowledge of either the nature of the difficulty or its proper surgical treatment.

Soft corns will usually disappear if the parts can be kept clean and dry. Hard corns are essentially callosities, which should be pared down or trimmed off until the surface is almost ready to bleed. It may then be painted with a collodion containing 20 per cent. of salicylic acid and a little alcohol. If this mixture be applied to the surface of a clean and dry corn it can often be peeled away with the corn after a few days. When it is desirable to soften any callosity of this kind, previous to paring or trimming it, it can be done by applying for a few hours a mixture of equal parts of glycerin and liquor potassæ; this will so soften a callosity as, when applied over night, to make it endurable through the following day.

Bunions are so often associated with hypertrophy of the underlying bone as to entitle them to consideration under deformities of the feet. The most pronounced expressions are usually seen in connection with hallux valgus (q. v.), and their treatment comprises excision of the bunion and its underlying bursal sac, along with exsection of the joint. By this radical local measure complete relief is usually afforded.

Cutaneous Horns.

—These have the consistence of an ordinary nail, are epiblastic products, varying in size, length, color, and shape. They have been alluded to in the chapter on Tumors. Sutton has divided them into sebaceous, which occur most often upon the head and spring from an old sebaceous cyst (see above); warty horns, which much resemble them; cicatricial and nail horns, which are instances of exaggerated growth of the finger-nails.

Treatment.

—A simple excision of the growth with its base is all that is needed in these cases.

Warts; Verrucæ.

—These constitute one variety of papillomas, the overgrowth having its original site in the prickle-cell layer of the rete. The most common form occurs upon young subjects on the exposed parts, as the face, hands, and feet. These are usually multiple; they frequently occur upon the surface, and retain dirt in such a manner as to be nearly always recognizable on the surrounding skin. They frequently disappear with as little known reason as that which caused their appearance.

Dilated papillary growths, like a fringe, are sometimes seen about the face and neck of elderly people. These have been known as filiform warts, while Unna gave them the name fibrokeratomas.

A form described as the seborrheic wart occurs upon the face and elsewhere in elderly people. It is frequently pigmented, may itch intolerably, and is perhaps the form which most often undergoes malignant degeneration. To the acuminate form of wart, which is usually soft, and most often met with as a venereal wart about the genital region, has been given the name condyloma. These appear in either sex, grow rapidly, are covered with a puruloid secretion, bleed easily, and assume often such shape and resemblance as to give rise to expressions “strawberry growth,” “raspberry growth,” etc. They are always produced by irritation, usually in connection with one of the venereal diseases, and are generally due to lack of cleanliness. They may grow luxuriantly and over a considerable area, and, when appearing on the surface of the vulva, conceal completely the parts underneath. They also occur in connection with the mucous patches of tertiary or hereditary syphilis, but have essentially the same structure, no matter how produced.

Treatment.

—In the treatment of ordinary warts nothing is better than absolute cleanliness. A dry wart touched daily with formalin solution, or covered with collodion containing 1 to 2 per cent. of corrosive sublimate, will usually shrink and become detached in a few days. Thorough excision of any true wart is sufficient to finally dispose of it. If the wart be cut through it is likely to bleed profusely, since its vessels are larger than those of the surrounding skin. Any growth of this kind can also be destroyed by the actual cautery, or by one of the strong caustic agents, which, however, should be used with great care.

Venereal warts, condylomas, are best treated radically, either with the actual cautery or with scissors and sharp spoon. Local anesthesia is always advisable in order that this may be thoroughly done. In instances of extensive growths of this kind a general anesthetic may be profitably given.

Molluscum Contagiosum.

—Molluscum contagiosum, sometimes known as epithelial molluscum, is a name applied to small warty growths more or less embedded in the skin, from which, by pressure, some epithelial debris can be forced out. The lesions are rarely single and yet rarely numerous. They may be met upon any part of the body, especially upon exposed portions. They are doubtless results of skin infections by various organisms. The best treatment is excision, although they may be split and cauterized and thus made to shrivel, or the same effect may be produced by electrolysis.

Fig. 107

Keloid occurring in a laparotomy scar. (Lexer.)

Keloid.

—This has already been mentioned under the heading Fibroma, in the chapter on Cysts and Tumors. It deserves further mention here, however, because of the disfigurement produced by keloid scars, and because the spontaneous expressions of the disease may occasionally demand surgical intervention. In cicatricial tissue it often follows the scars left by burns or excision of tuberculous lesions. Since subcutaneous sutures have been introduced there is less keloid than there was years ago (Fig. 107).

PLATE XXIX

Keloid. (Hardaway.)

Treatment.

—The surface indication is always for excision or eradication, but one cannot give the slightest guarantee against recurrence in even worse form in the same scar. Electrolysis may have a beneficial effect on some of the lesions, but will only occasionally prove satisfactory. A number of years ago thiosinamin was introduced, and has perhaps given a larger measure of success than any other remedy. It is used in 5 or 10 per cent. solution, which is injected into and around the growth, and may lead to gradual absorption of the hypertrophied tissue. The pain which the injection produces does not last long and I have seen many excellent results follow its use.

The same injections may be resorted to in general keloidal disease, which is seen most often in the colored race. In negroes it may follow traumatism of the skin surface, and attain the size of a saucer or plate. (See Plate XXIX.)

Neurofibroma.

—Fibroma of the skin may happen at any time and is likely to develop in the finer branches of the cutaneous nerves, where it will constitute a small tumor, known as painful subcutaneous tubercle. These little tumors attain the size of a pea and appear between the skin and superficial fascia. Sometimes they are painful and are always tender. Unless thoroughly removed they tend to recur. Nevertheless complete removal is the only remedy.

Fibroma Molluscum.

—A much larger, softer, and more complex tumor is that known by Virchow as fibroma molluscum. These tumors may attain large size, and may be single or multiple. Over four thousand of these lesions have been counted on one subject. They develop from the connective tissue of the cutaneous nerves, and involve later the globular and follicular structures of the skin, softening and undergoing such changes as to deserve the adjective molluscum. Changes analogous to these lead to what has been described as dermatolysis, i. e., hypertrophy of the skin, with loosening of the subcutaneous tissue, by which it is thrown more or less into folds. Another clinical expression of the same condition has been known as pachydermatocele, in which pendulous masses of skin hang from various parts of the body, especially the face and neck, and undergo pigmentation and other changes.

Treatment.

—These lesions can be excised, always with temporary cosmetic improvement, but not always with a guarantee against recurrence of the trouble.

Scleroderma.

—This name is given to a leathery induration of the skin occurring in circumscribed areas, which have been called “morphea,” or in diffuse patches, which shade off into surrounding normal skin. The first indication is a stiffening accompanied by some thickening and hardness. Sometimes the affection is painful, and the brawny hardening which it produces makes it irksome and uncomfortable. The skin thus affected can not be picked up between the fingers, and is more or less adherent to the tissues beneath. When the difficulty is pronounced the sweat and sebaceous glands cease to functionate. If it occur about a joint the movement of the latter may be interfered with, even to the extent of producing ankylosis. Wherever it appears there is impediment to motion and flexibility of the parts beneath. The tendency usually is to spontaneous disappearance with atrophy. While subsiding at one locality it may recur in another. Upon the hands it may effect such great disturbance of function as to produce what has been described as “sclerodactylia.” The skin over bony prominences, when irritated, may break down; ordinarily it does not go on to ulceration.

Pathology.

—The pathology of scleroderma is very obscure. Whether it depend upon primary disturbances of circulation, both of blood and lymph, or whether it is produced by cellular hypertrophies has not been determined.

The characteristic induration of this disease is not imitated in other affections except scleroma neonatorum, but it may, nevertheless, be confused with the infiltration of tuberculosis, of syphilis, or of malignant disease. While the disease persists, in most cases it is not often fatal.

Treatment.

—It is to be treated mainly by tension, the general and constitutional conditions by massage, and inunction with soothing oils or with the ichthyol-mercurial ointment. It has been successfully treated, as is keloid, by the subcutaneous use of a 10 per cent. alcoholic solution of thiosinamin. The ultraviolet rays and even the x-rays, used judiciously and carefully, may also be of service.

Rhinophyma.

—This form of tumor is to be differentiated from rhinoscleroma, the latter being due to a peculiar specific bacillus, while rhinophyma is a filth disease, due to hypertrophy of the sebaceous structures of the nose from obstruction of the sebaceous ducts. It is often seen among alcoholics, perhaps less frequently at home than abroad. Pathologically it consists of enormous and irregular hypertrophy of the sebaceous gland elements and connective tissue of the skin of the nose. Each hypertrophied gland secretes in proportion to its increase in size, and even the vessels of the part become engorged. In consequence there results a lobulated, distorted, most disagreeable appearance, which often becomes exceedingly offensive. The tumors thus formed sometimes increase to a size sufficient to interfere with breathing and with feeding. The resulting nasal enlargement is usually trilobed. The first impetus to the overgrowth comes sometimes from such cutaneous irritation as frostbite, or local irritation of some kind.

Treatment.

—The treatment of rhinophyma consists in the unrestricted use of scissors and the sharp spoon, with the preservation of so much of the integumentary structure as may serve to cover the reduced dimension of the nose. These lesions will bleed freely at first, but bleeding is usually easily checked. When a plastic covering of the defect is impossible, the surface may be left to granulate, with a certain feeling of security that the cicatricial contraction following will reduce the enlargement to normal proportions.

Xanthoma.

—This name is applied to a macular lesion, papillary or tuberculous, marked by the appearance of yellowish spots, occurring singly or in groups, often about the eyelids, but seen anywhere upon the skin. When occurring in papules it is called xanthoma planum; when in nodules, xanthoma tuberosum. There is a variety met with in diabetes which is temporary and usually disappears spontaneously.

Treatment.

—The treatment for xanthomatous patches is either electrolysis or complete excision, under local anesthesia.

Keratosis.

—Keratosis is a term applied to thickening of the normal epidermis, occurring in limited areas, the skin being transformed into tense or almost horny tissue. The form which occurs in elderly individuals is called keratosis senilis. It occurs upon the face, the hands, and forearms, but may be seen on any part of the body. The involved areas become discolored, sometimes by true pigmentation, more often by a deposit of dirt. As long as epithelial reproduction occurs away from the basement membrane the lesions are simple and innocent, but in elderly people it requires but little irritation to provoke a down-growth of epithelium, and then the development of epithelioma is rapid.

Treatment.

—These reduplicated epithelial elements can be kept soft by an application of equal parts of glycerin and liquor potassæ. After being softened they may be easily scraped down to a normal level, but will later reform. If they begin to ulcerate they should be excised. Should excision be declined the area may be treated with the thermocautery or with one of the caustic pastes.

Vascular Growths.

—These have already been mentioned in the chapter on Tumors, under the head of Angioma. So far as the skin is concerned they usually occur in the shape of nevi (called strawberry growths) or the more disseminated form, sometimes involving considerable areas, commonly known as “port-wine marks,” which are essentially cutaneous telangiectases, are almost always of congenital origin, and frequently appear in complete form even at birth. They may occur rapidly or slowly. An isolated nevus should be treated by complete excision. Large vascular areas, or port-wine marks, are best treated by repeated electrolysis. If treated early they are sometimes eradicated by the local use of sodium ethylate.

The so-called nevus pigmentosus, or pigmented mole, is generally of congenital origin, and may or may not be accompanied by vascular changes. It is not infrequently covered with hair, and sometimes forms a patch of considerable size, often upon the face. These lesions occasionally occur in such form as to entitle them to be styled nevus verrucosus or nevus pilosus. Occurring upon the back or trunk they are usually disregarded. When upon the face they should receive surgical treatment.

Treatment.

—Excision is, of course, the best method of treatment unless a disfiguring scar be feared. This can usually be prevented by proper plastic methods. When excision seems inadvisable electrolysis is the next best method of attack. No matter how vascular may be the lesion itself, the vessels a short distance from the margin of these growths are rarely dilated, and hemorrhage is not a feature which need deter one from radical treatment.

Lymphangioma.

—This has also been described in the chapter on Tumors. A circumscribed form is occasionally found in or beneath the skin. It occurs early in life, constitutes a more or less sessile tumor, which collapses on pressure, fills slowly, its surface being often irregular, warty, or horny. Should the surface be injured lymph will escape rather than blood. An extended form of it constitutes one kind of elephantiasis. (See chapter on Lymphatics.) Any septic infection of a growth of this character is likely to result seriously and at once.

Treatment.

—The best treatment is excision under thorough aseptic precautions; next to this is destruction with the cautery, which will lead to resulting sloughing and cicatrization.

Malignant Disease.

—All forms of cancer may appear, primarily, in or upon the skin. From the ordinary surface epithelium springs epithelioma; from the glandular elements possibly round-cell carcinoma; and from the mesodermic elements any of the radical varieties of sarcoma, while endothelioma is less common.

Epithelioma.

—This is a frequent infection of the skin, which may arise primarily as an original lesion, usually following surface irritation, or secondarily, either as the extension of similar disease from other parts or of degeneration of previously innocent epithelial tumors. Epithelial outgrowth, so long as it be an outgrowth, and do not transgress the limits of the basement membrane, is essentially innocent in character; but so soon as growth in the downward direction begins we have the beginning of a skin cancer, which may proceed to fatal extent if not promptly recognized and properly treated. These growths vary very much in rapidity and malignancy. Occurring upon surfaces which are kept constantly moist and warm they develop more rapidly, as upon the tongue, within the vulva, rectum, etc. The slowest form of growth of this kind is the so-called rodent ulcer. Epithelioma which begins in or upon the skin or mucous membrane tends to spread to and involve everything in its neighborhood; even bone and cartilage succumb to its ravages, and, becoming involved, lose all their characteristics and melt away in the surrounding ulcer. This produces in the course of time hideous and serious developments. No tissue is exempt from its ravages, and yet life may be prolonged for many years, even when the face is almost entirely eaten away. Epithelioma and rodent ulcer have been described in the chapter on Tumors.

Fig. 108

Epithelioma.

More deeply seated carcinomas of the skin infiltrate in both directions alike, and grow downward, sometimes in cylinder form, thus giving rise to a clinical type called cylindroma. Lenticular carcinoma is also described as differing from the ordinary epithelioma, in that it exhibits a true alveolar structure. This form is rare, and is distinguished from the common form by the absence of the so-called “pearly bodies,” which characterize common epithelioma. The lenticular form is most often seen in recurring cancer of the breast, or in the vicinity of scars showing where deep-seated cancer had existed.

Diagnosis.

—Epithelioma in its various forms should be distinguished from skin lesions due to syphilis and tuberculosis. A diagnostic table has been given (see p. 293) by which diagnosis as between it and lupus may ordinarily be made. The lesions of syphilis are usually multiple and accompanied by other manifestations which stamp their character. There is, moreover, usually a history which will be suggestive if not actually helpful. In cases of actual doubt, as upon the tongue and elsewhere, the therapeutic test may be applied. If resorted to, it should be vigorously made. When mercurial inunction is thoroughly practised, and the internal administration of the iodides effects no improvement within three weeks, the hypothesis of syphilis may be abandoned.

All cancerous lesions tend to advance and to destroy in spite of all local measures. There never appears about them any indication of a tendency toward cicatrization, and, while the edges of malignant ulcers may be thickened and everted, the more central portions are always excavated. They cause, moreover, involvement of the adjoining lymphatics, although this may be said as well of syphilitic and tuberculous lesions.

Treatment.

—Concerning the treatment of epithelioma and other malignant skin diseases there is little to be said which has not already been summarized in the general considerations concerning the treatment of cancer. Radical excision of the original lesion, in its early stages, will usually lead to final recovery. If there be involvement of the lymphatics the indication is made thereby more positive for cleaning out all infected areas, while, at the same time, the prognosis is rendered less favorable. There comes a time in the history of all these cases when excision can be recommended only as a palliative measure, i. e., when it may be regarded as useless. In the more hopeless cases benefit will but rarely be obtained from the use of x-rays, ultraviolet light, or radium.

Paget’s Disease.

—Paget’s disease includes lesions now regarded as a precancerous stage, which appear upon the breasts and around the nipples of women during the middle decades of life. Something similar is seen in other parts of the body and in both sexes, but it is most common around the nipple on one side. For a long time it appears as an ordinary eczema, which, however, does not tend to heal but to spread, while the skin beneath becomes more or less infiltrated. A gradual retrocession of the nipple is usually seen. Certain discomfort accompanies the lesion, which may go on indefinitely until it becomes unmistakably cancerous. This is a precursor not so much of round-cell cancer (scirrhus) as of epithelioma. Eczema of the nipple is to be regarded with suspicion, especially when occurring after the menopause. Until diagnosis is fairly established it is best treated with soothing applications. So soon as the cancerous stage has been determined the breast should be removed. (See Plate XXVI.)

Other forms of malignant or border-land tumors which occur upon the skin are chimney-sweeper’s cancer, paraffin cancer, and that met with in aniline workers. Chimney-sweeper’s cancer was the name applied to epithelioma of the scrotum occurring among a class of laborers whose occupation is now almost entirely extinct. It began usually as papilloma and merged into epithelioma. Among workers in paraffin and coal-tar factories there is an analogous lesion, the result of surface irritation, the skin becoming dry, thickened, covered with acne-like pustules, and then with papillomas which ulcerate and frequently change over into true epitheliomas.

Sarcoma.

—Only the outer layers of the skin are truly epiblastic. In the depths of the integument mesoblastic elements enter largely, and from these various forms of sarcoma may develop. These have already been treated in the chapter on Tumors. They may be single or multiple, and a general disseminated sarcomatosis is occasionally observed. It corresponds to miliary tuberculosis, but presents many distinctive lesions in the skin, by which it may be easily recognized. A form of multiple pigmented sarcoma involving the hands is represented in Fig. 109. These growths are almost always tender on pressure and more or less painful. They coalesce and finally form fatal lesions.

Melanoma.

—This term was introduced by Virchow, who made it cover all pigmented growths. By common consent it is today limited to tumors of the skin and uveal tract which contain pigment; metastases may occur in any or all of them. They occur as malignant degenerations of nevi, moles, and other small growths. Pathologists are still disputing as to whether they should be considered sarcomas or endotheliomas. The coloring matter which they contain is amorphous, finely granular material, lying between the cells in moles, but occurring free in the tissues and blood and even in the urine. It is soluble in strong alkalies, from which it can be recovered as melanic acid, containing a small proportion of sulphur. Of its origin nothing is positively known. It seems to be generally accepted that the deposit of pigment is not of itself a causative agent of the growth of the tumor, but that the growth of cells and their pigmentation are coincident processes. Johnston has offered much evidence lately to the effect that growths from nevi are really of endothelial origin. Hutchinson has described melanotic whitlow. (See below, the Nails.)

Melanoma is a pigmented ulcerating neoplasm, which possesses at first only a local malignancy like that of rodent ulcer; the more it assumes the endotheliomatous type of growth the more it tends to disseminate and to prove fatal.

The melanoma arising from a mole or nevus, thus known as melano-endothelioma, begins to increase in size and becomes more full, as well as to assume a darker tint. For a variable time it is a single, rather firm, gradually growing, flat tumor, rarely ulcerating, but sometimes exuding a thin dark fluid. Suddenly there appears rapid local spread as well as dissemination. The latter may be first noted in the adjoining lymph nodes. Thus numerous secondary tumors may be felt in and beneath the skin, at first colorless, becoming more or less rapidly pigmented. Metastasis may take place to every organ in the body, but usually the liver and lungs—less often the brain—are involved. In one case known to the writer the heart was a mass of nodules of this same secondary character.

Another expression of the same serious condition is seen in a lesion called by the French malignant lentigo, which also begins with pigmented spots, on the feet of old men, sometimes upon the face. These lesions cause thickening of the skin and early ulceration.

Rodent ulcer, which is one form of epithelioma, occasionally assumes the melanotic type, and is called melano-epithelioma.

Fig. 109

Fibrosarcoma of hands. (Hardaway.)

The most marked collection of pigment in the human body, within small space, is along the uveal tract within the eye, and orbital melanomas are not infrequent. Beginning within the sclerotic they rapidly perforate this dense membrane and spread to adjoining tissues, while dissemination and metastasis occur early and rapidly.

Treatment.

—For melanoma there is but one successful treatment, and this is successful only when practised early, i. e., complete excision or destruction. Every mole, nevus, or other skin lesion which shows the slightest tendency to changes noted above should be promptly excised, along with a wide area of its surrounding tissue. It may be thus possible to make a radical cure. Neither x-rays nor any other less radical method of treatment will have the slightest effect. The treatment of any case left to itself until mistake in diagnosis is impossible will probably be of little avail.

The only lesions of the hair and hair follicles that concern the surgeon are those which have been described under the head of Syphilis of the Skin, or some of the congenital growths, such as plexiform neuroma, lymphangioma, etc., whose surfaces are frequently pigmented and hairy, and may call for excision, along with the underlying tumor.

The Nails.

—Onychia implies any disturbance of the nail border and matrix. Simple onychia occurs frequently in the fingers of marasmic children. It is evidenced by softening and swelling of the skin around the nail, by more or less pain, disturbance of circulation beneath the nail, which becomes finally loosened, sometimes leaving a foul ulcer. This ulceration may extend and involve nearly the whole finger. It may occur in one or in several fingers. Lesions of this kind are regarded as local infections, occurring usually in vitiated constitutions. It is a common expression or complication of syphilis; when of such origin it yields readily to treatment; at other times it is often slow and tedious. Except in specific cases, where mercurials locally and internally will usually be sufficient, the treatment should be radical and should consist of thorough exposure of the ulcerating and fungous surfaces, thorough curetting, and the use of suitable caustics and antiseptic dressings.

Onychia Maligna.

—Onychia maligna implies, according to some writers, a more distinctive type of phlegmonous lesion, while the term has also been applied to malignant ulcers, sometimes pigmented (see Melanoma above) and sometimes of more ordinary type. In either type of lesion granulation tissue may be exuberant and fungating, and it is possible that at times there will be doubt in diagnosis. The finger-tips, with their peculiar tactile sensibility, should never be sacrificed unnecessarily, yet any malignant lesion calls for amputation of the finger.

Ingrowing Toenail.

—This is due almost invariably to ill-fitting footwear, the toes being crowded into too narrow shoes, with too high heels. The real lesion is not so much an excessive growth of the nail as overgrowth and overriding of the skin margin around the matrix. It is painful and annoying, sometimes even disabling. The maceration of a perspiring foot in a warm and tight shoe serves to aggravate the difficulty. Palliative treatment is afforded by chiropodists and quacks, who pack cotton beneath the edge of the nail and keep patients under treatment for indefinite periods, never remedying the footwear and never curing the case. In simple cases it is usually sufficient to excise a portion of reasonably healthy skin on either side of the terminal phalanx, in order that by cicatricial contraction the skin may be drawn away from the nail border. Serious and long-standing cases are best treated by avulsion of the nail, which may be usually performed under local anesthesia or by the aid of nitrous oxide gas. The blade of a knife or scissors is driven under the centre of the nail sufficiently to ensure its passing completely beneath the hidden matrix. The nail is then split in the middle, each half seized at its split border by strong forceps, and by a rapid movement torn loose from its bed. The border of the skin should be scraped, after which a simple dressing suffices, providing the operation has been performed with proper antiseptic precautions.

Many an individual is tattooed in youth who would gladly be relieved of the discoloration later in life. Tattoo marks are difficult to erase. The following is a method attributed to Ohmann-Dumesnil: “Wash the skin with soap and water, then with eight or ten fine cambric needles, tied together and dipped in glycerole of papoid, tattoo the stained skin, driving the needles into the tissues so as to deposit the digestive in the corium, where the carbon is located. Repeat as necessary. The pigment is liberated by the digestant.”

CHAPTER XXVIII. SURGICAL DISEASES OF THE FASCIÆ; APONEUROSES; TENDONS AND TENDON SHEATHS; MUSCLES AND BURSÆ. — DUPUYTREN’S CONTRACTION. — LOCK OR TRIGGER-FINGER. — HAMMER-TOE. — SURGICAL DISEASES OF THE TENDONS AND TENDON SHEATHS. — SURGICAL DISEASES OF THE MUSCLES. — ATROPHIES AND CONTRACTURES OF MUSCLES. — DISEASES OF THE BURSÆ.

Fasciæ and aponeuroses are such non-vascular and indifferent tissues that they have practically no primary diseases, except such fibrous and malignant tumors as have their origin in them; nevertheless they suffer in a variety of morbid processes. They lose vitality and break down under the influence of both acute and chronic septic infections. By virtue of their resistant structure, when they slough they break down slowly and the process ends usually with the help of scissors and forceps. Many an old suppurating lesion, especially of the hand and foot, is kept active by the fact that dense, fibrous tissue remains concealed, which ought to have separated. Under these circumstances free incisions should be made and all necrotic tissue trimmed away.

Pus which has formed beneath these fibrous investments will give pain largely in proportion to the intensity of the process and the unyielding character of the fasciæ; hence the urgency of early incision in case of deep phlegmon. Moreover, the direction of least resistance may cause pus when confined to travel where its presence is most undesirable, as from the neck beneath the deeper muscle planes down into the thorax. When pus escapes from beneath firm tissue it is usually by a small opening, after which it may spread out again beneath the skin before finally escaping. This condition has been called “collar-button abscess.” Care should be exercised in opening the superficial collection not to miss the small opening. The fascia must be split sufficiently to permit of thorough cleaning out of whatever collection there may be beneath it.

In the presence of cicatricial contraction of the skin, in shortening of muscles by chronic spasm, as in wryneck, or in certain deformities—for instance of the foot—numerous signs of a shortening or contraction of fasciæ and aponeuroses are seen. In many instances of club-foot it thus becomes necessary not merely to divide tendons but to make extensive incisions through the plantar aponeurosis or elsewhere, in order to release sufficiently the parts whose extension is desired. Underneath the joint contractures which have been produced by burns and their resulting scars similar conditions will be found, which in old and extensive cases constitute bridles of dense tissue that make it almost impossible to release the parts.

Dupuytren’s contraction presents the most serious and insidious appearance of slow but almost irresistible contraction of fibrous elements which the human body presents. It is produced by contraction of the palmar fascia, with its numerous minute prolongations, rather than by flexor tendons. It is seen in the hands of men who from the nature of their occupations are subject to much irritation of the palmar surface. It begins nearly always in the fourth or fifth fingers, but may spread to and involve all the digits and even the thumb. The view held by Adams and others that it is a chronic hyperplastic inflammation, with scar-tissue contraction of the palmar fascia and of the adjoining connective and fatty tissue, which does not involve them evenly, but only at certain points, is correct, at least when small nodules may be felt in the palm which are the precursors of the disease. Either hand may be affected, but generally both are involved. It is found in from 1 to 2 per cent. of those who depend upon their hands for their support. Deformity may proceed to pressure dislocation and finally to ankylosis. Its causation then is very obscure; it is rarely the result of definite injury, but follows continued irritation of the surface. It seems to have a local origin, and yet it is frequently associated with the gouty diathesis to such an extent that the prolonged use of alkalies will relieve some cases. The first significant sign of the condition is the formation of small nodules in the palm of the hand, as stated, and this usually precedes the finger contraction by a year or two.

Fig. 110

Dupuytren’s contraction. (Adams.)

Fig. 111

Dupuytren’s contraction of palmar fascia, showing contracted fingers. (Burrell.)

 

Treatment.

—There is considerable difficulty in treating these cases satisfactorily. Cooper advised subcutaneous division of the tense bands and forcible stretching of the fingers; this rarely proves sufficient. Adams advocated multiple sections made with a small tenotome, which is more effective. The best method is that of Kocher, which consists in excision of the fascial bands by longitudinal incisions along the cords, and the dissection of the skin from the underlying fascia. The cord is carefully dissected, with its prolongations and then completely removed, while the margins of the skin wounds are closed with sutures. The more thoroughly the dissection is performed the more satisfactory the result. The fingers should be straightened and kept from contraction by the use of a mechanical device. In desperate cases the entire skin of the palm has been removed, with the diseased fascia, and a plastic operation made with skin taken from the thigh or the chest, the flap being sutured in place but not detached completely for ten to twelve days.

Two somewhat allied conditions involving the hand and the foot are the so-called lock or trigger-finger and hammer-toe.

Lock or trigger-finger implies a peculiar obstruction to free movement of the finger, which requires extra effort and then is overcome quickly, as if a knot had been slipped through a small opening. It is supposed to be due to a thickening of the tendon at some point, as by a small fibroma, which becomes entangled along the course of the sheath, through which it is moved with difficulty. It is probably due to a local irritation, as in the case of Dupuytren’s contraction. Injury to the tendon sheath may also produce a similar condition.

Treatment.

—Should it fail to respond to rest and massage the sheath should be opened and the cause of the difficulty sought out and removed.

Hammer-toe produces deformity with more or less ankylosis. An angle is formed between the first and second phalanges, and the tip of the toe is made to bear more than its proportion of weight. This deformity is in large degree due to the use of shoes which are too short. In consequence there will develop over the protruding joint a corn or bunion.

Treatment.

—Should the trouble come on in childhood the toes should be fastened to a straight splint and shoes for a time abandoned, while later they should be properly adapted to the needs of the case. In troublesome cases complete excision of the involved joint gives satisfactory results.

TENDOSYNOVITIS.

Acute inflammation of a tendon sheath is known as tendovaginitis or tendosynovitis. It always implies an infection, and occurs about the hands and feet. It is a frequent complication of felons. Many felons begin in such a manner that it is difficult to decide which part of the fibrous structures of the finger is first involved. Infection having once occurred within a tendon sheath will travel rapidly until it meets with a natural barrier. The frequency of these lesions makes it important to recall here the anatomy of the tendon sheaths of the hand. There is a common palmar tendon cavity, which connects with the thumb and little finger and the space above the annular ligament, but communication with the first, second, and third fingers is ordinarily destroyed. This accounts for the apparent vagaries of cases where infection beginning in the thumb spreads to the little finger before the others are involved. It will also show the location where incisions should be made.

Fig. 112

Cicatricial contraction and deformity resulting from consequences of neglected phlegmon and osteomyelitis of hand. (Lexer.)

Suppurative Tendosynovitis.

—Suppurative tendosynovitis needs prompt intervention, as adhesions may result from retention of exudate, or lest necrosis of tendon occur from perversion of its nutritive supply. Ordinarily it is the result of a local infection, perhaps through a small, trifling surface irritation, but it results occasionally as a metastatic expression of gonorrhea, or distinct septic infection. A gonorrheal tendosynovitis is, however, less likely to suppurate, but more likely to assume the plastic form and interfere with function by producing adhesions between a tendon and its sheath. The combination of virulent bacteria and susceptible tissues will produce local destruction in almost as short a time as in the appendix. The pain is intense, because of the inelasticity of the structures.

Fig. 113

Suppurative tendosynovitis (felon), with sloughing tendons and necrotic bone. Unfortunately poulticed for two weeks. (Lexer.)

Treatment.

—Every appearance of this kind calls for early incision, by which not only the skin but the tendon sheath as well should be freely incised. An incision at either end of the involved sheath, with flushing and drainage, may save a tendon and preserve function. Incision should not be delayed, as destruction may have occurred and deformity be the result. When the common palmar sheath is involved a long incision from the base of the index finger, around the base of the thumb and up the wrist to a point considerably above the annular ligament, will afford considerable relief. It will, moreover, shorten the time of ultimate restoration of function.

Chronic Tendosynovitis.

—Chronic tendosynovitis may be the result of rheumatism, in which case it assumes the plastic form, or of gonorrhea; the same being true of a tuberculous invasion, which may vary much in intensity. In the subacute forms the deposition of tubercles may lead to a plastic outpour which, being detached by constant motion of the parts, is broken into masses whose minute portions become rounded off by friction and condensed by time, and appear as the so-called “melon-seed or rice-grain bodies.” Some of the same material may be found adherent to the walls of such a cavity. In slower forms there is less tendency to plastic outpour, but much more to the formation of granulation tissue, such as is seen in tuberculous lesions in all parts of the body. When, therefore, a case of this general character presents we have the signs of local tuberculosis, or of dropsy of the tendon sheaths, with the fluctuation somewhat modified by the presence in the fluid of rice-grain or melon-seed bodies. Should, in such a case, an acute infection be added we will have the chronic symptoms merged suddenly into acute. A tendovaginitis of this type appears as a ridge or swelling along the course of one or more tendons. It will be elastic and fluctuate in proportion to the distention of the sheath. When the palmar bursa is involved there is usually, in the palm of the hand, a bag of fluid which may be forced above the wrist by pressure, while frequently the little bodies above described are recognizable by the sensations (crepitus) which they produce. The plastic type rarely proceeds to suppuration or ulceration unless secondarily infected. The granulation type proceeds to ulceration and destruction.

Treatment.

—Treatment of the rheumatic and gonorrheal forms is at first rest, with later passive and forced motion, in order to break up adhesions and prevent their re-formation. If one wait too long he meets with great difficulty in these efforts and the cases become exceedingly tedious. Forcible motion should be practised under nitrous oxide anesthesia and should be repeated every two or three days. Meanwhile massage should be employed. If pain or reaction be extreme ice-cold applications should be applied. Extreme swelling may be combated by the use of a rubber glove. If this be worn, ichthyol-mercurial ointment should be used beneath it, in order to promote absorption.

Treatment of the tuberculous cases is often disappointing. Non-operative measures afford but temporary benefit, while operation to be effective should be thorough. It should consist of free incision, with exposure in whole or in part of the affected channel or cavity, thorough cleaning out of its contents, removal of all edematous or tuberculous tissue or granulations, and the use of an antiseptic as strong as it can be employed.

The new opsonic serum treatment, now being placed on trial as this work goes to press, promises much in the treatment of all these septic affections, though detailed statements would be premature.

TENDOPLASTY.

It was a step in advance in surgical technique when Stromeyer and Dieffenbach, in 1842, introduced the method of subcutaneous division of tendons and aponeuroses, and showed how easily contracted tendons could be lengthened by tenotomy. From their time until somewhat recently tenotomy has held its place in the treatment of various deformities, and until Anger, Gluck, Hoffa, and others have taught the surgical profession what can be done by various plastic and suture methods in overcoming defects and atoning for loss of function in paralyzed muscles. To the surgery of tendons and muscle terminations have been added the further resources of tendon suture, i. e., tenorrhaphy, and tendoplasty, by which latter something more than the mere suture is meant, i. e., the plastic rearrangement and grafting of tendons one upon another.[20]

Fig. 114

Fig. 115

 

Fig. 116

Fig. 117

Fig. 118

 

Fig. 119

Fig. 120

Fig. 121

 

Illustrating various methods of dealing with tendons in tendoplasty. (After Vulpius.)

Tendon suture is practised as an emergency measure when one or more tendons has been accidentally divided, this being considered now as much a part of the surgeon’s duty as to close any other part of the wound. No additional resource or expedient is needed, it being necessary only to observe the principles of asepsis, which should be maintained in every case. A tendon raggedly divided should be cleanly cut and its edges brought together with formalin-gut or freshly boiled silk. A series of divided tendons should be treated after the same fashion, matching the ends as closely and completely as possible. After uniting the tendon ends, if the case be clean, the tendon sheath should be closed and the parts put at rest, in such a position that no tension is made upon the injured sinew until it is seen to have united.

Fig. 122

Fig. 123

Shortening a tendon.

It was a great service, in which perhaps Gluck figured most conspicuously, to show that when tendon ends could not be neatly coapted an animal material could be interposed in such a way as to serve as a trellis along which cells could group, or around which they might organize, and thus gradually and finally become a part of the complete tendinous cord. Silk and catgut have best served this purpose, and new tendons have gradually formed around these artificial substitutes, to the length of 10 Cm. In every fresh case where there has been such loss of original structure as to justify a measure of this kind, or in certain old cases where tendons have long since sloughed away, it may be possible to resort to these expedients.

It has been possible to transplant fresh tendons from the smaller animals and to see them serve the same purpose in a satisfactory manner.

Among these methods of tendoplasty is tendon grafting, by which a part or all of the tendon of an active muscle is inserted into the terminal portion of a paralyzed muscle and thus made to assume to a greater or less extent the purpose and function of the latter; in other words it assists in ingeniously diverting the activity and direction of a given muscle to a purpose different from its original intent. By this diversion a more equal or equable distribution of muscle force is afforded the parts into which the affected muscles are inserted. For its successful performance only those muscles which are still active can be utilized. Among the simplest of cases where this expedient can be used are those produced by traumatic and peripheral paralyses, or traumatic loss of a given tendon or a set of tendons. It is rarely to be practised as an emergency measure, but as an expedient to be availed of later. It finds its greatest usefulness in cases of long standing. It is equally applicable where muscles and tendons have been divided by injury, or paralyzed by injury to their nerve supply, as well as where deformities are produced by chronic neurotic disturbance, by scars, by excessive callus, etc. It proves equally serviceable in paralyses of spinal origin, particularly those due to anterior poliomyelitis.

Tendon grafting will serve both as a substitute in cases of lost function and as a provision against future deformity. In cases of the ordinary paralyses of children, tendoplasty should be deferred for several months after the occurrence of the paralysis. In the case of growing children it is desirable not to wait too long, as other objectionable features may present themselves. In the congenital and hereditary paralyses and in conditions like athetosis or the dystrophies of syringomyelia, meningocele, etc., also in such conditions as habitual dislocations of the patella, much can be accomplished by a carefully planned tendoplasty. It will be easily seen then how wide a field of usefulness lies before one who familiarizes himself with the recent technique of tendon surgery.

Fig. 124

Fig. 125

Two methods of tendon implantation and fixation. (After Vulpius.)

Fig. 126

Fig. 127

Fig. 128

Transplantation of a portion of the anterior tibial tendon, into the bone or into the opposed group of muscles. (After Vulpius.)

So far as technical considerations are concerned these operations should be performed only with the minutest attention to asepsis. When this has been secured a permanent dressing may be applied, the limb being left in the position most desired, and maintained there for several weeks. For this plaster of Paris makes the best support. The use of the rubber bandage will permit the operation to be bloodlessly made, by which it is greatly facilitated. If careful suturing be practised, there will be but little tendency to subsequent oozing or interference with repair. Fine discrimination is always needed in the matter of adjusting the length of tendon ends and the point of their fixation. A useless tendon which has been long stretched over a curved joint will have become elongated, and the tendon to be applied to it should be affixed farther down than would be otherwise necessary. The disposition of the upper portion of the useless tendon and muscle may also call for serious attention. It is rarely necessary to extirpate them. They are already atrophied, and to remove them would be to still further reduce the dimensions of the part. The excluded portions can thus be simply discarded. When there has been deformity with more or less pseudo-ankylosis the malposition should be forcibly redressed and the tendon grafting deferred until a subsequent time; the latter, to be successful, should be performed alone.

Incisions are usually made along and over the course of the tendons to be exposed, but not so close that the cutaneous scar can interfere with the tendon sheath. The lower end of a paralyzed muscle will appear very differently from that of one which is healthy; in the former instance the tissue will have lost its muscular character, and will be yellowish white and fatty. A fascia which has been stretched out of shape may be sutured in folds and will serve of itself to give support and shape to the part which is renewed.

The methods of uniting tendons are so numerous that they can be better estimated by a glance at the accompanying diagrams after Vulpius than by description (Figs. 124 to 128). It is not necessary to utilize all of the tendon of a healthy muscle, as it can be split and a portion diverted to its new function. It is not to be expected that tendons thus arranged will perfectly serve their purpose the first time they are used. There must elapse a period of education of the nerves and muscles whose relations are thus altered, and improvement in the use of the parts thus operated will accrue for months and even years. It is desirable that tendon surfaces thus applied to each other be made broad and extensive in order that their adhesion may be more firm.

Fig. 129

Showing methods of lengthening tendons. (Burrell.)

A modification of tendon grafting consists in implanting the tendon end into the periosteum instead of into some other tendon. There are various ways of making this implantation, either by simple suture or by boring into the bone or canalizing under a periosteal bridge. Fig. 129 illustrates how the tendon of the tibialis anticus can be utilized in both ways. It will thus be seen that a tendon can be given either tendinous, periosteal, or osteal implantation. Tendons thus utilized rarely undergo necrosis or degeneration. So long as the possibility of infection be excluded almost anything can be done with these structures, in spite of their apparent lack of vascularity and vitality.

There are times when it is necessary to lengthen a tendon as well as to shorten it. Fig. 129 illustrates methods by which both of these measures can be performed. Analogous methods have been practised with muscles themselves, although here the circumstances are different and nothing similar can be accomplished. Portions of the pectoralis major have been grafted into the biceps for paralysis of the latter.

Liberating the ring finger in musicians, by dividing the accessory tendons of the extensor communis digitorum, is an expedient suggested some years ago by Brinton. It is made by an incision less than a quarter of an inch long, through the skin and fascia, just below the carpal articulation of the metacarpal bone of the ring finger, and above the radial accessory slip, parallel with and on the radial aspect of the extensor tendon of that finger. The point of a narrow blunt-pointed bistoury is then inserted flatwise beneath the accessory slip down to a point just in front of the knuckles of the ring and middle fingers, where the blunt point should be felt beneath the skin. The bistoury is now turned upward, the middle finger strongly flexed, and the ring finger extended so as to make the slip tense when it is divided. The accessory slip on the other side of the extensor tendon is similarly divided through a distinct incision. Snug compression is made with a bandage over the wounds, with the thumb free, and after two days the patient is permitted to use the fingers in piano-playing in order to prevent reunion of cut surfaces.

MYOTOMY AND TENOTOMY.

Myotomy is a measure seldom practised. It is performed either subcutaneously or by open incision. Tenotomy is indicated whenever contracted tendons need simply to be divided, either in chronic orthopedic cases or after injuries or operations when it is desired to put muscles temporarily at rest. The tendo Achillis has thus been divided to prevent the consequences of muscle spasm when dealing with certain fractures, especially compound fractures of the leg. There are obvious advantages obtaining in subcutaneous tenotomy when properly performed; the freedom from hemorrhage, the minuteness of the opening, the rapidity of healing, are all in its favor. It is performed with a small-bladed knife, known as the tenotome, with either sharp or blunt point, the cutting portion being from 1 to 2 Cm. in length. The sharp-pointed tenotome suffices for its own insertion, the blunt one being used after an opening has been made with a sharp one. The puncture is made obliquely through the skin, which should be drawn a little aside from the site of the deeper opening in order that it may be hermetically closed as it slips back into place. Whether the cutting blade should be turned outward or inward will depend largely on the preference of the operator and the location of the tendon. In some locations, as about the hamstring tendons, the puncture should be made with the sharp instrument and the deeper tenotomy with the blunt one. If the tendons alone have been divided there will be trifling hemorrhage and the puncture can be occluded without entrance of air. Similarly an aponeurotomy may be performed. Not only may the tendons be divided by the open method, but everything else which resists. This is practised more in contracted knee-joint and in club-foot, when operated on by Phelps’ method, than anywhere else. Special indications for the operation will be given in other parts of this work.

GANGLION.

This term is applied to a cyst of new-formation, which occurs in connection with the sheath of a tendon, having a lining membrane continuous with the sheath and containing thick, gelatinous, mucoid fluid. It is termed “weeping sinew.” It is often seen on the back of the wrist in connection with the extensor tendons, but may occur in various parts of the body. It probably begins as a hernia of the synovial membrane through a weak spot in the tendon sheath, which tends to increase in size, weakening surrounding structures by pressure, and interfering more or less with the function of the tendon whose sheath is involved. These cysts sometimes connect with joint cavities, especially those occurring behind the knee-joint; as a rule, however, they do not. At first they constitute merely a disfigurement; later they produce natural impairment of function. In the majority of cases the sac becomes finally shut off from the tube with which it originally connected.

When these lesions are new they may be successfully dealt with by forcible rupture, such as can be made by firm pressure. When old, or when rupture has failed, they should be treated by incision, practised the same as a tenotomy, by moving the skin to one side, pricking the sac, turning the blade of the tenotome so as to permit the fluid to be emptied by pressure, and then, by manipulating the point, irritate and do some damage to the sac lining. Such provocation as this will be followed by a hemorrhage, and the resulting clot may obliterate the sac by organization and cicatricial contraction. This failing, excision is the only expedient which promises success. The slightest operation upon a ganglion should be done under aseptic precautions.

FELON, OR WHITLOW.

Felon, or whitlow, was discussed in the previous chapter, especially the form which has its origin around the root of the nail. It often originates in tendon sheaths and even in bone or close to it. It is so often accompanied by a suppurative thecitis, i. e., tendosynovitis of destructive form, especially when not primarily incised, that the necessity for early treatment needs to be emphasized. It gives rise to excessive pain, with throbbing, and to swelling of livid hue and intense degree. The parts involved are too essentially fibrous and resisting to yield, hence the intensity of the pain. Deep incision at the earliest moment, for the purpose of relieving tension, is the only proper treatment. To temporize with hot poultices, etc., is to invite necrosis and sepsis. This incision may be made with local anesthesia. Even though little pus be obtained the relief of tension will afford the greatest comfort (Figs. 130, 131 and 132).

Fig. 130

Felon of thumb. (Burrell.)

Fig. 131

Neglected suppurating thecitis resulting in palmar abscess. (Burrell.)

Fig. 132

Same, dorsal aspect. (Burrell.)

 

A more striking example of similar trouble is that which gives rise to palmar abscess, the suppurative process extending up the wrist beneath the annular ligament, and down into the little finger and thumb. This is not infrequently the result of infection of callosities in the palm of the hand. Infection may travel rapidly, and when confined beneath resisting structures will prove exceedingly destructive; the muscles of the forearm may melt down and great permanent damage be done.

Here, as when the finger alone is involved, early, free, and deep incision will prove the salvation of the part. These incisions should be made as indicated in Figs. 133 and 134, i. e., parallel with the nerves, tendons, and vessels, all of which should be spared, as well as the palmar arch. Should the latter be divided, the vessel ends may be ligated or the wound packed. If cavities be left by the destructive process they should be opened and the part treated by continuous immersion in warm water, or the openings may be packed with gauze saturated in brewers’ yeast. A few days of this treatment will clean up all sloughs.

Fig. 133

Diagram of palmar incisions.

Fig. 134

Diagram of dorsal incisions. (Burrell.)

CONTUSIONS OF THE MUSCLES.

Muscles react like other tissues under the influence of contusions. Hemorrhages not too copious are gradually absorbed, and muscle tissue repairs itself, as indicated in the chapter on Wounds and their Repair. Much outpour of blood into a muscle will temporarily seriously impair its function, while pigmentation or ecchymosis may result after a few hours or days, according to the depth of the injury. There is the same liability to suppuration after infection of muscles as elsewhere. A large hematoma can scarcely form within a muscle, save in consequence of a rupture of a considerable portion of its substance. Strains and sprains of lesser degree of violence provoke impairment of function proportionate to their severity. In nearly every instance there is a certain amount of rupture of muscle fiber and outpour of blood.

RUPTURE OF THE MUSCLES.

Complete rupture across a muscle is unusual. It may occur in the belly of the muscle or near one of its terminations. A tendon may be torn out of a muscle or may itself snap. These accidents are almost invariably accompanied by symptoms that indicate both the nature and location of the injury. A severe strain followed by intense pain, with a sensation of yielding, leaves little doubt as to what has happened. Unless the muscle lie deeply its parting may be appreciated by palpation, though the depression or interval may be obliterated by the outpour of blood. The large tendons of the arm and shoulder have been ruptured by a violent effort, the abdominal muscles by contusions and by such efforts as wrestling, the sternomastoid by excessive traction during forceps delivery, and the tendons of the legs and ankles by jumps during such games as lawn tennis, etc.; while the frequency with which the muscles of the perineum and even the sphincter ani are torn during parturition is well known. It is also well known that muscles are weakened by the exanthemas and the infectious diseases.

Treatment.

—An injury of this kind and of moderate degree seen early may be treated by physiological rest and position. (See chapter on Treatment of Wounds.) When, however, there is marked impairment of function, such as will follow the yielding of one or more tendons or muscle insertions, then suturing offers the greatest promise of a cure. When the quadriceps tendon is torn away from the patella or the tendo Achillis from the heel, prompt suture under aseptic precautions will save a long period spent in partial recovery of function.

Occasionally one or more tendons will be completely avulsed, as when a finger is torn out of the hand and brings with it one or more of the tendons belonging to it. In accidents of this kind six to twelve inches of tendon and muscles may be lost. In such a case nothing can be done except to care for the wound resulting from the injury.

DISLOCATION OF TENDONS AND MUSCLES.

Tendons and muscles are occasionally dislocated, that is, forced from their normal positions. Accidents of this kind usually occur with the long tendon of the biceps, which is torn from its bicipital groove; the peronei and the posterior tibial in the leg, the extensor muscles of the thigh, and those of the back of the wrist. The lower angle of the scapula is normally held down by a small portion of the latissimus dorsi; should this be displaced the scapula rises somewhat in wing form. These injuries lead to more or less loss of function, and, when they become disabling, may justify operation, which would include incision, exposure of the tendon in its abnormal position, and its restoration to its proper place where it should be held by sutures. Such operation should be followed by enforced physiological rest of the part.

HERNIA OF MUSCLES.

Hernia of muscle is the name applied to the escape of muscle through a ruptured fascial or aponeurotic covering. Such a protrusion will be recognized only during the contraction of the muscle and will disappear at other times. When the diagnosis is made the edges of the rent in the fascia should be united by sutures and the part put at rest.

WOUNDS OF MUSCLES.

Wounds of muscles in no way differ from other wounds which have been considered in the chapter on Wounds and their Treatment. If circumstances permit there is every indication for the suture of a divided muscle in order that its function may be less impaired after the wound is healed. These sutures, when inserted, should be made to separately include the divided fascia or aponeurosis with which the injured muscle is in relation.

MYALGIA.

There are numerous painful affections of muscles known as myalgia. It is questionable whether a rheumatism of muscle fiber ever occurs. That which patients describe as muscular rheumatism is not that which it is termed. Sometimes it is the result of previous exudate between muscle fibers, sometimes the result of hemorrhage of interstitial type. Muscles thus affected are more or less tender and give pain when used. It will usually be found that there is some marked toxic condition, such as uric acid, syphilis, or lead poisoning, behind it.

Treatment.

—Many of the muscle pains of which patients complain after operation, which are also toxic, are relieved by the administration of aspirin in 0.5 Gm. doses. The injection of a small amount of atropine into the body of the muscle will often give relief. Those remedies which hasten elimination, including hot baths and massage, are often of great value.

MYOSITIS.

This may be non-inflammatory and be due to prolonged use of a member, as in writers’ cramp; or toxic, as in lead palsy; or traumatic, caused by minute lacerations and hemorrhage. The more acute forms may be due to extension from neighboring foci or to direct infection. A form of infection involving both muscles and tendon sheaths, and lately recognized, is the postgonorrheal. It has been shown that gonorrhea may produce an active disturbance in synovial sheaths and in muscle structures and a gonococcus myositis, as well as a gonococcus tendovaginitis, are now well recognized. These do not always proceed to suppuration, but may provoke loss of function for some time.

The suppurative form of myositis is seen more often after typhoid and gonorrhea than after the other internal infections, but may occur after any of them. In these cases abscess results in the belly of the muscle involved, while the pus evacuated will show the appropriate organism. It is met with less often in endocarditis and erysipelas.

Any or all the active and destructive infections may occur primarily in muscle structure. They are usually the result of an extension, although they maybe even in this way very disastrous. The amount of muscle destruction that may be seen in a limb after an infected and neglected compound fracture is astonishing.

Myositis Calcificans.

—Calcification and ossification of muscles are alike due to deposition of calcium salts, but under different circumstances. Myositis calcificans may be the result of tuberculous disease following caseation, as it does in lymph nodes and in other parts of the body, or occurring as a general deposit throughout the muscles, essentially an infiltration, as is seen in the muscles of the legs. Myositis ossificans implies a formation of true bone in muscle substance. A peculiar form arising in the adductor longus results from the pressure of the limb against the saddle; this has been known as rider’s or cavalryman’s bone. Something similar in the deltoid has been called drill bone, because usually seen in soldiers who carry their weapons upon the shoulders; while a form which occurs in the brachialis anticus has been referred to as fencer’s bone, and one in the calf muscles as dancer’s bone. It occurs in two types, one of which is characterized by ossification in succession of the various muscles, this occurring first in the trapezii, latissimi, and rhomboidei. In explanation of these lesions, it has been suggested that all of these connective mesoblastic tissues may manifest certain atavistic tendencies and thus revert to bone. The question is certainly not one of periosteal origin. Binnie has shown, in a remarkable case reported by himself, that ossification is both of the fibrous and cartilaginous type. Only in the localized forms can the periosteum be suspected. In these it may be that there has been detachment of some of its tissue or escape of some of its cells into the muscle area. The ossifying lesions of surrounding muscles will sometimes interfere with the motions of joints after they have been injured. Any localized calcareous or ossific deposit which can be recognized may be removed.

Myositis Syphilitica.

—This occurs in gummatous form, no muscles being exempt; those of the tongue are most frequently involved. It is seen also in the sternomastoid. Not infrequently these gummas have been mistaken for malignant tumors. Sometimes they degenerate and sometimes suppurate. A lesion of this kind will usually be multiple, but it may have enough infiltration around it to be difficult of recognition. Lesions of this kind are also seen in hereditary cases. A more distinctively interstitial affection of muscles leads sometimes to their contracture, as seen about the arms, beginning with malaise and incoördination, and extending to disabling lesions. These will yield to properly directed antisyphilitic treatment.

Myositis Tuberculosa.

—This affection is usually the result of extension from adjoining foci. As in the case of syphilis it may assume the infiltrating or the gummatous type. It is more frequently encountered than the muscular expressions of syphilis; it does not yield nearly as readily to treatment, and calls for excision of the affected area and for cauterization or other protection as against re-infection.

PARALYTIC AFFECTIONS OF MUSCLES.

More or less permanent paralysis is sometimes the result of contusion or direct injury of a nerve trunk. Thus the paralysis of the deltoid which follows injury to the circumflex nerve in connection with dislocations of the shoulder is a frequent accident. It does not require continued pressure upon the nerve to produce this. It may follow a dislocation reduced within a few moments. Again, paralysis of the arm muscles is occasionally the result of pressure made by crutches. It has been known to occur from similar pressure while the patient was upon the operating table with his arm hanging over the table’s edge. This is an accident which should be carefully avoided. Moreover, it follows sometimes from mere violent muscle effort. The condition, while simple in its etiology, is difficult and sometimes impossible to cure.

Treatment.

—The treatment should consist mainly of massage and electricity, with the elimination of all possibility of toxemia. The resources of tendoplasty (see above) should also be considered, as well as those of neuroplasty.

Muscular paralysis is always followed by atrophy, which will lead to marked diminution in size of the part; when the atrophy concerns a single muscle or muscle group it will frequently be followed by deformity due to action of the opposing muscles. Tonic spasm of muscles unopposed may lead to contractures, often with ankylosis. The degree of deformity which is produced may eventually require amputation of a limb.

Other forms of contractures are produced either as the result of central or spinal scleroses or as expressions of irritative spasm provoked by a neighboring bone or joint trouble. The two types may cause similar deformities, which vary widely in their etiology. The former are seen in certain cases of brain and spinal-cord diseases, the latter especially in connection with tuberculous arthritis. Inasmuch as the flexors are stronger than the extensors these deformities consist largely of hyperflexion. Ultimately the shape and growth of bones and the nutrition, appearance, and function of the part are influenced.

Muscle atrophy which is the result of confinement in one position, as after the treatment of fractures, is of minor importance and tends to disappear spontaneously as soon as function is resumed.

Treatment.

—In most of these instances patience may be easily overtaxed while waiting the tardy results of massage and such correction as apparatus may afford. Very frequently the additional help of an anesthetic, with forced movements, often with tenotomies and sometimes with tendon grafting, will be required. When contractures can be foreseen, as they may be in connection with many lesions which produce them, such as burns and others not specifically mentioned, they should be guarded against by splints, apparatus, or whatever may best serve the purpose.

PARASITIC AFFECTIONS OF THE MUSCLES.

The parasitic affections of muscles are rare. Trichinosis rarely produces tumors which come under the surgeon’s hands. Still there may result from it a form of myositis with formation of cysts which may so far interfere with muscle function as to demand removal. Hydatid cysts and cysticercus are extremely rare, especially in this country.

There are two types of bursæ in the body: first, the subcutaneous, or mucous, which are loose sacs containing a clear mucoid fluid. They develop regularly when bony prominences are exposed to friction and develop adventitiously wherever undue irritation is produced. Thus beneath every bunion there will be found a good-sized and thickened bursa.

Synovial bursæ, the second type, are met with in close proximity to joints, and between tendons which play upon each other. They frequently communicate with the joint which they overlie, and infection may easily spread from one to the other. They are liable to traumatism, either extrinsic or intrinsic, the former from chafing or more direct injury, the latter by excessive muscle exertion. When infected they suppurate, forming abscesses of conventional type. As the result of contusions they are frequently filled with blood, in which case there is a bursal hematoma. Acute bursitis usually merges into localized abscess.

PLATE XXX

Foreign Body (Broken Needle) in Foot. Buffalo Clinic. (Skiagram by Dr. Plummer.) Illustrating the Value of this Method of Exactly Locating a Foreign Body and involving the Tissues Considered in Chapter XXVIII.

Fig. 135

Hygroma of a prepatellar bursa (“housemaid’s knee”). (Lexer.)

Chronic bursitis constitutes a circumscribed collection of fluid, often with thickening of the bursal sac, and frequent deposition of products of exudation. Here, too, pus may form as the result of infection, while calcification sometimes takes place in old cases. A chronic bursitis is likely to be either of syphilitic or tuberculous origin. It is usually seen beneath old bunions, and in the prepatellar bursa, which is equally exposed to irritation, and which also gives rise to housemaid’s knee. This lesion used to be considered as always of syphilitic character, but this is far from correct.

Hygroma, or hydrops, is a term frequently applied to these localized collections of fluid. The former is more likely to be of tuberculous origin, and the retained fluid may contain rice-grain bodies. A chronic bursitis, originally of traumatic origin, may become infected and present a tuberculous lesion, or it may be influenced if not caused by a syphilitic diathesis, especially about the knee, where these conditions generally occur. Other bursæ which produce disturbances that eventually take the patient to a surgeon are met with in the following locations: beneath the ligamentum patellæ, which will give a prominence on each side of the ligament, particularly when the knee is flexed; over the tubercle of the tibia; beneath the quadriceps extensor tendon, which will cause a swelling two or three inches above the upper border of the patella; between the tendon of the semimembranosus and inner head of the gastrocnemius, which will present in the popliteal space as a somewhat globular swelling; beneath the deltoid; beneath the gluteus muscles, where the tendons pass over the great trochanter; between the tendo Achillis and the calcis; over the outer malleolus, occurring in tailors by virtue of the position in which they work. Large bursæ often develop on the outer sides of club-feet, on the ends of amputation stumps, and wherever there is prolonged irritation of mild degree.[21]

The treatment of acute bursitis is that of threatening phlegmon in any other part of the body. As soon as the presence of pus can be determined, or even before, a free incision should be made. Such an incision should not be entirely closed after evacuation of the sac, but should be permitted to heal by granulation.

Chronic bursitis, whether with or without formation of granuloma, is best treated by excision, when the sac has become thickened and a new formation has practically occurred. Housemaid’s knee, for instance, like bunion, is more satisfactorily treated by a clean excision of all diseased tissue than by any other less radical method. Every tuberculous lesion of this kind should be rigorously extirpated, and every syphilitic lesion should be treated by constitutional as well as by local measures, the former being, save in exceptional instances, the more important of the two.[22]

CHAPTER XXIX. SURGICAL DISEASES OF THE HEART AND VASCULAR SYSTEM. — MALPOSITIONS OF THE HEART. — WOUNDS OF THE HEART. — RUPTURE OF THE HEART. — TUMORS OF THE HEART. — THE PERICARDIUM. — THE ARTERIES. — THE VEINS.

A generation ago a chapter on the surgery of the heart would have been regarded as a surgical fantasy. Today the subject is not only a live one, but experience is constantly accumulating as to the value of surgical intervention in diseases of the heart and pericardium.

The heart may be displaced by congenital or acquired causes. Malpositions of the former type may vary from dextrocardia, where the heart is placed upon the right side, and may be accompanied by a general or partial transposition of the viscera, to those cases where there are defects in the diaphragm or the chest wall, through which the heart protrudes. Dextrocardia has an interest for the surgeon, as, for example, in the following case under the writer’s observation: Disease on the left side which simulated appendicitis, in which the diagnosis was confirmed by finding the heart upon the right side, and later by operation. It was a case of complete transposition.

The acquired malpositions may be due to intrinsic or extrinsic causes. They are pressure effects, usually found in connection with intrathoracic aneurysms and other tumors or collections of fluid, or may be due to change in the shape of the spine in pronounced curvatures. Occasionally the heart is hindered in its action by pressure from beneath the diaphragm. These cardiac displacements are surgically interesting when the cause can be removed by operative measures.

Wounds of the heart are mainly of the punctured or gunshot type. It was formerly considered that injuries of the heart were essentially fatal. This has been disproved by human and comparative observations. As far back as 1855, Carnochan reported a case of gunshot wound of the heart where the bullet was found in the heart substance after the patient had lived eleven days. The museums contain many illustrations of penetrating wounds of the heart or of foreign bodies in it, some of which had remained embedded for many years. Nevertheless the fact remains that the majority of wounds of the heart are fatal, either by arrest of its activity, by shock, by the outpour of blood between it and the pericardium or outside the latter, or later by processes which consume at least a few days, either infective or degenerative. Other things being equal the larger the wound the more dangerous, while an injury to the heart muscle which has not opened one of its cavities is less dangerous than one which perforates them. A punctured wound made by a small stiletto or knife-blade, or even by a needle used for homicidal purposes, may leave but small trace and not prove fatal, save through injury to one of the cardiac vessels, especially a coronary artery.[23]

In practically all of these injuries there will be evidence of some external violence. It is of advantage to ascertain the nature of the accident and the character of the missile or instrument. If the depth of penetration of a knife-blade, for instance, can be ascertained more accurate conclusions can be drawn. The special indications of cardiac injury pertain to disturbance of its own function, that is, embarrassment and uncertainty of action, bellows sounds, enlarged area of dulness owing to distention of the pericardium with blood, dyspnea, and distress, and sometimes pain and syncope. These symptoms and signs do not appear instantaneously, but increase in severity.

Treatment.

—In such an emergency everything possible should be done to relieve the embarrassment of the heart’s action—the head should be kept low, the body absolutely quiet, and nervous excitement should be allayed at once with a full dose of morphine. Heart stimulants should not be given. Ice applied over the chest will help quiet cardiac activity. If the patient be not failing too rapidly operation is advisable, and should be done in a well-equipped hospital, with trained assistants. The purpose of the operation is to expose the injured portion of the heart substance and close it with suture; at least to remove the fluid or partially coagulated blood within the pericardium.[24] As it is not always possible to expose the heart without opening the pleural cavity, there should be at hand not only the means for a tracheotomy, but an apparatus by which artificial inflation of at least one lung can be effected. Pneumatic cabinets have been devised for this purpose, especially by Sauerbruch, where a difference of pressure can be maintained between the outside and the inside of the cabinet, so that the chest may be widely opened and the lung not collapsed; but such a cabinet is available in few places in the United States. The improved Fell apparatus, by which a mask is kept over the face and pressure maintained with the foot through a bellows, has been found useful. Even in the absence of such apparatus the surgeon should not abstain from the effort, though it may appear less promising.

In the operative procedure one may feel inclined to utilize the already existing wound, either as a part of his incision or for exploratory purposes, or he may decide to disregard it. The operation consists in raising an osteoplastic flap on the chest wall, by which the pericardium and then the heart are exposed. The incision through the skin is extended to the bone and only enough of the soft structures separated from the ribs and cartilages to expose them sufficiently for division. Ordinarily it would be preferable to divide the third, fourth, and fifth costal cartilages at their rib terminations, and then to turn up the flap with its base at the sternum, though the procedure can be reversed to almost as good advantage. The cartilages and the ribs may be divided with the costotome and the rest of the structures with stout scissors. The flap, having been gently elevated at the edge, is separated from the underlying cellular tissue and pericardium until its sternal margin has been reached. When detached it may be sprung upward, and thus a complete window is made in the chest wall. When more room is desired bone and cartilage may be cut away with a rongeur.

Fig. 136

Result after thoracotomy for heart wound. (E. J. Meyer.)

The pericardium being thus exposed may be found much distended or altered by the imbibition of blood. It should be opened to an extent sufficient to permit evacuation of its bloody contents and sufficient exposure of the heart to permit not merely inspection but suture of any wound in the heart substance. This is exceedingly difficult on account of motions of the heart, and the insertion of sutures will be as difficult as trying to hit a flying target. Nevertheless it may be done in many cases. Unless imperative, a coronary artery should not be included in the heart suture. Hemorrhage from the heart being checked the pericardium is then to be united, preferably with hardened catgut sutures, with or without drainage. In most instances the former is the better plan, and the drain may be of the cigarette type, that is, gauze wrapped in oiled silk.

Should it be found that the pericardium alone is injured and not the heart the case may be regarded in a more favorable light.

There are sufficient cases on record where procedures analogous to the above have been practised to justify the attempt in every case. Hardened animal sutures may be used in the heart substance, and the interrupted method will probably prove the better. A suture which will hold firmly for three or four days will suffice, as has been proved on animals.

Rupture of the heart can scarcely be considered a surgical condition, though it has frequently been one of medicolegal interest. It may, however, afford a sudden and unexpected termination to surgical cases. The cardiac muscle may be so softened by the poisons of diphtheria and other acute infections as to be greatly weakened, even though an intubation or tracheotomy has apparently afforded security.

Primary malignant tumors of the heart are very rare. Secondary and metastatic manifestation are much more frequent. True primary sarcoma has been repeatedly observed, and, with the exception of endothelioma, is practically the only primary cancer that could appear in this location. Carcinoma is found only as a secondary deposit, with which, however, the heart may become so involved as to permit of terminal rupture.

This closed sac is interesting to the surgeon in cases where it becomes filled with air; with blood, as the result of injury (see above); with fluid, as in acute pericarditis, or with pus, as a later stage of the latter, with its consequent pyopericardium. With the introduction of the aspirating needle it is possible to draw off collections of serum or pus, and paracentesis of the pericardium is now a conventional minor operation. It is managed in the same way and with the same instruments as when the pleural cavity is involved. It is ordinarily safe, and affords much relief.

The surgeon may go even farther than this and practise cardicentesis, as the writer did once by accident while hospital interne. After introducing the needle and withdrawing three or four ounces of pus he discovered that he had given great relief, which, however, was only temporary. The autopsy two days later revealed that he had passed the needle point through the pericardial sac into the heart wall and had tapped the abscess therein. This was in 1877, and was probably the first time that the heart wall was ever thus entered.

Now the operator goes still farther than this and practises intentional cardicentesis in cases of engorgement of the right side of the heart connected with lung disease which is threatening death from dyspnea with an overstrained heart. In such cases the needle may be introduced just above the fourth rib, from one-half to one inch to the right of the sternum, or entrance can be effected just above the fifth rib in an upward direction. From 100 to 250 Cc. of blood may be withdrawn.

For ordinary tapping of the pericardium the needle is inserted two inches to the left of the median line and in the fourth or fifth left interspaces, pushing it carefully until resistance is no longer felt and fluid flows through the tube. For either of these purposes the patient should be recumbent, unless the distress in this position is too great, in order that the heart may fall away from the chest wall. Aspiration can be repeated in case it gives relief. Little or no harm seems to ensue from the wound which a needle-point will make upon the heart substance. As the sac is progressively emptied the needle-point should be gradually withdrawn. When aspiration, exploratory or therapeutic, reveals the presence of pus, the well-known rule will apply, i. e., that pus left to itself will do more harm than will the surgeon’s knife. For pyopericardium there is but one successful treatment when aspiration fails, and that is open incision and drainage. This is not so severe a measure as exposure of the heart, as it may not even require the removal of one costal cartilage, although it would probably be better to take out at least one, since the shape of the pericardial cavity will change to such an extent after it is emptied as to raise the opening to a higher level than is given it at first. Open incision, then, with drainage, in these cases is no longer an experiment but a life-saving procedure. It will prove successful in at least half of the cases, which otherwise would certainly perish without it.

PNEUMOPERICARDIUM.

Pneumopericardium implies the presence of air in the pericardial sac, a condition of which there are now about 40 cases on record. The air nearly always enters through an ulcerative perforation from adjoining parts or through a wound, yet in 5 of these cases no opening could be found. In these it was probably due to the presence of a gas-forming bacillus, such as may also cause pneumothorax under certain circumstances. The perforation was in the esophageal wall in 7 cases, in 4 cases it was the result of softening of a lymph node, while in other instances it has followed abscess of the left lobe of the liver, pleuropneumonia and gastric ulcer perforating through the diaphragm. Of the 8 cases of penetrating wound from without, I included the small puncture made by paracentesis, while in 7 cases there had been fracture of the ribs or the sternum, with wound or laceration of the lung or the pericardium.

The most characteristic sign is a splashing, gurgling sound, synchronous with the heart beats, such as the French have called the “water-wheel bruit.” These sounds are louder than in hydropneumothorax, and are heard distinctly over the heart. The area of precordial dulness will change with position.

In unmistakable cases operation is indicated, the trap-door exposure being the best, the inner end of the fifth and sixth ribs being elevated. Irrigation and drainage will be necessary. It is encouraging to know that 11 of the 40 cases above mentioned have recovered.

CARDIOLYSIS.

Cardiolysis refers to the operative release of the heart from adhesions which have formed between it and the pericardium or the chest wall. When with every contraction the heart itself is subjected to the strain of an adhesion the work proves excessive and it will finally succumb. It has been suggested by Delorme, Peterson, and Simon to either temporarily resect the chest wall, open the pericardium and break down or divide the adhesions, or else to resect those bony portions of the chest wall, i. e., the sternum, cartilages, or ribs, which are so inflexible as not to yield, not removing the bands but making them harmless.[25]

There are few parts of the body which adhere more closely to the normal standard than do the larger arteries. Even here malformations and congenital defects are met with. In calculating the chances of a given procedure the surgeon should consider the condition of the venous and lymphatic systems before deciding to operate on a portion of the arterial system. This is particularly true when ligating the femoral artery for elephantiasis of the leg.

Thrombosis and embolism have already been considered in the chapter on the Blood. Nevertheless it may be well to remind the student at this point that thrombus means a blood clot, while thrombosis refers to the process of its formation; that embolus means something which has passed into the blood current of an artery and plugged it, the obstruction usually being a fragment of clot or tissue, though it may be a droplet of fat or a bubble of air. Emboli, like thrombi, may be sterile, and in this respect innocent, or it may be composed of material loaded with septic, tuberculous, or cancerous germs.

Fig. 137

Fig. 138

Fig. 139

Anastomosing circulation in sartorius and pectineus of dog, three months after ligature of femoral. (After Porta.)

Collateral venous circulation, from a woman aged forty-seven, under the care of W. W. Gull, in whom the inferior vena cava was completely obstructed from cancer. (Guy’s Hosp. Mus., Drawing 44⁴⁰.)

Direct anastomosing vessels of right carotid of goat, five months after ligature. (After Porta.)

 

The readiness with which vessels, both arteries and veins, lend themselves to the exigencies of extra work has long been recognized, and the natural provision for collateral circulation is one of which surgeons have for centuries availed themselves. On the contrary, vessels which are no longer needed or whose function is lost will undergo atrophy almost to obliteration; thus after amputation of the thigh the corresponding iliac vessels become much reduced in size (Figs. 137, 138 and 139).

ARTERITIS; ENDARTERITIS.

That arterial walls are resistant is shown by the fact that they are usually the last tissues to yield to gangrene. Whether a primary acute arteritis often occurs is a question of less interest in this place than the fact that even arterial walls will succumb to infection and that secondary hemorrhages from ulcerative processes are by no means rare. The pathological processes which occur in the various structures of the heart are repeated in the arterial walls; thus there may be a periarteritis corresponding to pericarditis, a mesarteritis which in many ways resembles myocarditis, and an endarteritis which corresponds more or less closely to endocarditis, and all of these in their acute or chronic forms. The acute forms which concern the surgeon are due usually to the presence of infected emboli, which have the same effect upon the arterial walls that infected thrombi have upon the venous walls, i. e., they lead to occlusion, infiltration, and suppuration.

Of the more chronic types those produced by syphilis are the most common. Here it is usually the outer and inner coats which suffer most. Tuberculous infection of an artery is of frequent occurrence and pertains only to those vessels which are in intimate relation with previous tuberculous lesions, while the syphilitic forms are diffuse and generalized and as likely to involve one part of the body as another. It is well known that arteritis in various degrees of intensity may be met with in most of the infectious diseases. Whether they are due to the living germs or to toxins generated during the process concerns us at this point but little. It is of importance, however, to realize that vessels so compromised may thus receive their first impetus to degeneration and subsequently form aneurysm. The degenerative types of greatest interest to the surgeon are fatty degeneration, which occurs in the interior rather than the exterior, and calcification, which is rather an involvement of peripheral vessels and which occurs mainly in the middle and the outer coats. The latter may be limited or may involve an entire vessel. When the radial arteries are involved the condition may be appreciated at the wrist. Calcification frequently follows other degenerations, especially fatty, of the intima, and then may be seen in the interior of an artery. A true ossification has been described, but is exceedingly rare.

ARTERIOSCLEROSIS.

Arteriosclerosis is a term generally applied to a combination of these degenerations, with thickening and diminution of caliber. The changes combined are comprehended in the term atheroma, which is seen as a localized lesion in nodules or plaques in the aorta and larger vessels and in diffuse form in the smaller. Atheroma, as a complex degeneration, constitutes an interesting study, as it leads to well-marked changes in the vessel walls, which are softened at points by fatty changes, the little mass of debris resulting being called an atheromatous abscess (an unfortunate name), which may empty into the vessel, leaving a small cavity and opening known as the atheromatous ulcer. Around this occur usually the calcific changes above described. The disturbance and the roughening thus produced lead to the formation of fibrinous thrombi, which attach themselves firmly at these points. When to such a weakening of the vessel wall as is thus produced are added the elements of compensatory cardiac hypertrophy, and the sudden changes of blood pressure produced by certain occupations and alcoholic and other excesses, it will be seen how atheromatous patches constitute points of least resistance, where blood pressure may cause a vessel wall at least to bulge and thus to afford the beginnings of an aneurysm; while, by combination of various processes, final rupture may result.

The conditions are not so very different in the more diffuse forms, especially in patients who have not only a tendency to vascular disease but to increase it by the added toxemias of gout and syphilis, of various excesses and bad habits, in which not only do arterial coats suffer, but the heart muscle and lining as well. The relations then of systematic toxemias to arterial disease and finally to surgical conditions are not so circuitous as may at first appear.

ANEURYSM.

An aneurysm is a tumor communicating with an artery and containing circulating or coagulated blood, or both. It may be formed entirely from the wall of the vessel, or some portion of it may be formed by surrounding tissue. Several varieties of aneurysm are indicated by descriptive adjectives. They are divided, first, into true and false, the former being composed of all the vascular coats and being small and infrequent; the false aneurysms imply those in which the entire arterial wall does not participate. Aneurysms inside the body cavities are called internal, and those involving the limbs external. The terms spontaneous and traumatic apply here as elsewhere. Fusiform aneurysm implies a spindle-like dilatation of the vessel in somewhat regular form. The sacculated aneurysm is essentially a pouch protruding from one side of the vessel with which it communicates. When the sac ruptures the aneurysm becomes diffuse. If the outer coat gives way and the inner protrudes there is a hernial aneurysm. The dissecting aneurysm is one formed by separation between the arterial coats, so that blood coagulates or flows between them. Such an aneurysm tends to assume a sacculate form and to rupture. A varicose aneurysm is a sac through which an artery and adjoining vein communicate. A cirsoid aneurysm corresponds to a varix on the venous side of the circulation, and implies dilatation of an artery and its branches. (See Figs. 140 to 145.)

Fig. 140

Fig. 141

Fig. 142

 

True aneurysm; the sac formed by all the coats. (Holmes.)

False aneurysm; the sac formed by the outer coat only. (Holmes.)

Traumatic aneurysm; the sac formed by the tissues around the vessel. (Holmes.)

 

Fig. 143

Fig. 144

Fig. 145

 

Dissecting aneurysm. (Holmes.)

Hernial aneurysm; the sac formed by the inner coat only. (Holmes.)

Sacculated aneurysm of ascending aorta. Death by pressure. (Erichsen.)

 

The formation of an aneurysm implies previous disease of the bloodvessel or traumatism, by either of which its coats must have been weakened or divided. The previous disease which leads to this change is either of syphilitic or other toxic origin, and usually of the type of the endarteritis already alluded to, or its continuation into atheroma. A so-called atheromatous ulcer may lead to giving way of the intima and the passage of blood between the coats of the vessel. It is in this way that most dissecting aneurysms are formed. On the other hand, violent strain may stretch the vessels already weakened by increasing blood pressure, or those conditions which induce abnormally high blood pressure may produce it by slow processes. Lastly a vessel may be partly divided, as by a bullet or stab wound, or its adjoining supports may have been weakened by disease or by accident to such an extent that it constitutes a weakening of the arterial wall. The result of this will be expansion in the direction of least resistance and the formation of a sacculated aneurysm.

As a morbid condition spontaneous aneurysm seems to be less frequent now than in the past. Certain features pertain to all cases, the most essential being a pulsating tumor, giving physical signs of its presence by pressure, which causes pain, sometimes paralysis, and nearly always absorption of surrounding tissues as the tumor expands. Pulsation is characteristic and pathognomonic of aneurysm, but an aneurysmal sac may have become so filled with clots as to minimize the prominence of this symptom. The same is true of the aneurysmal bruit or murmur which is heard on auscultation. This sound and pulsation, especially of the expansile type, when present will rarely deceive. They may, however, be simulated by a solid tumor which overlies a large vessel and transmits its pulsation or even some of its murmur. Even in this case the significant expansile character of the pulsation will be lacking.

The progress of an aneurysm may be checked by spontaneous or surgical processes, but no vessel involved in this way can return to its previous condition. As the vessel expands the tendency is to fortification of its weakened walls by coagulation of the blood around the periphery of the sac. This process may be a continuous one or may occur at intervals in such a way as to produce laminated coats of blood clot, complete or incomplete, which in certain specimens can be peeled off, one after another, much as an onion can be peeled, the innermost portion representing the most recent coagulum. In this way an aneurysm is strengthened and thickened, and rupture postponed for an indefinite period. On the other hand, as the aneurysmal tumor grows slowly but steadily it tends to make way for itself at the expense of every other tissue in the body. The hardest bone will disappear before the constant advance of such a growth, and this permits aneurysms which have had their origin in the thorax to develop into large extrathoracic tumors whose walls, lacking resistance, become thinner and finally give way, death from hemorrhage being the result. In fact, rupture is the natural tendency of such lesion, the question being whether it may be averted by spontaneous or non-operative methods, or whether it should be subjected to operation (Fig. 146).

Fig. 146

Thoracic (aortic) aneurysm. Death from external rupture.

Aneurysms may be minute and multiple, or single and large. The former are seen in the brain in connection with syphilis, and in the mesentery (Fig. 147). No artery in the body is necessarily exempt, though obviously the larger arterial trunks are the more frequent sufferers.

Spontaneous cure by natural methods is brought about in one of the following ways: (a) By consolidation of laminated clots. (b) A portion of the clot may become detached and plug the vessel on the distal side, effecting the same occlusion there that is produced with a ligature; in some cases the vessel may be occluded above the sac by a clot from the heart. (c) That which occurs naturally may be caused by accident as the result of some trifling injury. (d) The clot contained within the sac may have become infected, so that suppuration with necrosis of the sac contents is produced. In connection with this there is sufficient acute arteritis to occlude the vessel, and the resulting abscess within the sac may be opened and its contents cleared out. This method is extremely rare and can only terminate happily when the surgeon intervenes promptly.

In an aneurysm in which spontaneous cure has occurred there may be progressive condensation of its contents, obliteration and partial reduction in size, and a slow process of absorption.

The importance of collateral circulation, in recovery from aneurysm, cannot be overestimated, as only by taking advantage of it is it possible to furnish blood for the needs of the part affected. There is no vessel with which the surgeon can interfere where natural provisions in this direction appear insufficient (Fig. 148).

Certain conditions predispose to aneurysm of the idiopathic type, such as age, with its accompaniment of arteriosclerosis; syphilis, with its well-known tendency to chronic endarteritis; occupation and sex, in that it is most frequent in those who are liable to violent exertion and dissipation, because of the well-known tendency to arterial structural changes after excesses of all kinds. Again, aneurysm may be the secondary result of embolism when an embolus leads to a local arteritis with disorganization.