Friday, July 27, 2007

Critiquing Hillsong

If there is one thing I believe the Church as a whole would benefit from, it is open dialogue. Too often, the Church finds itself shutting down debate on important issues. Those who have been prepared to speak out against the status quo have been branded trouble-makers, malcontents and even heretics. Throughout the centuries, many of these "heretics" have put to death merely for the crime of calling for accountability.

If one looks at the history of the Church, freedom of thought and speech has often been prevented when the Church was at its most powerful. It is interesting to note that while the Reformation was just starting to develop, John Calvin led the charge for religious freedom. However, as the Reformed community in Geneva grew in influence and power, the same John Calvin used the full weight of his influence to prevent the freedom of individuals to express opinions about the Bible that disagreed with his understanding. As is well documented, Calvin even played a pivotal role in the execution of the dissident Michael Servetus. Many of his followers even today have embraced similarly censorious approaches to opinions that conflict with their own. If nothing else, it is good to see that they are carrying on the family tradition!

In the pursuit of promoting open and honest dialogue, a friend of mine has creating Critiquing Hillsong, a site dedicated to encourage transparency in financial and leadership matters at Hillsong - which I shall also place on my links page. My friend has had extensive experience within Hillsong and has already attempted to look at their financial records - unfortunately without success. This has occurred despite the fact that Hillsong has previously claimed that all of its financial records are openly available to the public.

Now, I should point out that even while the openly expressed agenda of Hillsong grates against my values, I haven't personally taken the lead in pushing for transparency in the affairs of Hillsong. The primary reason for this is because I haven't had any significant degree of involvement in Hillsong and thus my testimony contributes relatively little weight to the cause. However, I am willing to promote Critiquing Hillson - firstly, because I believe my friend to be a trustworthy individual with integrity and secondly, because I believe heavily in the pursuit of transparency and honesty. Quite simply, I believe that an organisation that is meant to represent truth has no business in embracing censorship.

Short of comments defaming the character of others or otherwise creating messy legal implications, I have made the very conscious decision to encourage open discussion on my blog. It is an incredibly defensive strategy to censor comments and shows a real lack of faith in one's position. My rationale has always been that if my position cannot withstand attack, it is not worth having. And what do I fear from transparency, apart from that which will come to light eventually anyway? I can only hope that Hillsong and others will adopt a similar approach.

8 comments:

emblazoned said...

Thanks mate I appreciate the support.

Whilst it is true that there is no perfect organisation, and that every organisation has 'dirt' if we dig deep enough, I think there is a real problem when there is a serious shortage of accountability and openess.

I still support the existence of an organised church, accepting it is not for everybody, but if it's going to exist...i think it should be held accountable for the claims it makes..

Anonymous said...

CHAPTER I

REPAIR


Introduction--Process of repair--Healing by primary union--Granulation
tissue--Cicatricial tissue--Modifications of process of
repair--Repair in individual tissues--Transplantation or grafting
of tissues--Conditions--Sources of grafts--Grafting of individual
tissues--Methods.


INTRODUCTION

To prolong human life and to alleviate suffering are the ultimate
objects of scientific medicine. The two great branches of the healing
art--Medicine and Surgery--are so intimately related that it is
impossible to draw a hard-and-fast line between them, but for
convenience Surgery may be defined as "the art of treating lesions and
malformations of the human body by manual operations, mediate and
immediate." To apply his art intelligently and successfully, it is
essential that the surgeon should be conversant not only with the normal
anatomy and physiology of the body and with the various pathological
conditions to which it is liable, but also with the nature of the
process by which repair of injured or diseased tissues is effected.
Without this knowledge he is unable to recognise such deviations from
the normal as result from mal-development, injury, or disease, or
rationally to direct his efforts towards the correction or removal of
these.


PROCESS OF REPAIR

The process of repair in living tissue depends upon an inherent power
possessed by vital cells of reacting to the irritation caused by injury
or disease. The cells of the damaged tissues, under the influence of
this irritation, undergo certain proliferative changes, which are
designed to restore the normal structure and configuration of the part.
The process by which this restoration is effected is essentially the
same in all tissues, but the extent to which different tissues can carry
the recuperative process varies. Simple structures, such as skin,
cartilage, bone, periosteum, and tendon, for example, have a high power
of regeneration, and in them the reparative process may result in almost
perfect restitution to the normal. More complex structures, on the other
hand, such as secreting glands, muscle, and the tissues of the central
nervous system, are but imperfectly restored, simple cicatricial
connective tissue taking the place of what has been lost or destroyed.
Any given tissue can be replaced only by tissue of a similar kind, and
in a damaged part each element takes its share in the reparative process
by producing new material which approximates more or less closely to the
normal according to the recuperative capacity of the particular tissue.
The normal process of repair may be interfered with by various
extraneous agencies, the most important of which are infection by
disease-producing micro-organisms, the presence of foreign substances,
undue movement of the affected part, and improper applications and
dressings. The effect of these agencies is to delay repair or to prevent
the individual tissues carrying the process to the furthest degree of
which they are capable.

In the management of wounds and other diseased conditions the main
object of the surgeon is to promote the natural reparative process by
preventing or eliminating any factor by which it may be disturbed.

#Healing by Primary Union.#--The most favourable conditions for the
progress of the reparative process are to be found in a clean-cut wound
of the integument, which is uncomplicated by loss of tissue, by the
presence of foreign substances, or by infection with disease-producing
micro-organisms, and its edges are in contact. Such a wound in virtue of
the absence of infection is said to be _aseptic_, and under these
conditions healing takes place by what is called "primary union"--the
"healing by first intention" of the older writers.

#Granulation Tissue.#--The essential and invariable medium of repair in
all structures is an elementary form of new tissue known as _granulation
tissue_, which is produced in the damaged area in response to the
irritation caused by injury or disease. The vital reaction induced by
such irritation results in dilatation of the vessels of the part,
emigration of leucocytes, transudation of lymph, and certain
proliferative changes in the fixed tissue cells. These changes are
common to the processes of inflammation and repair; no hard-and-fast
line can be drawn between these processes, and the two may go on
together. It is, however, only when the proliferative changes have come
to predominate that the reparative process is effectively established by
the production of healthy granulation tissue.

_Formation of Granulation Tissue._--When a wound is made in the
integument under aseptic conditions, the passage of the knife through
the tissues is immediately followed by an oozing of blood, which soon
coagulates on the cut surfaces. In each of the divided vessels a clot
forms, and extends as far as the nearest collateral branch; and on the
surface of the wound there is a microscopic layer of bruised and
devitalised tissue. If the wound is closed, the narrow space between its
edges is occupied by blood-clot, which consists of red and white
corpuscles mixed with a quantity of fibrin, and this forms a temporary
uniting medium between the divided surfaces. During the first twelve
hours, the minute vessels in the vicinity of the wound dilate, and from
them lymph exudes and leucocytes migrate into the tissues. In from
twenty-four to thirty-six hours, the capillaries of the part adjacent to
the wound begin to throw out minute buds and fine processes, which
bridge the gap and form a firmer, but still temporary, connection
between the two sides. Each bud begins in the wall of the capillary as a
small accumulation of granular protoplasm, which gradually elongates
into a filament containing a nucleus. This filament either joins with a
neighbouring capillary or with a similar filament, and in time these
become hollow and are filled with blood from the vessels that gave them
origin. In this way a series of young _capillary loops_ is formed.

The spaces between these loops are filled by cells of various kinds, the
most important being the _fibroblasts_, which are destined to form
cicatricial fibrous tissue. These fibroblasts are large irregular
nucleated cells derived mainly from the proliferation of the fixed
connective-tissue cells of the part, and to a less extent from the
lymphocytes and other mononuclear cells which have migrated from the
vessels. Among the fibroblasts, larger multi-nucleated cells--_giant
cells_--are sometimes found, particularly when resistant substances,
such as silk ligatures or fragments of bone, are embedded in the
tissues, and their function seems to be to soften such substances
preliminary to their being removed by the phagocytes. Numerous
_polymorpho-nuclear leucocytes_, which have wandered from the vessels,
are also present in the spaces. These act as phagocytes, their function
being to remove the red corpuscles and fibrin of the original clot, and
this performed, they either pass back into the circulation in virtue of
their amoeboid movement, or are themselves eaten up by the growing
fibroblasts. Beyond this phagocytic action, they do not appear to play
any direct part in the reparative process. These young capillary loops,
with their supporting cells and fluids, constitute granulation tissue,
which is usually fully formed in from three to five days, after which it
begins to be replaced by cicatricial or scar tissue.

_Formation of Cicatricial Tissue._--The transformation of this temporary
granulation tissue into scar tissue is effected by the fibroblasts,
which become elongated and spindle-shaped, and produce in and around
them a fine fibrillated material which gradually increases in quantity
till it replaces the cell protoplasm. In this way white fibrous tissue
is formed, the cells of which are arranged in parallel lines and
eventually become grouped in bundles, constituting fully formed white
fibrous tissue. In its growth it gradually obliterates the capillaries,
until at the end of two, three, or four weeks both vessels and cells
have almost entirely disappeared, and the original wound is occupied by
cicatricial tissue. In course of time this tissue becomes consolidated,
and the cicatrix undergoes a certain amount of contraction--_cicatricial
contraction_.

_Healing of Epidermis._--While these changes are taking place in the
deeper parts of the wound, the surface is being covered over by
_epidermis_ growing in from the margins. Within twelve hours the cells
of the rete Malpighii close to the cut edge begin to sprout on to the
surface of the wound, and by their proliferation gradually cover the
granulations with a thin pink pellicle. As the epithelium increases in
thickness it assumes a bluish hue and eventually the cells become
cornified and the epithelium assumes a greyish-white colour.

_Clinical Aspects._--So long as the process of repair is not complicated
by infection with micro-organisms, there is no interference with the
general health of the patient. The temperature remains normal; the
circulatory, gastro-intestinal, nervous, and other functions are
undisturbed; locally, the part is cool, of natural colour and free from
pain.

#Modifications of the Process of Repair.#--The process of repair by
primary union, above described, is to be looked upon as the type of all
reparative processes, such modifications as are met with depending
merely upon incidental differences in the conditions present, such as
loss of tissue, infection by micro-organisms, etc.

_Repair after Loss or Destruction of Tissue._--When the edges of a wound
cannot be approximated either because tissue has been lost, for example
in excising a tumour or because a drainage tube or gauze packing has
been necessary, a greater amount of granulation tissue is required to
fill the gap, but the process is essentially the same as in the ideal
method of repair.

The raw surface is first covered by a layer of coagulated blood and
fibrin. An extensive new formation of capillary loops and fibroblasts
takes place towards the free surface, and goes on until the gap is
filled by a fine velvet-like mass of granulation tissue. This
granulation tissue is gradually replaced by young cicatricial tissue,
and the surface is covered by the ingrowth of epithelium from the edges.

This modification of the reparative process can be best studied
clinically in a recent wound which has been packed with gauze. When the
plug is introduced, the walls of the cavity consist of raw tissue with
numerous oozing blood vessels. On removing the packing on the fifth or
sixth day, the surface is found to be covered with minute, red,
papillary granulations, which are beginning to fill up the cavity. At
the edges the epithelium has proliferated and is covering over the newly
formed granulation tissue. As lymph and leucocytes escape from the
exposed surface there is a certain amount of serous or sero-purulent
discharge. On examining the wound at intervals of a few days, it is
found that the granulation tissue gradually increases in amount till the
gap is completely filled up, and that coincidently the epithelium
spreads in and covers over its surface. In course of time the epithelium
thickens, and as the granulation tissue is slowly replaced by young
cicatricial tissue, which has a peculiar tendency to contract and so to
obliterate the blood vessels in it, the scar that is left becomes
smooth, pale, and depressed. This method of healing is sometimes spoken
of as "healing by granulation"--although, as we have seen, it is by
granulation that all repair takes place.

_Healing by Union of two Granulating Surfaces._--In gaping wounds union
is sometimes obtained by bringing the two surfaces into apposition after
each has become covered with healthy granulations. The exudate on the
surfaces causes them to adhere, capillary loops pass from one to the
other, and their final fusion takes place by the further development of
granulation and cicatricial tissue.

_Reunion of Parts entirely Separated from the Body._--Small portions of
tissue, such as the end of a finger, the tip of the nose or a portion of
the external ear, accidentally separated from the body, if accurately
replaced and fixed in position, occasionally adhere by primary union.

In the course of operations also, portions of skin, fascia, or bone, or
even a complete joint may be transplanted, and unite by primary union.

_Healing under a Scab._--When a small superficial wound is exposed to
the air, the blood and serum exuded on its surface may dry and form a
hard crust or _scab_, which serves to protect the surface from external
irritation in the same way as would a dry pad of sterilised gauze. Under
this scab the formation of granulation tissue, its transformation into
cicatricial tissue, and the growth of epithelium on the surface, go on
until in the course of time the crust separates, leaving a scar.

_Healing by Blood-clot._--In subcutaneous wounds, for example tenotomy,
in amputation wounds, and in wounds made in excising tumours or in
operating upon bones, the space left between the divided tissues becomes
filled with blood-clot, which acts as a temporary scaffolding in which
granulation tissue is built up. Capillary loops grow into the coagulum,
and migrated leucocytes from the adjacent blood vessels destroy the red
corpuscles, and are in turn disposed of by the developing fibroblasts,
which by their growth and proliferation fill up the gap with young
connective tissue. It will be evident that this process only differs
from healing by primary union in the _amount_ of blood-clot that is
present.

_Presence of a Foreign Body._--When an aseptic foreign body is present
in the tissues, _e.g._ a piece of unabsorbable chromicised catgut, the
healing process may be modified. After primary union has taken place the
scar may broaden, become raised above the surface, and assume a
bluish-brown colour; the epidermis gradually thins and gives way,
revealing the softened portion of catgut, which can be pulled out in
pieces, after which the wound rapidly heals and resumes a normal
appearance.

Anonymous said...

REPAIR IN INDIVIDUAL TISSUES

_Skin and Connective Tissue._--The mode of regeneration of these tissues
under aseptic conditions has already been described as the type of ideal
repair. In highly vascular parts, such as the face, the reparative
process goes on with great rapidity, and even extensive wounds may be
firmly united in from three to five days. Where the anastomosis is less
free the process is more prolonged. The more highly organised elements
of the skin, such as the hair follicles, the sweat and sebaceous glands,
are imperfectly reproduced; hence the scar remains smooth, dry, and
hairless.

_Epithelium._--Epithelium is only reproduced from pre-existing
epithelium, and, as a rule, from one of a similar type, although
metaplastic transformation of cells of one kind of epithelium into
another kind can take place. Thus a granulating surface may be covered
entirely by the ingrowing of the cutaneous epithelium from the margins;
or islets, originating in surviving cells of sebaceous glands or sweat
glands, or of hair follicles, may spring up in the centre of the raw
area. Such islets may also be due to the accidental transference of
loose epithelial cells from the edges. Even the fluid from a blister, in
virtue of the isolated cells of the rete Malpighii which it contains, is
capable of starting epithelial growth on a granulating surface. Hairs
and nails may be completely regenerated if a sufficient amount of the
hair follicles or of the nail matrix has escaped destruction. The
epithelium of a mucous membrane is regenerated in the same way as that
on a cutaneous surface.

Epithelial cells have the power of living for some time after being
separated from their normal surroundings, and of growing again when once
more placed in favourable circumstances. On this fact the practice of
skin grafting is based (p. 11).

_Cartilage._--When an articular cartilage is divided by incision or by
being implicated in a fracture involving the articular end of a bone, it
is repaired by ordinary cicatricial fibrous tissue derived from the
proliferating cells of the perichondrium. Cartilage being a non-vascular
tissue, the reparative process goes on slowly, and it may be many weeks
before it is complete.

It is possible for a metaplastic transformation of connective-tissue
cells into cartilage cells to take place, the characteristic hyaline
matrix being secreted by the new cells. This is sometimes observed as an
intermediary stage in the healing of fractures, especially in young
bones. It may also take place in the regeneration of lost portions of
cartilage, provided the new tissue is so situated as to constitute part
of a joint and to be subjected to pressure by an opposing cartilaginous
surface. This is illustrated by what takes place after excision of
joints where it is desired to restore the function of the articulation.
By carrying out movements between the constituent parts, the fibrous
tissue covering the ends of the bones becomes moulded into shape, its
cells take on the characters of cartilage cells, and, forming a matrix,
so develop a new cartilage.

Conversely, it is observed that when articular cartilage is no longer
subjected to pressure by an opposing cartilage, it tends to be
transformed into fibrous tissue, as may be seen in deformities attended
with displacement of articular surfaces, such as hallux valgus and
club-foot.

After fractures of costal cartilage or of the cartilages of the larynx
the cicatricial tissue may be ultimately replaced by bone.

_Tendons._--When a tendon is divided, for example by subcutaneous
tenotomy, the end nearer the muscle fibres is drawn away from the other,
leaving a gap which is speedily filled by blood-clot. In the course of a
few days this clot becomes permeated by granulation tissue, the
fibroblasts of which are derived from the sheath of the tendon, the
surrounding connective tissue, and probably also from the divided ends
of the tendon itself. These fibroblasts ultimately develop into typical
tendon cells, and the fibres which they form constitute the new tendon
fibres. Under aseptic conditions repair is complete in from two to three
weeks. In the course of the reparative process the tendon and its sheath
may become adherent, which leads to impaired movement and stiffness. If
the ends of an accidentally divided tendon are at once brought into
accurate apposition and secured by sutures, they unite directly with a
minimum amount of scar tissue, and function is perfectly restored.

_Muscle._--Unstriped muscle does not seem to be capable of being
regenerated to any but a moderate degree. If the ends of a divided
striped muscle are at once brought into apposition by stitches, primary
union takes place with a minimum of intervening fibrous tissue. The
nuclei of the muscle fibres in close proximity to this young cicatricial
tissue proliferate, and a few new muscle fibres may be developed, but
any gross loss of muscular tissue is replaced by a fibrous cicatrix. It
would appear that portions of muscle transplanted from animals to fill
up gaps in human muscle are similarly replaced by fibrous tissue. When a
muscle is paralysed from loss of its nerve supply and undergoes complete
degeneration, it is not capable of being regenerated, even should the
integrity of the nerve be restored, and so its function is permanently
lost.

_Secretory Glands._--The regeneration of secretory glands is usually
incomplete, cicatricial tissue taking the place of the glandular
substance which has been destroyed. In wounds of the liver, for example,
the gap is filled by fibrous tissue, but towards the periphery of the
wound the liver cells proliferate and a certain amount of regeneration
takes place. In the kidney also, repair mainly takes place by
cicatricial tissue, and although a few collecting tubules may be
reformed, no regeneration of secreting tissue takes place. After the
operation of decapsulation of the kidney a new capsule is formed, and
during the process young blood vessels permeate the superficial parts
of the kidney and temporarily increase its blood supply, but in the
consolidation of the new fibrous tissue these vessels are ultimately
obliterated. This does not prove that the operation is useless, as the
temporary improvement of the circulation in the kidney may serve to tide
the patient over a critical period of renal insufficiency.

_Stomach and Intestine._--Provided the peritoneal surfaces are
accurately apposed, wounds of the stomach and intestine heal with great
rapidity. Within a few hours the peritoneal surfaces are glued together
by a thin layer of fibrin and leucocytes, which is speedily organised
and replaced by fibrous tissue. Fibrous tissue takes the place of the
muscular elements, which are not regenerated. The mucous lining is
restored by ingrowth from the margins, and there is evidence that some
of the secreting glands may be reproduced.

Hollow viscera, like the oesophagus and urinary bladder, in so far
as they are not covered by peritoneum, heal less rapidly.

_Nerve Tissues._--There is no trustworthy evidence that regeneration of
the tissues of the brain or spinal cord in man ever takes place. Any
loss of substance is replaced by cicatricial tissue.

The repair of _Bone_, _Blood Vessels_, and _Peripheral Nerves_ is more
conveniently considered in the chapters dealing with these structures.

#Rate of Healing.#--While the rate at which wounds heal is remarkably
constant there are certain factors that influence it in one direction or
the other. Healing is more rapid when the edges are in contact, when
there is a minimum amount of blood-clot between them, when the patient
is in normal health and the vitality of the tissues has not been
impaired. Wounds heal slightly more quickly in the young than in the
old, although the difference is so small that it can only be
demonstrated by the most careful observations.

Certain tissues take longer to heal than others: for example, a fracture
of one of the larger long bones takes about six weeks to unite, and
divided nerve trunks take much longer--about a year.

Wounds of certain parts of the body heal more quickly than others: those
of the scalp, face, and neck, for example, heal more quickly than those
over the buttock or sacrum, probably because of their greater
vascularity.

The extent of the wound influences the rate of healing; it is only
natural that a long and deep wound should take longer to heal than a
short and superficial one, because there is so much more work to be
done in the conversion of blood-clot into granulation tissue, and this
again into scar tissue that will be strong enough to stand the strain on
the edges of the wound.


THE TRANSPLANTATION OR GRAFTING OF TISSUES

Conditions are not infrequently met with in which healing is promoted
and restoration of function made possible by the transference of a
portion of tissue from one part of the body to another; the tissue
transferred is known as the _graft_ or the _transplant_. The simplest
example of grafting is the transplantation of skin.

In order that the graft may survive and have a favourable chance of
"taking," as it is called, the transplanted tissue must retain its
vitality until it has formed an organic connection with the tissue in
which it is placed, so that it may derive the necessary nourishment from
its new bed. When these conditions are fulfilled the tissues of the
graft continue to proliferate, producing new tissue elements to replace
those that are lost and making it possible for the graft to become
incorporated with the tissue with which it is in contact.

Dead tissue, on the other hand, can do neither of these things; it is
only capable of acting as a model, or, at the most, as a scaffolding for
such mobile tissue elements as may be derived from, the parent tissue
with which the graft is in contact: a portion of sterilised marine
sponge, for example, may be observed to become permeated with
granulation tissue when it is embedded in the tissues.

A successful graft of living tissue is not only capable of regeneration,
but it acquires a system of lymph and blood vessels, so that in time it
bleeds when cut into, and is permeated by new nerve fibres spreading in
from the periphery towards the centre.

It is instructive to associate the period of survival of the different
tissues of the body after death, with their capacity of being used for
grafting purposes; the higher tissues such as those of the central
nervous system and highly specialised glandular tissues like those of
the kidney lose their vitality quickly after death and are therefore
useless for grafting; connective tissues, on the other hand, such as
fat, cartilage, and bone retain their vitality for several hours after
death, so that when they are transplanted, they readily "take" and do
all that is required of them: the same is true of the skin and its
appendages.

_Sources of Grafts._--It is convenient to differentiate between
_autoplastic_ grafts, that is those derived from the same individual;
_homoplastic_ grafts, derived from another animal of the same species;
and _heteroplastic_ grafts, derived from an animal of another species.
Other conditions being equal, the prospects of success are greatest with
autoplastic grafts, and these are therefore preferred whenever possible.

There are certain details making for success that merit attention: the
graft must not be roughly handled or allowed to dry, or be subjected to
chemical irritation; it must be brought into accurate contact with the
new soil, no blood-clot intervening between the two, no movement of the
one upon the other should be possible and all infection must be
excluded; it will be observed that these are exactly the same conditions
that permit of the primary healing of wounds, with which of course the
healing of grafts is exactly comparable.

_Preservation of Tissues for Grafting._--It was at one time believed
that tissues might be taken from the operating theatre and kept in cold
storage until they were required. It is now agreed that tissues which
have been separated from the body for some time inevitably lose their
vitality, become incapable of regeneration, and are therefore unsuited
for grafting purposes. If it is intended to preserve a portion of tissue
for future grafting, it should be embedded in the subcutaneous tissue of
the abdominal wall until it is wanted; this has been carried out with
portions of costal cartilage and of bone.


INDIVIDUAL TISSUES AS GRAFTS

#The Blood# lends itself in an ideal manner to transplantation, or, as
it has long been called, _transfusion_. Being always a homoplastic
transfer, the new blood is not always tolerated by the old, in which
case biochemical changes occur, resulting in hæmolysis, which
corresponds to the disintegration of other unsuccessful homoplastic
grafts. (See article on Transfusion, _Op. Surg._, p. 37.)

#The Skin.#--The skin was the first tissue to be used for grafting
purposes, and it is still employed with greater frequency than any
other, as lesions causing defects of skin are extremely common and
without the aid of grafts are tedious in healing.

Skin grafts may be applied to a raw surface or to one that is covered
with granulations.

_Skin grafting of raw surfaces_ is commonly indicated after operations
for malignant disease in which considerable areas of skin must be
sacrificed, and after accidents, such as avulsion of the scalp by
machinery.

_Skin grafting of granulating surfaces_ is chiefly employed to promote
healing in the large defects of skin caused by severe burns; the
grafting is carried out when the surface is covered by a uniform layer
of healthy granulations and before the inevitable contraction of scar
tissue makes itself manifest. Before applying the grafts it is usual to
scrape away the granulations until the young fibrous tissue underneath
is exposed, but, if the granulations are healthy and can be rendered
aseptic, the grafts may be placed on them directly.

If it is decided to scrape away the granulations, the oozing must be
arrested by pressure with a pad of gauze, a sheet of dental rubber or
green protective is placed next the raw surface to prevent the gauze
adhering and starting the bleeding afresh when it is removed.

#Methods of Skin-Grafting.#--Two methods are employed: one in which the
epidermis is mainly or exclusively employed--epidermis or epithelial
grafting; the other, in which the graft consists of the whole thickness
of the true skin--cutis-grafting.

_Epidermis or Epithelial Grafting._--The method introduced by the late
Professor Thiersch of Leipsic is that almost universally practised. It
consists in transplanting strips of epidermis shaved from the surface of
the skin, the razor passing through the tips of the papillæ, which
appear as tiny red points yielding a moderate ooze of blood.

The strips are obtained from the front and lateral aspects of the thigh
or upper arm, the skin in those regions being pliable and comparatively
free from hairs.

They are cut with a sharp hollow-ground razor or with Thiersch's
grafting knife, the blade of which is rinsed in alcohol and kept
moistened with warm saline solution. The cutting is made easier if the
skin is well stretched and kept flat and perfectly steady, the
operator's left hand exerting traction on the skin behind, the hands of
the assistant on the skin in front, one above and the other below the
seat of operation. To ensure uniform strips being cut, the razor is kept
parallel with the surface and used with a short, rapid, sawing movement,
so that, with a little practice, grafts six or eight inches long by one
or two inches broad can readily be cut. The patient is given a general
anæsthetic, or regional anæsthesia is obtained by injections of a
solution of one per cent. novocain into the line of the lateral and
middle cutaneous nerves; the disinfection of the skin is carried out on
the usual lines, any chemical agent being finally got rid of, however,
by means of alcohol followed by saline solution.

The strips of epidermis wrinkle up on the knife and are directly
transferred to the surface, for which they should be made to form a
complete carpet, slightly overlapping the edges of the area and of one
another; some blunt instrument is used to straighten out the strips,
which are then subjected to firm pressure with a pad of gauze to express
blood and air-bells and to ensure accurate contact, for this must be as
close as that between a postage stamp and the paper to which it is
affixed.

As a dressing for the grafted area and of that also from which the
grafts have been taken, gauze soaked in _liquid paraffin_--the patent
variety known as _ambrine_ is excellent--appears to be the best; the
gauze should be moistened every other day or so with fresh paraffin, so
that, at the end of a week, when the grafts should have united, the
gauze can be removed without risk of detaching them. _Dental wax_ is
another useful type of dressing; as is also _picric acid_ solution. Over
the gauze, there is applied a thick layer of cotton wool, and the whole
dressing is kept in place by a firmly applied bandage, and in the case
of the limbs some form of splint should be added to prevent movement.

A dressing may be dispensed with altogether, the grafts being protected
by a wire cage such as is used after vaccination, but they tend to dry
up and come to resemble a scab.

When the grafts have healed, it is well to protect them from injury and
to prevent them drying up and cracking by the liberal application of
lanoline or vaseline.

The new skin is at first insensitive and is fixed to the underlying
connective tissue or bone, but in course of time (from six weeks
onwards) sensation returns and the formation of elastic tissue beneath
renders the skin pliant and movable so that it can be pinched up between
the finger and thumb.

_Reverdin's_ method consists in planting out pieces of skin not bigger
than a pin-head over a granulating surface. It is seldom employed.

_Grafts of the Cutis Vera._--Grafts consisting of the entire thickness
of the true skin were specially advocated by Wolff and are often
associated with his name. They should be cut oval or spindle-shaped, to
facilitate the approximation of the edges of the resulting wound. The
graft should be cut to the exact size of the surface it is to cover;
Gillies believes that tension of the graft favours its taking. These
grafts may be placed either on a fresh raw surface or on healthy
granulations. It is sometimes an advantage to stitch them in position,
especially on the face. The dressing and the after-treatment are the
same as in epidermis grafting.

There is a degree of uncertainty about the graft retaining its vitality
long enough to permit of its deriving the necessary nourishment from its
new surroundings; in a certain number of cases the flap dies and is
thrown off as a slough--moist or dry according to the presence or
absence of septic infection.

The technique for cutis-grafting must be without a flaw, and the asepsis
absolute; there must not only be a complete absence of movement, but
there must be no traction on the flap that will endanger its blood
supply.

Owing to the uncertainty in the results of cutis-grafting the
_two-stage_ or _indirect method_ has been introduced, and its almost
uniform success has led to its sphere of application being widely
extended. The flap is raised as in the direct method but is left
attached at one of its margins for a period ranging from 14 to 21 days
until its blood supply from its new bed is assured; the detachment is
then made complete. The blood supply of the proposed flap may influence
its selection and the way in which it is fashioned; for example, a flap
cut from the side of the head to fill a defect in the cheek, having in
its margin of attachment or pedicle the superficial temporal artery, is
more likely to take than a flap cut with its base above.

Another modification is to raise the flap but leave it connected at both
ends like the piers of a bridge; this method is well suited to defects
of skin on the dorsum of the fingers, hand and forearm, the bridge of
skin is raised from the abdominal wall and the hand is passed beneath it
and securely fixed in position; after an interval of 14 to 21 days, when
the flap is assured of its blood supply, the piers of the bridge are
divided (Fig. 1). With undermining it is usually easy to bring the
edges of the gap in the abdominal wall together, even in children; the
skin flap on the dorsum of the hand appears rather thick and
prominent--almost like the pad of a boxing-glove--for some time, but
the restoration of function in the capacity to flex the fingers is
gratifying in the extreme.

[Illustration: FIG. 1.--Ulcer of back of Hand covered by flap of skin
raised from anterior abdominal wall. The lateral edges of the flap are
divided after the graft has adhered.]

The indirect element of this method of skin-grafting may be carried
still further by transferring the flap of skin first to one part of the
body and then, after it has taken, transferring it to a third part.
Gillies has especially developed this method in the remedying of
deformities of the face caused by gunshot wounds and by petrol burns in
air-men. A rectangular flap of skin is marked out in the neck and chest,
the lateral margins of the flap are raised sufficiently to enable them
to be brought together so as to form a tube of skin: after the
circulation has been restored, the lower end of the tube is detached and
is brought up to the lip or cheek, or eyelid, where it is wanted; when
this end has derived its new blood supply, the other end is detached
from the neck and brought up to where it is wanted. In this way, skin
from the chest may be brought up to form a new forehead and eyelids.

Grafts of _mucous membrane_ are used to cover defects in the lip, cheek,
and conjunctiva. The technique is similar to that employed in
skin-grafting; the sources of mucous membrane are limited and the
element of septic infection cannot always be excluded.

_Fat._--Adipose tissue has a low vitality, but it is easily retained and
it readily lends itself to transplantation. Portions of fat are often
obtainable at operations--from the omentum, for example, otherwise the
subcutaneous fat of the buttock is the most accessible; it may be
employed to fill up cavities of all kinds in order to obtain more rapid
and sounder healing and also to remedy deformity, as in filling up a
depression in the cheek or forehead. It is ultimately converted into
ordinary connective tissue _pari passu_ with the absorption of the fat.

The _fascia lata of the thigh_ is widely and successfully used as a
graft to fill defects in the dura mater, and interposed between the
bones of a joint--if the articular cartilage has been destroyed--to
prevent the occurrence of ankylosis.

The _peritoneum_ of hydrocele and hernial sacs and of the omentum
readily lends itself to transplantation.

_Cartilage and bone_, next to skin, are the tissues most frequently
employed for grafting purposes; their sphere of action is so extensive
and includes so much of technical detail in their employment, that they
will be considered later with the surgery of the bones and joints and
with the methods of re-forming the nose.

_Tendons and blood vessels_ readily lend themselves to transplantation
and will also be referred to later.

_Muscle and nerve_, on the other hand, do not retain their vitality when
severed from their surroundings and do not functionate as grafts except
for their connective-tissue elements, which it goes without saying are
more readily obtainable from other sources.

Portions of the _ovary_ and of the _thyreoid_ have been successfully
transplanted into the subcutaneous cellular tissue of the abdominal wall
by Tuffier and others. In these new surroundings, the ovary or thyreoid
is vascularised and has been shown to functionate, but there is not
sufficient regeneration of the essential tissue elements to "carry on";
the secreting tissue is gradually replaced by connective tissue and the
special function comes to an end. Even such temporary function may,
however, tide a patient over a difficult period.




CHAPTER II

CONDITIONS WHICH INTERFERE WITH REPAIR


SURGICAL BACTERIOLOGY

Want of rest--Irritation--Unhealthy tissues--Pathogenic bacteria.
SURGICAL BACTERIOLOGY--General characters of
bacteria--Classification of bacteria--Conditions of bacterial
life--Pathogenic powers of bacteria--Results of bacterial
growth--Death of bacteria--Immunity--Antitoxic sera--Identification
of bacteria--Pyogenic bacteria.

In the management of wounds and other surgical conditions it is
necessary to eliminate various extraneous influences which tend to delay
or arrest the natural process of repair.

Of these, one of the most important is undue movement of the affected
part. "The first and great requisite for the restoration of injured
parts is _rest_," said John Hunter; and physiological and mechanical
rest as the chief of natural therapeutic agents was the theme of John
Hilton's classical work--_Rest and Pain_. In this connection it must be
understood that "rest" implies more than the mere state of physical
repose: all physiological as well as mechanical function must be
prevented as far as is possible. For instance, the constituent bones of
a joint affected with tuberculosis must be controlled by splints or
other appliances so that no movement can take place between them, and
the limb may not be used for any purpose; physiological rest may be
secured to an inflamed colon by making an artificial anus in the cæcum;
the activity of a diseased kidney may be diminished by regulating the
quantity and quality of the fluids taken by the patient.

Another source of interference with repair in wounds is _irritation_,
either by mechanical agents such as rough, unsuitable dressings,
bandages, or ill-fitting splints; or by chemical agents in the form of
strong lotions or other applications.

An _unhealthy or devitalised condition of the patient's tissues_ also
hinders the reparative process. Bruised or lacerated skin heals less
kindly than skin cut with a smooth, sharp instrument; and persistent
venous congestion of a part, such as occurs, for example, in the leg
when the veins are varicose, by preventing the access of healthy blood,
tends to delay the healing of open wounds. The existence of grave
constitutional disease, such as Bright's disease, diabetes, syphilis,
scurvy, or alcoholism, also impedes healing.

Infection by disease-producing micro-organisms or _pathogenic bacteria_
is, however, the most potent factor in disturbing the natural process of
repair in wounds.


SURGICAL BACTERIOLOGY

The influence of micro-organisms in the causation of disease, and the
rôle played by them in interfering with the natural process of repair,
are so important that the science of applied bacteriology has now come
to dominate every department of surgery, and it is from the standpoint
of bacteriology that nearly all surgical questions have to be
considered.

The term _sepsis_ as now used in clinical surgery no longer retains its
original meaning as synonymous with "putrefaction," but is employed to
denote all conditions in which bacterial infection has taken place, and
more particularly those in which pyogenic bacteria are present. In the
same way the term _aseptic_ conveys the idea of freedom from all forms
of bacteria, putrefactive or otherwise; and the term _antiseptic_ is
used to denote a power of counteracting bacteria and their products.

#General Characters of Bacteria.#--A _bacterium_ consists of a finely
granular mass of protoplasm, enclosed in a thin gelatinous envelope.
Many forms are motile--some in virtue of fine thread-like flagella, and
others through contractility of the protoplasm. The great majority
multiply by simple fission, each parent cell giving rise to two daughter
cells, and this process goes on with extraordinary rapidity. Other
varieties, particularly bacilli, are propagated by the formation of
_spores_. A spore is a minute mass of protoplasm surrounded by a dense,
tough membrane, developed in the interior of the parent cell. Spores are
remarkable for their tenacity of life, and for the resistance they offer
to the action of heat and chemical germicides.

Bacteria are most conveniently classified according to their shape. Thus
we recognise (1) those that are globular--_cocci_; (2) those that
resemble a rod--_bacilli_; (3) the spiral or wavy forms--_spirilla_.

_Cocci_ or _micrococci_ are minute round bodies, averaging about 1 µ in
diameter. The great majority are non-motile. They multiply by fission;
and when they divide in such a way that the resulting cells remain in
pairs, are called _diplococci_, of which the bacteria of gonorrhoea and
pneumonia are examples (Fig. 5). When they divide irregularly, and form
grape-like bunches, they are known as _staphylococci_, and to this
variety the commonest pyogenic or pus-forming organisms belong (Fig. 2).
When division takes place only in one axis, so that long chains are
formed, the term _streptococcus_ is applied (Fig. 3). Streptococci are
met with in erysipelas and various other inflammatory and suppurative
processes of a spreading character.

_Bacilli_ are rod-shaped bacteria, usually at least twice as long as
they are broad (Fig. 4). Some multiply by fission, others by
sporulation. Some forms are motile, others are non-motile. Tuberculosis,
tetanus, anthrax, and many other surgical diseases are due to different
forms of bacilli.

_Spirilla_ are long, slender, thread-like cells, more or less spiral or
wavy. Some move by a screw-like contraction of the protoplasm, some by
flagellæ. The spirochæte associated with syphilis (Fig. 36) is the most
important member of this group.

#Conditions of Bacterial Life.#--Bacteria require for their growth and
development a suitable food-supply in the form of proteins,
carbohydrates, and salts of calcium and potassium which they break up
into simpler elements. An alkaline medium favours bacterial growth; and
moisture is a necessary condition; spores, however, can survive the want
of water for much longer periods than fully developed bacteria. The
necessity for oxygen varies in different species. Those that require
oxygen are known as _aërobic bacilli_ or _aërobes_; those that cannot
live in the presence of oxygen are spoken of as _anaërobes_. The great
majority of bacteria, however, while they prefer to have oxygen, are
able to live without it, and are called _facultative anaërobes_.

The most suitable temperature for bacterial life is from 95° to 102° F.,
roughly that of the human body. Extreme or prolonged cold paralyses but
does not kill micro-organisms. Few, however, survive being raised to a
temperature of 134½° F. Boiling for ten to twenty minutes will kill all
bacteria, and the great majority of spores. Steam applied in an
autoclave under a pressure of two atmospheres destroys even the most
resistant spores in a few minutes. Direct sunlight, electric light, or
even diffuse daylight, is inimical to the growth of bacteria, as are
also Röntgen rays and radium emanations.

#Pathogenic Properties of Bacteria.#--We are now only concerned with
pathogenic bacteria--that is, bacteria capable of producing disease in
the human subject. This capacity depends upon two sets of factors--(1)
certain features peculiar to the invading bacteria, and (2) others
peculiar to the host. Many bacteria have only the power of living upon
dead matter, and are known as _saphrophytes_. Such as do nourish in
living tissue are, by distinction, known as _parasites_. The power a
given parasitic micro-organism has of multiplying in the body and giving
rise to disease is spoken of as its _virulence_, and this varies not
only with different species, but in the same species at different times
and under varying circumstances. The actual number of organisms
introduced is also an important factor in determining their pathogenic
power. Healthy tissues can resist the invasion of a certain number of
bacteria of a given species, but when that number is exceeded, the
organisms get the upper hand and disease results. When the organisms
gain access directly to the blood-stream, as a rule they produce their
effects more certainly and with greater intensity than when they are
introduced into the tissues.

Further, the virulence of an organism is modified by the condition of
the patient into whose tissues it is introduced. So long as a person is
in good health, the tissues are able to resist the attacks of moderate
numbers of most bacteria. Any lowering of the vitality of the
individual, however, either locally or generally, at once renders him
more susceptible to infection. Thus bruised or torn tissue is much more
liable to infection with pus-producing organisms than tissues clean-cut
with a knife; also, after certain diseases, the liability to infection
by the organisms of diphtheria, pneumonia, or erysipelas is much
increased. Even such slight depression of vitality as results from
bodily fatigue, or exposure to cold and damp, may be sufficient to turn
the scale in the battle between the tissues and the bacteria. Age is an
important factor in regard to the action of certain bacteria. Young
subjects are attacked by diphtheria, tuberculosis, acute osteomyelitis,
and some other diseases with greater frequency and severity than those
of more advanced years.

In different races, localities, environment, and seasons, the pathogenic
powers of certain organisms, such as those of erysipelas, diphtheria,
and acute osteomyelitis, vary considerably.

There is evidence that a _mixed infection_--that is, the introduction of
more than one species of organism, for example, the tubercle bacillus
and a pyogenic staphylococcus--increases the severity of the resulting
disease. If one of the varieties gain the ascendancy, the poisons
produced by the others so devitalise the tissue cells, and diminish
their power of resistance, that the virulence of the most active
organisms is increased. On the other hand, there is reason to believe
that the products of certain organisms antagonise one another--for
example, an attack of erysipelas may effect the cure of a patch of
tuberculous lupus.

Lastly, in patients suffering from chronic wasting diseases, bacteria
may invade the internal organs by the blood-stream in enormous numbers
and with great rapidity, during the period of extreme debility which
shortly precedes death. The discovery of such collections of organisms
on post-mortem examination may lead to erroneous conclusions being drawn
as to the cause of death.

#Results of Bacterial Growth.#--Some organisms, such as those of tetanus
and erysipelas, and certain of the pyogenic bacteria, show little
tendency to pass far beyond the point at which they gain an entrance to
the body. Others, on the contrary--for example, the tubercle bacillus
and the organism of acute osteomyelitis--although frequently remaining
localised at the seat of inoculation, tend to pass to distant parts,
lodging in the capillaries of joints, bones, kidney, or lungs, and there
producing their deleterious effects.

In the human subject, multiplication in the blood-stream does not occur
to any great extent. In some general acute pyogenic infections, such as
osteomyelitis, cellulitis, etc., pure cultures of staphylococci or of
streptococci may be obtained from the blood. In pneumococcal and typhoid
infections, also, the organisms may be found in the blood.

It is by the vital changes they bring about in the parts where they
settle that micro-organisms disturb the health of the patient. In
deriving nourishment from the complex organic compounds in which they
nourish, the organisms evolve, probably by means of a ferment, certain
chemical products of unknown composition, but probably colloidal in
nature, and known as _toxins_. When these poisons are absorbed into the
general circulation they give rise to certain groups of symptoms--such
as rise of temperature, associated circulatory and respiratory
derangements, interference with the gastro-intestinal functions and also
with those of the nervous system--which go to make up the condition
known as blood-poisoning, toxæmia, or _bacterial intoxication_. In
addition to this, certain bacteria produce toxins that give rise to
definite and distinct groups of symptoms--such as the convulsions of
tetanus, or the paralyses that follow diphtheria.

_Death of Bacteria._--Under certain circumstances, it would appear that
the accumulation of the toxic products of bacterial action tends to
interfere with the continued life and growth of the organisms
themselves, and in this way the natural cure of certain diseases is
brought about. Outside the body, bacteria may be killed by starvation,
by want of moisture, by being subjected to high temperature, or by the
action of certain chemical agents of which carbolic acid, the
perchloride and biniodide of mercury, and various chlorine preparations
are the most powerful.

#Immunity.#--Some persons are insusceptible to infection by certain
diseases, from which they are said to enjoy a _natural immunity_. In
many acute diseases one attack protects the patient, for a time at
least, from a second attack--_acquired immunity_.

_Phagocytosis._--In the production of immunity the leucocytes and
certain other cells play an important part in virtue of the power they
possess of ingesting bacteria and of destroying them by a process of
intra-cellular digestion. To this process Metchnikoff gave the name of
_phagocytosis_, and he recognised two forms of _phagocytes_: (1) the
_microphages_, which are the polymorpho-nuclear leucocytes of the blood;
and (2) the _macrophages_, which include the larger hyaline leucocytes,
endothelial cells, and connective-tissue corpuscles.

During the process of phagocytosis, the polymorpho-nuclear leucocytes in
the circulating blood increase greatly in numbers (_leucocytosis_), as
well as in their phagocytic action, and in the course of destroying the
bacteria they produce certain ferments which enter the blood serum.
These are known as _opsonins_ or _alexins_, and they act on the bacteria
by a process comparable to narcotisation, and render them an easy prey
for the phagocytes.

_Artificial or Passive Immunity._--A form of immunity can be induced by
the introduction of protective substances obtained from an animal which
has been actively immunised. The process by which passive immunity is
acquired depends upon the fact that as a result of the reaction between
the specific virus of a particular disease (the _antigen_) and the
tissues of the animal attacked, certain substances--_antibodies_--are
produced, which when transferred to the body of a susceptible animal
protect it against that disease. The most important of these antibodies
are the _antitoxins_. From the study of the processes by which immunity
is secured against the effects of bacterial action the serum and vaccine
methods of treating certain infective diseases have been evolved. The
_serum treatment_ is designed to furnish the patient with a sufficiency
of antibodies to neutralise the infection. The anti-diphtheritic and the
anti-tetanic act by neutralising the specific toxins of the
disease--_antitoxic serums_; the anti-streptcoccic and the serum for
anthrax act upon the bacteria--_anti-bacterial serums_.

A _polyvalent_ serum, that is, one derived from an animal which has been
immunised by numerous strains of the organism derived from various
sources, is much more efficacious than when a single strain has been
used.

_Clinical Use of Serums._--Every precaution must be taken to prevent
organismal contamination of the serum or of the apparatus by means of
which it is injected. Syringes are so made that they can be sterilised
by boiling. The best situations for injection are under the skin of the
abdomen, the thorax, or the buttock, and the skin should be purified at
the seat of puncture. If the bulk of the full dose is large, it should
be divided and injected into different parts of the body, not more than
20 c.c. being injected at one place. The serum may be introduced
directly into a vein, or into the spinal canal, _e.g._ anti-tetanic
serum. The immunity produced by injections of antitoxic sera lasts only
for a comparatively short time, seldom longer than a few weeks.

_"Serum Disease" and Anaphylaxis._--It is to be borne in mind that some
patients exhibit a supersensitiveness with regard to protective sera, an
injection being followed in a few days by the appearance of an
urticarial or erythematous rash, pain and swelling of the joints, and a
variable degree of fever. These symptoms, to which the name _serum
disease_ is applied, usually disappear in the course of a few days.

The term _anaphylaxis_ is applied to an allied condition of
supersensitiveness which appears to be induced by the injection of
certain substances, including toxins and sera, that are capable of
acting as antigens. When a second injection is given after an interval
of some days, if anaphylaxis has been established by the first dose, the
patient suddenly manifests toxic symptoms of the nature of profound
shock which may even prove fatal. The conditions which render a person
liable to develop anaphylaxis and the mechanism by which it is
established are as yet imperfectly understood.

_Vaccine Treatment._--The vaccine treatment elaborated by A. E. Wright
consists in injecting, while the disease is still active, specially
prepared dead cultures of the causative organisms, and is based on the
fact that these "vaccines" render the bacteria in the tissues less able
to resist the attacks of the phagocytes. The method is most successful
when the vaccine is prepared from organisms isolated from the patient
himself, _autogenous vaccine_, but when this is impracticable, or takes
a considerable time, laboratory-prepared polyvalent _stock vaccines_ may
be used.

_Clinical Use of Vaccines._--Vaccines should not be given while a
patient is in a negative phase, as a certain amount of the opsonin in
the blood is used up in neutralising the substances injected, and this
may reduce the opsonic index to such an extent that the vaccines
themselves become dangerous. As a rule, the propriety of using a vaccine
can be determined from the general condition of the patient. The initial
dose should always be a small one, particularly if the disease is acute,
and the subsequent dosage will be regulated by the effect produced. If
marked constitutional disturbance with rise of temperature follows the
use of a vaccine, it indicates a negative phase, and calls for a
diminution in the next dose. If, on the other hand, the local as well as
the general condition of the patient improves after the injection, it
indicates a positive phase, and the original dose may be repeated or
even increased. Vaccines are best introduced subcutaneously, a part
being selected which is not liable to pressure, as there is sometimes
considerable local reaction. Repeated doses may be necessary at
intervals of a few days.

The vaccine treatment has been successfully employed in various
tuberculous lesions, in pyogenic infections such as acne, boils,
sycosis, streptococcal, pneumococcal, and gonococcal conditions, in
infections of the accessory air sinuses, and in other diseases caused by
bacteria.


PYOGENIC BACTERIA

From the point of view of the surgeon the most important varieties of
micro-organisms are those that cause inflammation and suppuration--the
_pyogenic bacteria_. This group includes a great many species, and these
are so widely distributed that they are to be met with under all
conditions of everyday life.

The nature of the inflammatory and suppurative processes will be
considered in detail later; suffice it here to say that they are brought
about by the action of one or other of the organisms that we have now to
consider.

It is found that the _staphylococci_, which cluster into groups, tend to
produce localised lesions; while the chain-forms--_streptococci_--give
rise to diffuse, spreading conditions. Many varieties of pyogenic
bacteria have now been differentiated, the best known being the
staphylococcus aureus, the streptococcus, and the bacillus coli
communis.

[Illustration: FIG. 2.--Staphylococcus aureus in Pus from case of
Osteomyelitis. × 1000 diam. Gram's stain.]

_Staphylococcus Aureus._--This is the commonest organism found in
localised inflammatory and suppurative conditions. It varies greatly in
its virulence, and is found in such widely different conditions as skin
pustules, boils, carbuncles, and some acute inflammations of bone. As
seen by the microscope it occurs in grape-like clusters, fission of the
individual cells taking place irregularly (Fig. 2). When grown in
artificial media, the colonies assume an orange-yellow colour--hence the
name _aureus_. It is of high vitality and resists more prolonged
exposure to high temperatures than most non-sporing bacteria. It is
capable of lying latent in the tissues for long periods, for example, in
the marrow of long bones, and of again becoming active and causing a
fresh outbreak of suppuration. This organism is widely distributed: it
is found on the skin, in the mouth, and in other situations in the body,
and as it is present in the dust of the air and on all objects upon
which dust has settled, it is a continual source of infection unless
means are taken to exclude it from wounds.

The _staphylococcus albus_ is much less common than the aureus, but has
the same properties and characters, save that its growth on artificial
media assumes a white colour. It is the common cause of stitch
abscesses, the skin being its normal habitat.

[Illustration: FIG. 3.--Streptococci in Pus from an acute abscess in
subcutaneous tissue. × 1000 diam. Gram's stain.]

_Streptococcus Pyogenes._--This organism also varies greatly in its
virulence; in some instances--for example in erysipelas--it causes a
sharp attack of acute spreading inflammation, which soon subsides
without showing any tendency to end in suppuration; under other
conditions it gives rise to a generalised infection which rapidly proves
fatal. The streptococcus has less capacity of liquefying the tissues
than the staphylococcus, so that pus formation takes place more slowly.
At the same time its products are very potent in destroying the tissues
in their vicinity, and so interfering with the exudation of leucocytes
which would otherwise exercise their protective influence. Streptococci
invade the lymph spaces, and are associated with acute spreading
conditions such as phlegmonous or erysipelatous inflammations and
suppurations, lymphangitis and suppuration in lymph glands, and
inflammation of serous and synovial membranes, also with a form of
pneumonia which is prone to follow on severe operations in the mouth and
throat. Streptococci are also concerned in the production of spreading
gangrene and pyæmia.

Division takes place in one axis, so that chains of varying length are
formed (Fig. 3). It is less easily cultivated by artificial media than
the staphylococcus; it forms a whitish growth.

[Illustration: FIG. 4.--Bacillus coli communis in Urine, from a case of
Cystitis. × 1000 diam. Leishman's stain.]

_Bacillus Coli Communis._--This organism, which is a normal inhabitant
of the intestinal tract, shows a great tendency to invade any organ or
tissue whose vitality is lowered. It is causatively associated with such
conditions as peritonitis and peritoneal suppuration resulting from
strangulated hernia, appendicitis, or perforation in any part of the
alimentary canal. In cystitis, pyelitis, abscess of the kidney,
suppuration in the bile-ducts or liver, and in many other abdominal
conditions, it plays a most important part. The discharge from wounds
infected by this organism has usually a foetid, or even a fæcal odour,
and often contains gases resulting from putrefaction.

It is a small rod-shaped organism with short flagellæ, which render it
motile (Fig. 4). It closely resembles the typhoid bacillus, but is
distinguished from it by its behaviour in artificial culture media.

[Illustration: FIG. 5.--Fraenkel's Pneumococci in Pus from Empyema
following Pneumonia. × 100 diam. Stained with Muir's capsule stain.]

_Pneumo-bacteria._--Two forms of organism associated with
pneumonia--_Fraenkel's pneumococcus_ (one of the diplococci) (Fig. 5)
and _Friedländer's pneumo-bacillus_ (a short rod-shaped form)--are
frequently met with in inflammations of the serous and synovial
membranes, in suppuration in the liver, and in various other
inflammatory and suppurative conditions.

_Bacillus Typhosus._--This organism has been found in pure culture in
suppurative conditions of bone, of cellular tissue, and of internal
organs, especially during convalescence from typhoid fever. Like the
staphylococcus, it is capable of lying latent in the tissues for long
periods.

_Other Pyogenic Bacteria._--It is not necessary to do more than name
some of the other organisms that are known to be pyogenic, such as the
bacillus pyocyaneus, which is found in green and blue pus, the
micrococcus tetragenus, the gonococcus, actinomyces, the glanders
bacillus, and the tubercle bacillus. Most of these will receive further
mention in connection with the diseases to which they give rise.

#Leucocytosis.#--Most bacterial diseases, as well as certain other
pathological conditions, are associated with an increase in the number
of leucocytes in the blood throughout the circulatory system. This
condition of the blood, which is known as _leucocytosis_, is believed to
be due to an excessive output and rapid formation of leucocytes by the
bone marrow, and it probably has as its object the arrest and
destruction of the invading organisms or toxins. To increase the
resisting power of the system to pathogenic organisms, an artificial
leucocytosis may be induced by subcutaneous injection of a solution of
nucleinate of soda (16 minims of a 5 per cent. solution).

The _normal_ number of leucocytes per cubic millimetre varies in
different individuals, and in the same individual under different
conditions, from 5000 to 10,000: 7500 is a normal average, and anything
above 12,000 is considered abnormal. When leucocytosis is present, the
number may range from 12,000 to 30,000 or even higher; 40,000 is looked
upon as a high degree of leucocytosis. According to Ehrlich, the
following may be taken as the standard proportion of the various forms
of leucocytes in normal blood: polynuclear neutrophile leucocytes, 70 to
72 per cent.; lymphocytes, 22 to 25 per cent.; eosinophile cells, 2 to 4
per cent.; large mononuclear and transitional leucocytes, 2 to 4 per
cent.; mast-cells, 0.5 to 2 per cent.

In estimating the clinical importance of a leucocytosis, it is not
sufficient merely to count the aggregate number of leucocytes present. A
differential count must be made to determine which variety of cells is
in excess. In the majority of surgical affections it is chiefly the
granular polymorpho-nuclear neutrophile leucocytes that are in excess
(_ordinary leucocytosis_). In some cases, and particularly in parasitic
diseases such as trichiniasis and hydatid disease, the eosinophile
leucocytes also show a proportionate increase (_eosinophilia_). The term
_lymphocytosis_ is applied when there is an increase in the number of
circulating lymphocytes, as occurs, for example, in lymphatic leucæmia,
and in certain cases of syphilis.

Leucocytosis is met with in nearly all acute infective diseases, and in
acute pyogenic inflammatory affections, particularly in those attended
with suppuration. In exceptionally acute septic conditions the extreme
virulence of the toxins may prevent the leucocytes reacting, and
leucocytosis may be absent. The absence of leucocytosis in a disease in
which it is usually present is therefore to be looked upon as a grave
omen, particularly when the general symptoms are severe. In some cases
of malignant disease the number of leucocytes is increased to 15,000 or
20,000. A few hours after a severe hæmorrhage also there is usually a
leucocytosis of from 15,000 to 30,000, which lasts for three or four
days (Lyon). In cases of hæmorrhage the leucocytosis is increased by
infusion of fluids into the circulation. After all operations there is
at least a transient leucocytosis (_post-operative leucocytosis_)
(F. I. Dawson).

The leucocytosis begins soon after the infection manifests itself--for
example, by shivering, rigor, or rise of temperature. The number of
leucocytes rises somewhat rapidly, increases while the condition is
progressing, and remains high during the febrile period, but there is no
constant correspondence between the number of leucocytes and the height
of the temperature. The arrest of the inflammation and its resolution
are accompanied by a fall in the number of leucocytes, while the
occurrence of suppuration is attended with a further increase in their
number.

In interpreting the "blood count," it is to be kept in mind that a
_physiological leucocytosis_ occurs within three or four hours of taking
a meal, especially one rich in proteins, from 1500 to 2000 being added
to the normal number. In this _digestion leucocytosis_ the increase is
chiefly in the polynuclear neutrophile leucocytes. Immediately before
and after delivery, particularly in primiparæ, there is usually a
moderate degree of leucocytosis. If the labour is normal and the
puerperium uncomplicated, the number of leucocytes regains the normal in
about a week. Lactation has no appreciable effect on the number of
leucocytes. In new-born infants the leucocyte count is abnormally high,
ranging from 15,000 to 20,000. In children under one year of age, the
normal average is from 10,000 to 20,000.

_Absence of Leucocytosis--Leucopenia._--In certain infective diseases
the number of leucocytes in the circulating blood is abnormally
low--3000 or 4000--and this condition is known as _leucopenia_. It
occurs in typhoid fever, especially in the later stages of the disease,
in tuberculous lesions unaccompanied by suppuration, in malaria, and in
most cases of uncomplicated influenza. The occurrence of leucocytosis in
any of these conditions is to be looked upon as an indication that a
mixed infection has taken place, and that some suppurative process is
present.

The absence of leucocytosis in some cases of virulent septic poisoning
has already been referred to.

It will be evident that too much reliance must not be placed upon a
single observation, particularly in emergency cases. Whenever possible,
a series of observations should be made, the blood being examined about
four hours after meals, and about the same hour each day.

The clinical significance of the blood count in individual diseases will
be further referred to.

_The Iodine or Glycogen Reaction._--The leucocyte count may be
supplemented by staining films of the blood with a watery solution of
iodine and potassium iodide. In all advancing purulent conditions, in
septic poisonings, in pneumonia, and in cancerous growths associated
with ulceration, a certain number of the polynuclear leucocytes are
stained a brown or reddish-brown colour, due to the action of the iodine
on some substance in the cells of the nature of glycogen. This reaction
is absent in serous effusions, in unmixed tuberculous infections, in
uncomplicated typhoid fever, and in the early stages of cancerous
growths.




CHAPTER III

INFLAMMATION


Definition--Nature of inflammation from surgical point of
view--Sequence of changes in bacterial inflammation--Clinical
aspects of inflammation--General principles of treatment--Chronic
inflammation.

Inflammation may be defined as the series of vital changes that occurs
in the tissues in response to irritation. These changes represent the
reaction of the tissue elements to the irritant, and constitute the
attempt made by nature to arrest or to limit its injurious effects, and
to repair the damage done by it.

The phenomena which characterise the inflammatory reaction can be
induced by any form of irritation--such, for example, as mechanical
injury, the application of heat or of chemical substances, or the action
of pathogenic bacteria and their toxins--and they are essentially
similar in kind whatever the irritant may be. The extent to which the
process may go, however, and its effects on the part implicated and on
the system as a whole, vary with different irritants and with the
intensity and duration of their action. A mechanical, a thermal, or a
chemical irritant, acting alone, induces a degree of reaction directly
proportionate to its physical properties, and so long as it does not
completely destroy the vitality of the part involved, the changes in the
tissues are chiefly directed towards repairing the damage done to the
part, and the inflammatory reaction is not only compatible with the
occurrence of ideal repair, but may be looked upon as an integral step
in the reparative process.

The irritation caused by infection with bacteria, on the other hand, is
cumulative, as the organisms not only multiply in the tissues, but in
addition produce chemical poisons (toxins) which aggravate the
irritative effects. The resulting reaction is correspondingly
progressive, and has as its primary object the expulsion of the irritant
and the limitation of its action. If the natural protective effort is
successful, the resulting tissue changes subserve the process of repair,
but if the bacteria gain the upper hand in the struggle, the
inflammatory reaction becomes more intense, certain of the tissue
elements succumb, and the process for the time being is a destructive
one. During the stage of bacterial inflammation, reparative processes
are in abeyance, and it is only after the inflammation has been allayed,
either by natural means or by the aid of the surgeon, that repair takes
place.

In applying the antiseptic principle to the treatment of wounds, our
main object is to exclude or to eliminate the bacterial factor, and so
to prevent the inflammatory reaction going beyond the stage in which it
is protective, and just in proportion as we succeed in attaining this
object, do we favour the occurrence of ideal repair.

#Sequence of Changes in Bacterial Inflammation.#--As the form of
inflammation with which we are most concerned is that due to the action
of bacteria, in describing the process by which the protective influence
of the inflammatory reaction is brought into play, we shall assume the
presence of a bacterial irritant.

The introduction of a colony of micro-organisms is quickly followed by
an accumulation of wandering cells, and proliferation of
connective-tissue cells in the tissues at the site of infection. The
various cells are attracted to the bacteria by a peculiar chemical or
biological power known as _chemotaxis_, which seems to result from
variations in the surface tension of different varieties of cells,
probably caused by some substance produced by the micro-organisms.
Changes in the blood vessels then ensue, the arteries becoming dilated
and the rate of the current in them being for a time increased--_active
hyperæmia_. Soon, however, the rate of the blood flow becomes slower
than normal, and in course of time the current may cease (_stasis_), and
the blood in the vessels may even coagulate (_thrombosis_). Coincidently
with these changes in the vessels, the leucocytes in the blood of the
inflamed part rapidly increase in number, and they become viscous and
adhere to the vessel wall, where they may accumulate in large numbers.
In course of time the leucocytes pass through the vessel
wall--_emigration of leucocytes_--and move towards the seat of
infection, giving rise to a marked degree of _local leucocytosis_.
Through the openings by which the leucocytes have escaped from the
vessels, red corpuscles may be passively extruded--_diapedesis of red
corpuscles_. These processes are accompanied by changes in the
endothelium of the vessel walls, which result in an increased formation
of lymph, which transudes into the meshes of the connective tissue
giving rise to an _inflammatory oedema_, or, if the inflammation is on a
free surface, forming an _inflammatory exudate_. The quantity and
characters of this exudate vary in different parts of the body, and
according to the nature, virulence, and location of the organisms
causing the inflammation. Thus it may be _serous_, as in some forms of
synovitis; _sero-fibrinous_, as in certain varieties of peritonitis, the
fibrin tending to limit the spread of the inflammation by forming
adhesions; _croupous_, when it coagulates on a free surface and forms a
false membrane, as in diphtheria; _hæmorrhagic_ when mixed with blood;
or _purulent_, when suppuration has occurred. The protective effects of
the inflammatory reaction depend for the most part upon the transudation
of lymph and the emigration of leucocytes. The lymph contains the
opsonins which act on the bacteria and render them less able to resist
the attack of the phagocytes, as well as the various protective
antibodies which neutralise the toxins. The polymorph leucocytes are the
principal agents in the process of phagocytosis (p. 22), and together
with the other forms of phagocytes they ingest and destroy the bacteria.

If the attempt to repel the invading organisms is successful, the
irritant effects are overcome, the inflammation is arrested, and
_resolution_ is said to take place.

Certain of the vascular and cellular changes are now utilised to restore
the condition to the normal, and _repair_ ensues after the manner
already described. In certain situations, notably in tendon sheaths, in
the cavities of joints, and in the interior of serous cavities, for
example the pleura and peritoneum, the restoration to the normal is not
perfect, adhesions forming between the opposing surfaces.

If, however, the reaction induced by the infection is insufficient to
check the growth and spread of the organisms, or to inhibit their toxin
production, local necrosis of tissue may take place, either in the form
of suppuration or of gangrene, or the toxins absorbed into the
circulation may produce blood-poisoning, which may even prove fatal.

#Clinical Aspects of Inflammation.#--It must clearly be understood that
inflammation is not to be looked upon as a disease in itself, but rather
as an evidence of some infective process going on in the tissues in
which it occurs, and of an effort on the part of these tissues to
overcome the invading organisms and their products. The chief danger to
the patient lies, not in the reactive changes that constitute the
inflammatory process, but in the fact that he is liable to be poisoned
by the toxins of the bacteria at work in the inflamed area.

Since the days of Celsus (first century A.D.), heat, redness, swelling,
and pain have been recognised as cardinal signs of inflammation, and to
these may be added, interference with function in the inflamed part, and
general constitutional disturbance. Variations in these signs and
symptoms depend upon the acuteness of the condition, the nature of the
causative organism and of the tissue attacked, the situation of the part
in relation to the surface, and other factors.

The _heat_ of the inflamed part is to be attributed to the increased
quantity of blood present in it, and the more superficial the affected
area the more readily is the local increase of temperature detected by
the hand. This clinical point is best tested by placing the palm of the
hand and fingers for a few seconds alternately over an uninflamed and an
inflamed area, otherwise under similar conditions as to coverings and
exposure. In this way even slight differences may be recognised.

_Redness_, similarly, is due to the increased afflux of blood to the
inflamed part. The shade of colour varies with the stage of the
inflammation, being lighter and brighter in the early, hyperæmic stages,
and darker and duskier when the blood flow is slowed or when stasis has
occurred and the oxygenation of the blood is defective. In the
thrombotic stage the part may assume a purplish hue.

The _swelling_ is partly due to the increased amount of blood in the
affected part and to the accumulation of leucocytes and proliferated
tissue cells, but chiefly to the exudate in the connective
tissue--_inflammatory oedema_. The more open the structure of the tissue
of the part, the greater is the amount of swelling--witness the marked
degree of oedema that occurs in such parts as the scrotum or the eyelids.

_Pain_ is a symptom seldom absent in inflammation. _Tenderness_--that
is, pain elicited on pressure--is one of the most valuable diagnostic
signs we possess, and is often present before pain is experienced by the
patient. That the area of tenderness corresponds to the area of
inflammation is almost an axiom of surgery. Pain and tenderness are due
to the irritation of nerve filaments of the part, rendered all the more
sensitive by the abnormal conditions of their blood supply. In
inflammatory conditions of internal organs, for example the abdominal
viscera, the pain is frequently referred to other parts, usually to an
area supplied by branches from the same segment of the cord as that
supplying the inflamed part.

For purposes of diagnosis, attention should be paid to the terms in
which the patient describes his pain. For example, the pain caused by
an inflammation of the skin is usually described as of a _burning_ or
_itching_ character; that of inflammation in dense tissues like
periosteum or bone, or in encapsuled organs, as _dull_, _boring_, or
_aching_. When inflammation is passing on to suppuration the pain
assumes a _throbbing_ character, and as the pus reaches the surface, or
"points," as it is called, sharp, _darting_, or _lancinating_ pains are
experienced. Inflammation involving a nerve-trunk may cause a _boring_
or a _tingling_ pain; while the implication of a serous membrane such as
the pleura or peritoneum gives rise to a pain of a sharp, _stabbing_
character.

_Interference with the function_ of the inflamed part is always present
to a greater or less extent.

#Constitutional Disturbances.#--Under the term constitutional
disturbances are included the presence of fever or elevation of
temperature; certain changes in the pulse rate and the respiration;
gastro-intestinal and urinary disturbances; and derangements of the
central nervous system. These are all due to the absorption of toxins
into the general circulation.

_Temperature._--A marked rise of temperature is one of the most constant
and important concomitants of acute inflammatory conditions, and the
temperature chart forms a fairly reliable index of the state of the
patient. The toxins interfere with the nerve-centres in the medulla that
regulate the balance between the production and the loss of body heat.

Clinically the temperature is estimated by means of a self-registering
thermometer placed, for from one to five minutes, in close contact with
the skin in the axilla, or in the mouth. Sometimes the thermometer is
inserted into the rectum, where, however, the temperature is normally
¾° F. higher than in the axilla.

_In health_ the temperature of the body is maintained at a mean of about
98.4° F. (37° C.) by the heat-regulating mechanism. It varies from hour
to hour even in health, reaching its maximum between four and eight in
the evening, when it may rise to 99° F., and is at its lowest between
four and six in the morning, when it may be about 97° F.

The temperature is more easily disturbed in children than in adults, and
may become markedly elevated (104° or 105° F.) from comparatively slight
causes; in the aged it is less liable to change, so that a rise to 103°
or 104° F. is to be looked upon as indicating a high state of fever.

A sudden rise of temperature is usually associated with a feeling of
chilliness down the back and in the limbs, which may be so marked that
the patient shivers violently, while the skin becomes cold, pale, and
shrivelled--_cutis anserina_. This is a nervous reaction due to a want
of correspondence between the internal and the surface temperature of
the body, and is known clinically as a _rigor_. When the temperature
rises gradually the chill is usually slight and may be unobserved. Even
during the cold stage, however, the internal temperature is already
raised, and by the time the chill has passed off its maximum has been
reached.

The _pulse_ is always increased in frequency, and usually varies
directly with the height of the temperature. _Respiration_ is more
active during the progress of an inflammation; and bronchial catarrh is
common apart from any antecedent respiratory disease.

_Gastro-intestinal disturbances_ take the form of loss of appetite,
vomiting, diminished secretion of the alimentary juices, and weakening
of the peristalsis of the bowel, leading to thirst, dry, furred tongue,
and constipation. Diarrhoea is sometimes present. The _urine_ is usually
scanty, of high specific gravity, rich in nitrogenous substances,
especially urea and uric acid, and in calcium salts, while sodium
chloride is deficient. Albumin and hyaline casts may be present in cases
of severe inflammation with high temperature. The significance of
general _leucocytosis_ has already been referred to.

#General Principles of Treatment.#--The capacity of the inflammatory
reaction for dealing with bacterial infections being limited, it often
becomes necessary for the surgeon to aid the natural defensive
processes, as well as to counteract the local and general effects of the
reaction, and to relieve symptoms.

The ideal means of helping the tissues is by removing the focus of
infection, and when this can be done, as for example in a carbuncle or
an anthrax pustule, the infected area may be completely excised. When
the focus is not sufficiently limited to admit of this, the infected
tissue may be scraped away with the sharp spoon, or destroyed by
caustics or by the actual cautery. If this is inadvisable, the organisms
may be attacked by strong antiseptics, such as pure carbolic acid.

Moist dressings favour the removal of bacteria by promoting the escape
of the inflammatory exudate, in which they are washed out.

#Artificial Hyperæmia.#--When such direct means as the above are
impracticable, much can be done to aid the tissues in their struggle by
improving the condition of the circulation in the inflamed area, so as
to ensure that a plentiful supply of fresh arterial blood reaches it.
The beneficial effects of _hot fomentations and poultices_ depend on
their causing a dilatation of the vessels, and so inducing a hyperæmia
in the affected area. It has been shown experimentally that repeated,
short applications of moist heat (not exceeding 106° F.) are more
efficacious than continuous application. It is now believed that the
so-called _counter-irritants_--mustard, iodine, cantharides, actual
cautery--act in the same way; and the method of treating erysipelas by
applying a strong solution of iodine around the affected area is based
on the same principle.

[Illustration: FIG. 6.--Passive Hyperæmia of Hand and Forearm induced by
Bier's Bandage.]

While these and similar methods have long been employed in the treatment
of inflammatory conditions, it is only within comparatively recent years
that their mode of action has been properly understood, and to August
Bier belongs the credit of having put the treatment of inflammation on a
scientific and rational basis. Recognising the "beneficent intention" of
the inflammatory reaction, and the protective action of the leucocytosis
which accompanies the hyperæmic stages of the process, Bier was led to
study the effects of increasing the hyperæmia by artificial means. As a
result of his observations, he has formulated a method of treatment
which consists in inducing an artificial hyperæmia in the inflamed area,
either by obstructing the venous return from the part (_passive
hyperæmia_), or by stimulating the arterial flow through it (_active
hyperæmia_).

_Bier's Constricting Bandage._--To induce a _passive hyperæmia_ in a
limb, an elastic bandage is applied some distance above the inflamed
area sufficiently tightly to obstruct the venous return from the distal
parts without arresting in any way the inflow of arterial blood (Fig. 6).
If the constricting band is correctly applied, the parts beyond
become swollen and oedematous, and assume a bluish-red hue, but they
retain their normal temperature, the pulse is unchanged, and there is no
pain. If the part becomes blue, cold, or painful, or if any existing
pain is increased, the band has been applied too tightly. The hyperæmia
is kept up from twenty to twenty-two hours out of the twenty-four, and
in the intervals the limb is elevated to get rid of the oedema and to
empty it of impure blood, and so make room for a fresh supply of healthy
blood when the bandage is re-applied. As the inflammation subsides, the
period during which the band is kept on each day is diminished; but the
treatment should be continued for some days after all signs of
inflammation have subsided.

This method of treating acute inflammatory conditions necessitates
close supervision until the correct degree of tightness of the band has
been determined.

[Illustration: FIG. 7.--Passive Hyperæmia of Finger induced by Klapp's
Suction Bell.]

_Klapp's Suction Bells._--In inflammatory conditions to which the
constricting band cannot be applied, as for example an acute mastitis, a
bubo in the groin, or a boil on the neck, the affected area may be
rendered hyperæmic by an appropriately shaped glass bell applied over it
and exhausted by means of a suction-pump, the rarefaction of the air in
the bell determining a flow of blood into the tissues enclosed within it
(Figs. 7 and 8). The edge of the bell is smeared with vaseline, and the
suction applied for from five to ten minutes at a time, with a
corresponding interval between the applications. Each sitting lasts for
from half an hour to an hour, and the treatment may be carried out once
or twice a day according to circumstances. This apparatus acts in the
same way as the old-fashioned _dry cup_, and is more convenient and
equally efficacious.

[Illustration: FIG. 8.--Passive Hyperæmia induced by Klapp's Suction
Bell for Inflammation of Inguinal Gland.]

_Active hyperæmia_ is induced by the local application of heat,
particularly by means of hot air. It has not proved so useful in acute
inflammation as passive hyperæmia, but is of great value in hastening
the absorption of inflammatory products and in overcoming adhesions and
stiffness in tendons and joints.

_General Treatment._--The patient should be kept at rest, preferably in
bed, to diminish the general tissue waste; and the diet should be
restricted to fluids, such as milk, beef-tea, meat juices or gruel, and
these may be rendered more easily assimilable by artificial digestion if
necessary. To counteract the general effect of toxins absorbed into
the circulation, specific antitoxic sera are employed in certain forms
of infection, such as diphtheria, streptococcal septicæmia, and tetanus.
In other forms of infection, vaccines are employed to increase the
opsonic power of the blood. When such means are not available, the
circulating toxins may to some extent be diluted by giving plenty of
bland fluids by the mouth or normal salt solution by the rectum.

The elimination of the toxins is promoted by securing free action of the
emunctories. A saline purge, such as half an ounce of sulphate of
magnesium in a small quantity of water, ensures a free evacuation of the
bowels. The kidneys are flushed by such diluent drinks as equal parts of
milk and lime water, or milk with a dram of liquor calcis saccharatus
added to each tumblerful. Barley-water and "Imperial drink," which
consists of a dram and a half of cream of tartar added to a pint of
boiling water and sweetened with sugar after cooling, are also useful
and non-irritating diuretics. The skin may be stimulated by Dover's
powder (10 grains) or liquor ammoniæ acetatis in three-dram doses every
four hours.

Various drugs administered internally, such as quinine, salol,
salicylate of iron, and others, have a reputation, more or less
deserved, as internal antiseptics.

Weakness of the heart, as indicated by the condition of the pulse, is
treated by the use of such drugs as digitalis, strophanthus, or
strychnin, according to circumstances.

Gastro-intestinal disturbances are met by ordinary medical means.
Vomiting, for example, can sometimes be checked by effervescing drinks,
such as citrate of caffein, or by dilute hydrocyanic acid and bismuth.
In severe cases, and especially when the vomited matter resembles
coffee-grounds from admixture with altered blood--the so-called
post-operative hæmatemesis--the best means of arresting the vomiting is
by washing out the stomach. Thirst is relieved by rectal injections of
saline solution. The introduction of saline solution into the veins or
by the rectum is also useful in diluting and hastening the elimination
of circulating toxins.

In surgical inflammations, as a rule, nothing is gained by lowering the
temperature, unless at the same time the cause is removed. When severe
or prolonged pyrexia becomes a source of danger, the use of hot or cold
sponging, or even the cold bath, is preferable to the administration of
drugs.

_Relief of Symptoms._--For the relief of _pain_, rest is essential. The
inflamed part should be placed in a splint or other appliance which will
prevent movement, and steps must be taken to reduce its functional
activity as far as possible. Locally, warm and moist dressings, such as
a poultice or fomentation, may be used. To make a fomentation, a piece
of flannel or lint is wrung out of very hot water or antiseptic lotion
and applied under a sheet of mackintosh. Fomentations should be renewed
as often as they cool. An ordinary india-rubber bag filled with hot
water and fixed over the fomentation, by retaining the heat, obviates
the necessity of frequently changing the application. The addition of a
few drops of laudanum sprinkled on the flannel has a soothing effect.
Lead and opium lotion is a useful, soothing application employed as a
fomentation. We prefer the application of lint soaked in a 10 per cent.
aqueous or glycerine solution of ichthyol, or smeared with ichthyol
ointment (1 in 3). Belladonna and glycerine, equal parts, may be used.

Dry cold obtained by means of icebags, or by Leiter's lead tubes through
which a continuous stream of ice-cold water is kept flowing, is
sometimes soothing to the patient, but when the vessels in the inflamed
part are greatly congested its use is attended with considerable risk,
as it not only contracts the arterioles supplying the part, but also
diminishes the outflow of venous blood, and so may determine gangrene of
tissues already devitalised.

A milder form of employing cold is by means of evaporating lotions: a
thin piece of lint or gauze is applied over the inflamed part and kept
constantly moist with the lotion, the dressing being left freely exposed
to allow of continuous evaporation. A useful evaporating lotion is made
up as follows: take of chloride of ammonium, half an ounce; rectified
spirit, one ounce; and water, seven ounces.

The administration of opiates may be necessary for the relief of pain.

The accumulation of an excessive amount of inflammatory exudate may
endanger the vitality of the tissues by pressing on the blood vessels to
such an extent as to cause stasis, and by concentrating the local action
of the toxins. Under such conditions the tension should be relieved and
the exudate with its contained toxins removed by making an incision into
the inflamed tissues, and applying a suction bell. When the exudate has
collected in a synovial cavity, such as a joint or bursa, it may be
withdrawn by means of a trocar and cannula. There are other methods of
withdrawing blood and exudate from an inflamed area, for example by
leeches or wet-cupping, but they are seldom employed now.

Before applying leeches the part must be thoroughly cleansed, and if
the leech is slow to bite, may be smeared with cream. The leech is
retained in position under an inverted wine-glass or wide test-tube till
it takes hold. After it has sucked its fill it usually drops off, having
withdrawn a dram or a dram and a half of blood. If it be desirable to
withdraw more blood, hot fomentations should be applied to the bite. As
it is sometimes necessary to employ considerable pressure to stop the
bleeding, leeches should, if possible, be applied over a bone which will
furnish the necessary resistance. The use of styptics may be called for.

_Wet-cupping_ has almost entirely been superseded by the use of Klapp's
suction bells.

_General blood-letting_ consists in opening a superficial vein
(venesection) and allowing from eight to ten ounces of blood to flow
from it. It is seldom used in the treatment of surgical forms of
inflammation.

_Counter-irritants._--In deep-seated inflammations, counter-irritants
are sometimes employed in the form of mustard leaves or blisters,
according to the degree of irritation required. A mustard leaf or
plaster should not be left on longer than ten or fifteen minutes, unless
it is desired to produce a blister. Blistering may be produced by a
_cantharides plaster_, or by painting with _liquor epispasticus_. The
plaster should be left on from eight to ten hours, and if it has failed
to raise a blister, a hot fomentation should be applied to the part.
_Liquor epispasticus_, alone or mixed with equal parts of collodion, is
painted on the part with a brush. Several paintings are often required
before a blister is raised. The preliminary removal of the natural
grease from the skin favours the action of these applications.

The treatment of inflammation in special tissues and organs will be
considered in the sections devoted to regional surgery.

#Chronic Inflammation.#--A variety of types of chronic and subacute
inflammation are met with which, owing to ignorance of their causations,
cannot at present be satisfactorily classified.

The best defined group is that of the _granulomata_, which includes such
important diseases as tuberculosis and syphilis, and in which different
types of chronic inflammation are caused by infection with a specific
organism, all having the common character, however, that abundant
granulation tissue is formed in which cellular changes are more in
evidence than changes in the blood vessels, and in which the subsequent
degeneration and necrosis of the granulation tissue results in the
breaking down and destruction of the tissue in which it is formed.
Another group is that in which chronic inflammation is due to mild or
attenuated forms of pyogenic infection affecting especially the lymph
glands and the bone marrow. In the glands of the groin, for example,
associated with various forms of irritation about the external genitals,
different types of _chronic lymphadenitis_ are met with; they do not
frankly suppurate as do the acute types, but are attended with a
hyperplasia of the tissue elements which results in enlargement of the
affected glands of a persistent, and sometimes of a relapsing character.
Similar varieties of _osteomyelitis_ are met with that do not, like the
acute forms, go on to suppuration or to death of bone, but result in
thickening of the bone affected, both on the surface and in the
interior, resulting in obliteration of the medullary canal.

A third group of chronic inflammations are those that begin as an acute
pyogenic inflammation, which, instead of resolving completely, persists
in a chronic form. It does so apparently because there is some factor
aiding the organisms and handicapping the tissues, such as the presence
of a foreign body, a piece of glass or metal, or a piece of dead bone;
in these circumstances the inflammation persists in a chronic form,
attended with the formation of fibrous tissue, and, in the case of bone,
with the formation of new bone in excess. It will be evident that in
this group, chronic inflammation and repair are practically
interchangeable terms.

There are other groups of chronic inflammation, the origin of which
continues to be the subject of controversy. Reference is here made to
the chronic inflammations of the synovial membrane of joints, of tendon
sheaths and of bursæ--_chronic synovitis_, _teno-synovitis_ and
_bursitis_; of the fibrous tissues of joints--chronic forms of
_arthritis_; of the blood vessels--chronic forms of _endarteritis_ and
of _phlebitis_ and of the peripheral nerves--_neuritis_. Also in the
breast and in the prostate, with the waning of sexual life there may
occur a formation of fibrous tissue--chronic _interstitial mastitis_,
_chronic prostatitis_, having analogies with the chronic interstitial
inflammations of internal organs like the kidney--_chronic interstitial
nephritis_; and in the breast and prostate, as in the kidney, the
formation of fibrous tissue leads to changes in the secreting epithelium
resulting in the formation of cysts.

Lastly, there are still other types of chronic inflammation attended
with the formation of fibrous tissue on such a liberal scale as to
suggest analogies with new growths. The best known of these are the
systematic forms of fibromatosis met with in the central nervous system
and in the peripheral nerves--_neuro-fibromatosis_; in the submucous
coat of the stomach--_gastric fibromatosis_; and in the
colon--_intestinal fibromatosis_.

These conditions will be described with the tissues and organs in which
they occur.

In the _treatment of chronic inflammations_, pending further knowledge
as to their causation, and beyond such obvious indications as to help
the tissues by removing a foreign body or a piece of dead bone, there
are employed--empirically--a number of procedures such as the induction
of hyperæmia, exposure to the X-rays, and the employment of blisters,
cauteries, and setons. Vaccines may be had recourse to in those of
bacterial origin.




CHAPTER IV

SUPPURATION


Definition--Pus--_Varieties_--Acute circumscribed abscess--_Acute
suppuration in a wound_--_Acute Suppuration in a mucous
membrane_--Diffuse cellulitis and diffuse suppuration--
_Whitlow_--_Suppurative cellulitis in different situations_--Chronic
suppuration--Sinus, Fistula--Constitutional manifestations of
pyogenic infection--_Sapræmia_--_Septicæmia_--_Pyæmia_.

Suppuration, or the formation of pus, is one of the results of the
action of bacteria on the tissues. The invading organism is usually one
of the staphylococci, less frequently a streptococcus, and still less
frequently one of the other bacteria capable of producing pus, such as
the bacillus coli communis, the gonococcus, the pneumococcus, or the
typhoid bacillus.

So long as the tissues are in a healthy condition they are able to
withstand the attacks of moderate numbers of pyogenic bacteria of
ordinary virulence, but when devitalised by disease, by injury, or by
inflammation due to the action of other pathogenic organisms,
suppuration ensues.

It would appear, for example, that pyogenic organisms can pass through
the healthy urinary tract without doing any damage, but if the pelvis of
the kidney, the ureter, or the bladder is the seat of stone, they give
rise to suppuration. Similarly, a calculus in one of the salivary ducts
frequently results in an abscess forming in the floor of the mouth. When
the lumen of a tubular organ, such as the appendix or the Fallopian tube
is blocked also, the action of pyogenic organisms is favoured and
suppuration ensues.

#Pus.#--The fluid resulting from the process of suppuration is known
as _pus_. In its typical form it is a yellowish creamy substance, of
alkaline reaction, with a specific gravity of about 1030, and it has a
peculiar mawkish odour. If allowed to stand in a test-tube it does not
coagulate, but separates into two layers: the upper, transparent,
straw-coloured fluid, the _liquor puris_ or pus serum, closely
resembling blood serum in its composition, but containing less protein
and more cholestrol; it also contains leucin, tyrosin, and certain
albumoses which prevent coagulation.

The layer at the bottom of the tube consists for the most part of
polymorph leucocytes, and proliferated connective tissue and endothelial
cells (_pus corpuscles_). Other forms of leucocytes may be present,
especially in long-standing suppurations; and there are usually some red
corpuscles, dead bacteria, fat cells and shreds of tissue, cholestrol
crystals, and other detritus in the deposit.

If a film of fresh pus is examined under the microscope, the pus cells
are seen to have a well-defined rounded outline, and to contain a finely
granular protoplasm and a multi-partite nucleus; if still warm, the
cells may exhibit amoeboid movement. In stained films the nuclei take the
stain well. In older pus cells the outline is irregular, the protoplasm
coarsely granular, and the nuclei disintegrated, no longer taking the
stain.

_Variations from Typical Pus._--Pus from old-standing sinuses is often
watery in consistence (ichorous), with few cells. Where the granulations
are vascular and bleed easily, it becomes sanious from admixture with
red corpuscles; while, if a blood-clot be broken down and the debris
mixed with the pus, it contains granules of blood pigment and is said to
be "grumous." The _odour_ of pus varies with the different bacteria
producing it. Pus due to ordinary pyogenic cocci has a mawkish odour;
when putrefactive organisms are present it has a putrid odour; when it
forms in the vicinity of the intestinal canal it usually contains the
bacillus coli communis and has a fæcal odour.

The _colour_ of pus also varies: when due to one or other of the
varieties of the bacillus pyocyaneus, it is usually of a blue or green
colour; when mixed with bile derivatives or altered blood pigment, it
may be of a bright orange colour. In wounds inflicted with rough iron
implements from which rust is deposited, the pus often presents the same
colour.

The pus may form and collect within a circumscribed area, constituting a
localised _abscess_; or it may infiltrate the tissues over a wide
area--_diffuse suppuration_.


ACUTE CIRCUMSCRIBED ABSCESS

Any tissue of the body may be the seat of an acute abscess, and there
are many routes by which the bacteria may gain access to the affected
area. For example: an abscess in the integument or subcutaneous
cellular tissue usually results from infection by organisms which have
entered through a wound or abrasion of the surface, or along the ducts
of the skin; an abscess in the breast from organisms which have passed
along the milk ducts opening on the nipple, or along the lymphatics
which accompany these. An abscess in a lymph gland is usually due to
infection passing by way of the lymph channels from the area of skin or
mucous membrane drained by them. Abscesses in internal organs, such as
the kidney, liver, or brain, usually result from organisms carried in
the blood-stream from some focus of infection elsewhere in the body.

A knowledge of the possible avenues of infection is of clinical
importance, as it may enable the source of a given abscess to be traced
and dealt with. In suppuration in the Fallopian tube (pyosalpynx), for
example, the fact that the most common origin of the infection is in the
genital passage, leads to examination for vaginal discharge; and if none
is present, the abscess is probably due to infection carried in the
blood-stream from some primary focus about the mouth, such as a gumboil
or an infective sore throat.

The exact location of an abscess also may furnish a key to its source;
in axillary abscess, for example, if the suppuration is in the lymph
glands the infection has come through the afferent lymphatics; if in the
cellular tissue, it has spread from the neck or chest wall; if in the
hair follicles, it is a local infection through the skin.

#Formation of an Abscess.#--When pyogenic bacteria are introduced into
the tissue there ensues an inflammatory reaction, which is characterised
by dilatation of the blood vessels, exudation of large numbers of
leucocytes, and proliferation of connective-tissue cells. These
wandering cells soon accumulate round the focus of infection, and form a
protective barrier which tends to prevent the spread of the organisms
and to restrict their field of action. Within the area thus
circumscribed the struggle between the bacteria and the phagocytes takes
place, and in the process toxins are formed by the organisms, a certain
number of the leucocytes succumb, and, becoming degenerated, set free
certain proteolytic enzymes or ferments. The toxins cause
coagulation-necrosis of the tissue cells with which they come in
contact, the ferments liquefy the exudate and other albuminous
substances, and in this way _pus_ is formed.

If the bacteria gain the upper hand, this process of liquefaction which
is characteristic of suppuration, extends into the surrounding tissues,
the protective barrier of leucocytes is broken down, and the
suppurative process spreads. A fresh accession of leucocytes, however,
forms a new barrier, and eventually the spread is arrested, and the
collection of pus so hemmed in constitutes an _abscess_.

Owing to the swelling and condensation of the parts around, the pus thus
formed is under considerable pressure, and this causes it to burrow
along the lines of least resistance. In the case of a subcutaneous
abscess the pus usually works its way towards the surface, and "points,"
as it is called. Where it approaches the surface the skin becomes soft
and thin, and eventually sloughs, allowing the pus to escape.

An abscess forming in the deeper planes is prevented from pointing
directly to the surface by the firm fasciæ and other fibrous structures.
The pus therefore tends to burrow along the line of the blood vessels
and in the connective-tissue septa, till it either finds a weak spot or
causes a portion of fascia to undergo necrosis and so reaches the
surface. Accordingly, many abscess cavities resulting from deep-seated
suppuration are of irregular shape, with pouches and loculi in various
directions--an arrangement which interferes with their successful
treatment by incision and drainage.

The relief of tension which follows the bursting of an abscess, the
removal of irritation by the escape of pus, and the casting off of
bacteria and toxins, allow the tissues once more to assert themselves,
and a process of repair sets in. The walls of the abscess fall in;
granulation tissue grows into the space and gradually fills it; and
later this is replaced by cicatricial tissue. As a result of the
subsequent contraction of the cicatricial tissue, the scar is usually
depressed below the level of the surrounding skin surface.

If an abscess is prevented from healing--for example, by the presence of
a foreign body or a piece of necrosed bone--a sinus results, and from it
pus escapes until the foreign body is removed.

#Clinical Features of an Acute Circumscribed Abscess.#--In the initial
stages the usual symptoms of inflammation are present. Increased
elevation of temperature, with or without a rigor, progressive
leucocytosis, and sweating, mark the transition between inflammation and
suppuration. An increasing leucocytosis is evidence that a suppurative
process is spreading.

The local symptoms vary with the seat of the abscess. When it is
situated superficially--for example, in the breast tissue--the affected
area is hot, the redness of inflammation gives place to a dusky purple
colour, with a pale, sometimes yellow, spot where the pus is near the
surface. The swelling increases in size, the firm brawny centre becomes
soft, projects as a cone beyond the level of the rest of the swollen
area, and is usually surrounded by a zone of induration.

By gently palpating with the finger-tips over the softened area, a fluid
wave may be detected--_fluctuation_--and when present this is a certain
indication of the existence of fluid in the swelling. Its recognition,
however, is by no means easy, and various fallacies are to be guarded
against in applying this test clinically. When, for example, the walls
of the abscess are thick and rigid, or when its contents are under
excessive tension, the fluid wave cannot be elicited. On the other hand,
a sensation closely resembling fluctuation may often be recognised in
oedematous tissues, in certain soft, solid tumours such as fatty tumours
or vascular sarcomata, in aneurysm, and in a muscle when it is palpated
in its transverse axis.

When pus has formed in deeper parts, and before it has reached the
surface, oedema of the overlying skin is frequently present, and the skin
pits on pressure.

With the formation of pus the continuous burning or boring pain of
inflammation assumes a throbbing character, with occasional sharp,
lancinating twinges. Should doubt remain as to the presence of pus,
recourse may be had to the use of an exploring needle.

_Differential Diagnosis of Acute Abscess._--A practical difficulty which
frequently arises is to decide whether or not pus has actually formed.
It may be accepted as a working rule in practice that when an acute
inflammation has lasted for four or five days without showing signs of
abatement, suppuration has almost certainly occurred. In deep-seated
suppuration, marked oedema of the skin and the occurrence of rigors and
sweating may be taken to indicate the formation of pus.

There are cases on record where rapidly growing sarcomatous and
angiomatous tumours, aneurysms, and the bruises that occur in
hæmophylics, have been mistaken for acute abscesses and incised, with
disastrous results.

#Treatment of Acute Abscesses.#--The dictum of John Bell, "Where there
is pus, let it out," summarises the treatment of abscess. The extent and
situation of the incision and the means taken to drain the cavity,
however, vary with the nature, site, and relations of the abscess. In a
superficial abscess, for example a bubo, or an abscess in the breast or
face where a disfiguring scar is undesirable, a small puncture should be
made where the pus threatens to point, and a Klapp's suction bell be
applied as already described (p. 39). A drain is not necessary, and in
the intervals between the applications of the bell the part is covered
with a moist antiseptic dressing.

In abscesses deeply placed, as for example under the gluteal or pectoral
muscles, one or more incisions should be made, and the cavity drained by
glass or rubber tubes or by strips of rubber tissue.

The wound should be dressed the next day, and the tube shortened, in the
case of a rubber tube, by cutting off a portion of its outer end. On the
second day or later, according to circumstances, the tube is removed,
and after this the dressing need not be repeated oftener than every
second or third day.

Where pus has formed in relation to important structures--as, for
example, in the deeper planes of the neck--_Hilton's method_ of opening
the abscess may be employed. An incision is made through the skin and
fascia, a grooved director is gently pushed through the deeper tissues
till pus escapes along its groove, and then the track is widened by
passing in a pair of dressing forceps and expanding the blades. A tube,
or strip of rubber tissue, is introduced, and the subsequent treatment
carried out as in other abscesses. When the drain lies in proximity to a
large blood vessel, care must be taken not to leave it in position long
enough to cause ulceration of the vessel wall by pressure.

In some abscesses, such as those in the vicinity of the anus, the cavity
should be laid freely open in its whole extent, stuffed with iodoform or
bismuth gauze, and treated by the open method.

It is seldom advisable to wash out an abscess cavity, and squeezing out
the pus is also to be avoided, lest the protective zone be broken down
and the infection be diffused into the surrounding tissues.

The importance of taking precautions against further infection in
opening an abscess can scarcely be exaggerated, and the rapidity with
which healing occurs when the access of fresh bacteria is prevented is
in marked contrast to what occurs when such precautions are neglected
and further infection is allowed to take place.

_Acute Suppuration in a Wound._--If in the course of an operation
infection of the wound has occurred, a marked inflammatory reaction soon
manifests itself, and the same changes as occur in the formation of an
acute abscess take place, modified, however, by the fact that the pus
can more readily reach the surface. In from twenty-four to forty-eight
hours the patient is conscious of a sensation of chilliness, or may
even have a rigor. At the same time he feels generally out of sorts,
with impaired appetite, headache, and it may be looseness of the bowels.
His temperature rises to 100° or 101° F., and the pulse quickens to 100
or 110.

On exposing the wound it is found that the parts for some distance
around are red, glazed, and oedematous. The discoloration and swelling
are most intense in the immediate vicinity of the wound, the edges of
which are everted and moist. Any stitches that may have been introduced
are tight, and the deep ones may be cutting into the tissues. There is
heat, and a constant burning or throbbing pain, which is increased by
pressure. If the stitches be cut, pus escapes, the wound gapes, and its
surfaces are found to be inflamed and covered with pus.

The open method is the only safe means of treating such wounds. The
infected surface may be sponged over with pure carbolic acid, the excess
of which is washed off with absolute alcohol, and the wound either
drained by tubes or packed with iodoform gauze. The practice of scraping
such surfaces with the sharp spoon, squeezing or even of washing them
out with antiseptic lotions, is attended with the risk of further
diffusing the organisms in the tissue, and is only to be employed under
exceptional circumstances. Continuous irrigation of infected wounds or
their immersion in antiseptic baths is sometimes useful. The free
opening up of the wound is almost immediately followed by a fall in the
temperature. The surrounding inflammation subsides, the discharge of pus
lessens, and healing takes place by the formation of granulation
tissue--the so-called "healing by second intention."

Wound infection may take place from _catgut_ which has not been
efficiently prepared. The local and general reactions may be slight,
and, as a rule, do not appear for seven or eight days after the
operation, and, it may be, not till after the skin edges have united.
The suppuration is strictly localised to the part of the wound where
catgut was employed for stitches or ligatures, and shows little tendency
to spread. The infected part, however, is often long of healing. The
irritation in these cases is probably due to toxins in the catgut and
not to bacteria.

When suppuration occurs in connection with buried sutures of
unabsorbable materials, such as silk, silkworm gut, or silver wire, it
is apt to persist till the foreign material is cast off or removed.

Suppuration may occur in the track of a skin stitch, producing a _stitch
abscess_. The infection may arise from the material used, especially
catgut or silk, or, more frequently perhaps, from the growth of
staphylococcus albus from the skin of the patient when this has been
imperfectly disinfected. The formation of pus under these conditions may
not be attended with any of the usual signs of suppuration, and beyond
some induration around the wound and a slight tenderness on pressure
there may be nothing to suggest the presence of an abscess.

_Acute Suppuration of a Mucous Membrane._--When pyogenic organisms gain
access to a mucous membrane, such as that of the bladder, urethra, or
middle ear, the usual phenomena of acute inflammation and suppuration
ensue, followed by the discharge of pus on the free surface. It would
appear that the most marked changes take place in the submucous tissue,
causing the covering epithelium in places to die and leave small
superficial ulcers, for example in gonorrhoeal urethritis, the
cicatricial contraction of the scar subsequently leading to the
formation of stricture. When mucous glands are present in the membrane,
the pus is mixed with mucus--_muco-pus_.


DIFFUSE CELLULITIS AND DIFFUSE SUPPURATION

Cellulitis is an acute affection resulting from the introduction of some
organism--commonly the _streptococcus pyogenes_--into the cellular
connective tissue of the integument, intermuscular septa, tendon
sheaths, or other structures. Infection always takes place through a
breach of the surface, although this may be superficial and
insignificant, such as a pin-prick, a scratch, or a crack under a nail,
and the wound may have been healed for some time before the inflammation
becomes manifest. The cellulitis, also, may develop at some distance
from the seat of inoculation, the organisms having travelled by the
lymphatics.

The virulence of the organisms, the loose, open nature of the tissues in
which they develop, and the free lymphatic circulation by means of which
they are spread, account for the diffuse nature of the process.
Sometimes numbers of cocci are carried for a considerable distance from
the primary area before they are arrested in the lymphatics, and thus
several patches of inflammation may appear with healthy areas between.

The pus infiltrates the meshes of the cellular tissue, there is
sloughing of considerable portions of tissue of low vitality, such as
fat, fascia, or tendon, and if the process continues for some time
several collections of pus may form.

_Clinical Features._--The reaction in cases of diffuse cellulitis is
severe, and is usually ushered in by a distinct chill or even a rigor,
while the temperature rises to 103°, 104°, or 105° F. The pulse is
proportionately increased in frequency, and is small, feeble, and often
irregular. The face is flushed, the tongue dry and brown, and the
patient may become delirious, especially during the night. Leucocytosis
is present in cases of moderate severity; but in severe cases the
virulence of the toxins prevents reaction taking place, and leucocytosis
is absent.

The local manifestations vary with the relation of the seat of the
inflammation to the surface. When the superficial cellular tissue is
involved, the skin assumes a dark bluish-red colour, is swollen,
oedematous, and the seat of burning pain. To the touch it is firm, hot,
and tender. When the primary focus is in the deeper tissues, the
constitutional disturbance is aggravated, while the local signs are
delayed, and only become prominent when pus forms and approaches the
surface. It is not uncommon for blebs containing dark serous fluid to
form on the skin. The infection frequently spreads along the line of the
main lymph vessels of the part (_septic lymphangitis_) and may reach the
lymph glands (_septic lymphadenitis_).

With the formation of pus the skin becomes soft and boggy at several
points, and eventually breaks, giving exit to a quantity of thick
grumous discharge. Sometimes several small collections under the skin
fuse, and an abscess is formed in which fluctuation can be detected.
Occasionally gases are evolved in the tissues, giving rise to emphysema.
It is common for portions of fascia, ligaments, or tendons to slough,
and this may often be recognised clinically by a peculiar crunching or
grating sensation transmitted to the fingers on making firm pressure on
the part.

If it is not let out by incision, the pus, travelling along the lines of
least resistance, tends to point at several places on the surface, or to
open into joints or other cavities.

_Prognosis._--The occurrence of _septicæmia_ is the most serious risk,
and it is in cases of diffuse suppurative cellulitis that this form of
blood-poisoning assumes its most aggravated forms. The toxins of the
streptococci are exceedingly virulent, and induce local death of tissue
so rapidly that the protective emigration of leucocytes fails to take
place. In some cases the passage of masses of free cocci in the
lymphatics, or of infective emboli in the blood vessels, leads to the
formation of _pyogenic abscesses_ in vital organs, such as the brain,
lungs, liver, kidneys, or other viscera. _Hæmorrhage_ from erosion of
arterial or venous trunks may take place and endanger life.

_Treatment._--The treatment of diffuse cellulitis depends to a large
extent on the situation and extent of the affected area, and on the
stage of the process.

_In the limbs_, for example, where the application of a constricting
band is practicable, Bier's method of inducing passive hyperæmia yields
excellent results. If pus is formed, one or more small incisions are
made and a light moist dressing placed over the wounds to absorb the
discharge, but no drain is inserted. The whole of the inflamed area
should be covered with gauze wrung out of a 1 in 10 solution of ichthyol
in glycerine. The dressing is changed as often as necessary, and in the
intervals when the band is off, gentle active and passive movements
should be carried out to prevent the formation of adhesions. After
incisions have been made, we have found the _immersion_ of the limb, for
a few hours at a time, in a water-bath containing warm boracic lotion or
eusol a useful adjuvant to the passive hyperæmia.

_Continuous irrigation_ of the part by a slow, steady stream of lotion,
at the body temperature, such as eusol, or Dakin's solution, or boracic
acid, or frequent washing with peroxide of hydrogen, has been found of
value.

A suitably arranged splint adds to the comfort of the patient; and the
limb should be placed in the attitude which, in the event of stiffness
resulting, will least interfere with its usefulness. The elbow, for
example, should be flexed to a little less than a right angle; at the
wrist, the hand should be dorsiflexed and the fingers flexed slightly
towards the palm.

Massage, passive movement, hot and cold douching, and other measures,
may be necessary to get rid of the chronic oedema, adhesions of tendons,
and stiffness of joints which sometimes remain.

In situations where a constricting band cannot be applied, for example,
on the trunk or the neck, Klapp's suction bells may be used, small
incisions being made to admit of the escape of pus.

If these measures fail or are impracticable, it may be necessary to make
one or more free incisions, and to insert drainage-tubes, portions of
rubber dam, or iodoform worsted.

The general treatment of toxæmia must be carried out, and in cases due
to infection by streptococci, anti-streptococcic serum may be used.

In a few cases, amputation well above the seat of disease, by removing
the source of toxin production, offers the only means of saving the
patient.


WHITLOW

The clinical term whitlow is applied to an acute infection, usually
followed by suppuration, commonly met with in the fingers, less
frequently in the toes. The point of infection is often trivial--a
pin-prick, a puncture caused by a splinter of wood, a scratch, or even
an imperceptible lesion of the skin.

Several varieties of whitlow are recognised, but while it is convenient
to describe them separately, it is to be clearly understood that
clinically they merge one into another, and it is not always possible to
determine in which connective-tissue plane a given infection has
originated.

_Initial Stage._--Attention is usually first attracted to the condition
by a sensation of tightness in the finger and tenderness when the part
is squeezed or knocked against anything. In the course of a few hours
the part becomes red and swollen; there is continuous pain, which soon
assumes a throbbing character, particularly when the hand is dependent,
and may be so severe as to prevent sleep, and the patient may feel
generally out of sorts.

If a constricting band is applied at this stage, the infection can
usually be checked and the occurrence of suppuration prevented. If this
fails, or if the condition is allowed to go untreated, the inflammatory
reaction increases and terminates in suppuration, giving rise to one or
other of the forms of whitlow to be described.

_The Purulent Blister._--In the most superficial variety, pus forms
between the rete Malpighii and the stratum corneum of the skin, the
latter being raised as a blister in which fluctuation can be detected
(Fig. 9, a). This is commonly met with in the palm of the hand of
labouring men who have recently resumed work after a spell of idleness.
When the blister forms near the tip of the finger, the pus burrows under
the nail--which corresponds to the stratum corneum--raising it from its
bed.

There is some local heat and discoloration, and considerable pain and
tenderness, but little or no constitutional disturbance. Superficial
lymphangitis may extend a short distance up the forearm. By clipping
away the raised epidermis, and if necessary the nail, the pus is allowed
to escape, and healing speedily takes place.

_Whitlow at the Nail Fold._--This variety, which is met with among those
who handle septic material, occurs in the sulcus between the nail and
the skin, and is due to the introduction of infective matter at the root
of the nail (Fig. 9, b). A small focus of suppuration forms under the
nail, with swelling and redness of the nail fold, causing intense pain
and discomfort, interfering with sleep, and producing a constitutional
reaction out of all proportion to the local lesion.

To allow the pus to escape, it is necessary, under local anæsthesia, to
cut away the nail fold as well as the portion of nail in the infected
area, or, it may be, to remove the nail entirely. If only a small
opening is made in the nail it is apt to be blocked by granulations.

[Illustration: FIG. 9.--Diagram of various forms of Whitlow.
a = Purulent blister.
b = Suppuration at nail fold.
c = Subcutaneous whitlow.
d = Whitlow in sheath of flexor tendon (e). ]

_Subcutaneous Whitlow._--In this variety the infection manifests itself
as a cellulitis of the pulp of the finger (Fig. 9, c), which sometimes
spreads towards the palm of the hand. The finger becomes red, swollen,
and tense; there is severe throbbing pain, which is usually worst at
night and prevents sleep, and the part is extremely tender on pressure.
When the palm is invaded there may be marked oedema of the back of the
hand, the dense integument of the palm preventing the swelling from
appearing on the front. The pus may be under such tension that
fluctuation cannot be detected. The patient is usually able to flex the
finger to a certain extent without increasing the pain--a point which
indicates that the tendon sheaths have not been invaded. The
suppurative process may, however, spread to the tendon sheaths, or even
to the bone. Sometimes the excessive tension and virulent toxins induce
actual gangrene of the distal part, or even of the whole finger. There
is considerable constitutional disturbance, the temperature often
reaching 101° or 102° F.

The treatment consists in applying a constriction band and making an
incision over the centre of the most tender area, care being taken to
avoid opening the tendon sheath lest the infection be conveyed to it.
Moist dressings should be employed while the suppuration lasts. Carbolic
fomentations, however, are to be avoided on account of the risk of
inducing gangrene.

_Whitlow of the Tendon Sheaths._--In this form the main incidence of the
infection is on the sheaths of the flexor tendons, but it is not always
possible to determine whether it started there or spread thither from
the subcutaneous cellular tissue (Fig. 9, d). In some cases both
connective tissue planes are involved. The affected finger becomes red,
painful, and swollen, the swelling spreading to the dorsum. The
involvement of the tendon sheath is usually indicated by the patient
being unable to flex the finger, and by the pain being increased when he
attempts to do so. On account of the anatomical arrangement of the
tendon sheaths, the process may spread into the forearm--directly in the
case of the thumb and little finger, and after invading the palm in the
case of the other fingers--and there give rise to a diffuse cellulitis
which may result in sloughing of fasciæ and tendons. When the infection
spreads into the common flexor sheath under the transverse carpal
(anterior annular) ligament, it is not uncommon for the intercarpal and
wrist joints to become implicated. Impaired movement of tendons and
joints is, therefore, a common sequel to this variety of whitlow.

The _treatment_ consists in inducing passive hyperæmia by Bier's method,
and, if this is done early, suppuration may be avoided. If pus forms,
small incisions are made, under local anæsthesia, to relieve the tension
in the sheath and to diminish the risk of the tendons sloughing. No form
of drain should be inserted. In the fingers the incisions should be made
in the middle line, and in the palm they should be made over the
metacarpal bones to avoid the digital vessels and nerves. If pus has
spread under the transverse carpal ligament, the incision must be made
above the wrist. Passive movements and massage must be commenced as
early as possible and be perseveringly employed to diminish the
formation of adhesions and resulting stiffness.

_Subperiosteal Whitlow._--This form is usually an extension of the
subcutaneous or of the thecal variety, but in some cases the
inflammation begins in the periosteum--usually of the terminal phalanx.
It may lead to necrosis of a portion or even of the entire phalanx. This
is usually recognised by the persistence of suppuration long after the
acute symptoms have passed off, and by feeling bare bone with the probe.
In such cases one or more of the joints are usually implicated also, and
lateral mobility and grating may be elicited. Recovery does not take
place until the dead bone is removed, and the usefulness of the finger
is often seriously impaired by fibrous or bony ankylosis of the
interphalangeal joints. This may render amputation advisable when a
stiff finger is likely to interfere with the patient's occupation.


SUPPURATIVE CELLULITIS IN DIFFERENT SITUATIONS

_Cellulitis of the forearm_ is usually a sequel to one of the deeper
varieties of whitlow.

In the _region of the elbow-joint_, cellulitis is common around the
olecranon. It may originate as an inflammation of the olecranon bursa,
or may invade the bursa secondarily. In exceptional cases the
elbow-joint is also involved.

Cellulitis of the _axilla_ may originate in suppuration in the lymph
glands, following an infected wound of the hand, or it may spread from a
septic wound on the chest wall or in the neck. In some cases it is
impossible to discover the primary seat of infection. A firm, brawny
swelling forms in the armpit and extends on to the chest wall. It is
attended with great pain, which is increased on moving the arm, and
there is marked constitutional disturbance. When suppuration occurs, its
spread is limited by the attachments of the axillary fascia, and the pus
tends to burrow on to the chest wall beneath the pectoral muscles, and
upwards towards the shoulder-joint, which may become infected. When the
pus forms in the axillary space, the treatment consists in making free
incisions, which should be placed on the thoracic side of the axilla to
avoid the axillary vessels and nerves. If the pus spreads on to the
chest wall, the abscess should be opened below the clavicle by Hilton's
method, and a counter opening may be made in the axilla.

Cellulitis of the _sole of the foot_ may follow whitlow of the toes.

In the _region of the ankle_ cellulitis is not common; but _around the
knee_ it frequently occurs in relation to the prepatellar bursa and to
the popliteal lymph glands, and may endanger the knee-joint. It is also
met with in the _groin_ following on inflammation and suppuration of the
inguinal glands, and cases are recorded in which the sloughing process
has implicated the femoral vessels and led to secondary hæmorrhage.

Cellulitis of the scalp, orbit, neck, pelvis, and perineum will be
considered with the diseases of these regions.


CHRONIC SUPPURATION

While it is true that a chronic pyogenic abscess is sometimes met
with--for example, in the breast and in the marrow of long bones--in the
great majority of instances the formation of a chronic or cold abscess
is the result of the action of the tubercle bacillus. It is therefore
more convenient to study this form of suppuration with tuberculosis
(p. 139).


SINUS AND FISTULA

#Sinus.#--A sinus is a track leading from a focus of suppuration to a
cutaneous or mucous surface. It usually represents the path by which the
discharge escapes from an abscess cavity that has been prevented from
closing completely, either from mechanical causes or from the persistent
formation of discharge which must find an exit. A sinus is lined by
granulation tissue, and when it is of long standing the opening may be
dragged below the level of the surrounding skin by contraction of the
scar tissue around it. As a sinus will persist until the obstacle to
closure of the original abscess is removed, it is necessary that this
should be sought for. It may be a foreign body, such as a piece of dead
bone, an infected ligature, or a bullet, acting mechanically or by
keeping up discharge, and if the body is removed the sinus usually
heals. The presence of a foreign body is often suggested by a mass of
redundant granulations at the mouth of the sinus. If a sinus passes
through a muscle, the repeated contractions tend to prevent healing
until the muscle is kept at rest by a splint, or put out of action by
division of its fibres. The sinuses associated with empyema are
prevented from healing by the rigidity of the chest wall, and will only
close after an operation which admits of the cavity being obliterated.
In any case it is necessary to disinfect the track, and, it may be, to
remove the unhealthy granulations lining it, by means of the sharp
spoon, or to excise it bodily. To encourage healing from the bottom the
cavity should be packed with bismuth or iodoform gauze. The healing of
long and tortuous sinuses is often hastened by the injection of Beck's
bismuth paste (p. 145). If disfigurement is likely to follow from
cicatricial contraction--for example, in a sinus over the lower jaw
associated with a carious tooth--the sinus should be excised and the raw
surfaces approximated with stitches.

The _tuberculous sinus_ is described under Tuberculosis.

A #fistula# is an abnormal canal passing from a mucous surface to the
skin or to another mucous surface. Fistulæ resulting from suppuration
usually occur near the natural openings of mucous canals--for example,
on the cheek, as a salivary fistula; beside the inner angle of the eye,
as a lacrymal fistula; near the ear, as a mastoid fistula; or close to
the anus, as a fistula-in-ano. Intestinal fistulæ are sometimes met with
in the abdominal wall after strangulated hernia, operations for
appendicitis, tuberculous peritonitis, and other conditions. In the
perineum, fistulæ frequently complicate stricture of the urethra.

Fistulæ also occur between the bladder and vagina (_vesico-vaginal
fistula_), or between the bladder and the rectum (_recto-vesical
fistula_).

The _treatment_ of these various forms of fistula will be described in
the sections dealing with the regions in which they occur.

_Congenital fistulæ_, such as occur in the neck from imperfect closure
of branchial clefts, or in the abdomen from unobliterated foetal ducts
such as the urachus or Meckel's diverticulum, will be described in their
proper places.


CONSTITUTIONAL MANIFESTATIONS OF PYOGENIC INFECTION

We have here to consider under the terms Sapræmia, Septicæmia, and
Pyæmia certain general effects of pyogenic infection, which, although
their clinical manifestations may vary, are all associated with the
action of the same forms of bacteria. They may occur separately or in
combination, or one may follow on and merge into another.

#Sapræmia#, or septic intoxication, is the name applied to a form of
poisoning resulting from the absorption into the blood of the toxic
products of pyogenic bacteria. These products, which are of the nature
of alkaloids, act immediately on their entrance into the circulation,
and produce effects in direct proportion to the amount absorbed. As the
toxins are gradually eliminated from the body the symptoms abate, and if
no more are introduced they disappear. Sapræmia in these respects,
therefore, is comparable to poisoning by any other form of alkaloid,
such as strychnin or morphin.

_Clinical Features._--The symptoms of sapræmia seldom manifest
themselves within twenty-four hours of an operation or injury, because
it takes some time for the bacteria to produce a sufficient dose of
their poisons. The onset of the condition is marked by a feeling of
chilliness, sometimes amounting to a rigor, and a rise of temperature to
102°, 103°, or 104° F., with morning remissions (Fig. 10). The heart's
action is markedly depressed, and the pulse is soft and compressible.
The appetite is lost, the tongue dry and covered with a thin
brownish-red fur, so that it has the appearance of "dried beef." The
urine is scanty and loaded with urates. In severe cases diarrhoea and
vomiting of dark coffee-ground material are often prominent features.
Death is usually impending when the skin becomes cold and clammy, the
mucous membranes livid, the pulse feeble and fluttering, the discharges
involuntary, and when a low form of muttering delirium is present.

[Illustration: FIG. 10.--Charts of Acute sapræmia from (a) case of
crushed foot, and (b) case of incomplete abortion.]

A local form of septic infection is always present--it may be an
abscess, an infected compound fracture, or an infection of the cavity of
the uterus, for example, from a retained portion of placenta.

_Treatment._--The first indication is the immediate and complete removal
of the infected material. The wound must be freely opened, all
blood-clot, discharge, or necrosed tissue removed, and the area
disinfected by washing with sterilised salt solution, peroxide of
hydrogen, or eusol. Stronger lotions are to be avoided as being likely
to depress the tissues, and so interfere with protective phagocytosis.
On account of its power of neutralising toxins, iodoform is useful in
these cases, and is best employed by packing the wound with iodoform
gauze, and treating it by the open method, if this is possible.

The general treatment is carried out on the same lines as for other
infective conditions.

#Chronic sapræmia or Hectic Fever.#--Hectic fever differs from acute
sapræmia merely in degree. It usually occurs in connection with
tuberculous conditions, such as bone or joint disease, psoas abscess, or
empyema, which have opened externally, and have thereby become infected
with pyogenic organisms. It is gradual in its development, and is of a
mild type throughout.

[Illustration: FIG. 11.--Chart of Hectic Fever.]

The pulse is small, feeble, and compressible, and the temperature rises
in the afternoon or evening to 102° or 103° F. (Fig. 11), the cheeks
becoming characteristically flushed. In the early morning the
temperature falls to normal or below it, and the patient breaks into a
profuse perspiration, which leaves him pale, weak, and exhausted. He
becomes rapidly and markedly emaciated, even although in some cases the
appetite remains good and is even voracious.

The poisons circulating in the blood produce _waxy degeneration_ in
certain viscera, notably the liver, spleen, kidneys, and intestines. The
process begins in the arterial walls, and spreads thence to the
connective-tissue structures, causing marked enlargement of the affected
organs. Albuminuria, ascites, oedema of the lower limbs, clubbing of the
fingers, and diarrhoea are among the most prominent symptoms of this
condition.

The _prognosis_ in hectic fever depends on the completeness with which
the further absorption of toxins can be prevented. In many cases this
can only be effected by an operation which provides for free drainage,
and, if possible, the removal of infected tissues. The resulting wound
is best treated by the open method. Even advanced waxy degeneration does
not contra-indicate this line of treatment, as the diseased organs
usually recover if the focus from which absorption of toxic material is
taking place is completely eradicated.

[Illustration: FIG. 12.--Chart of case of Septicæmia followed by
Pyæmia.]

#Septicæmia.#--This form of blood-poisoning is the result of the action
of pyogenic bacteria, which not only produce their toxins at the primary
seat of infection, but themselves enter the blood-stream and are carried
to other parts, where they settle and produce further effects.

_Clinical Features._--There may be an incubation period of some hours
between the infection and the first manifestation of acute septicæmia.
In such conditions as acute osteomyelitis or acute peritonitis, we see
the most typical clinical pictures of this condition. The onset is
marked by a chill, or a rigor, which may be repeated, while the
temperature rises to 103° or 104° F., although in very severe cases the
temperature may remain subnormal throughout, the virulence of the toxins
preventing reaction. It is in the general appearance of the patient and
in the condition of the pulse that we have our best guides as to the
severity of the condition. If the pulse remains firm, full, and regular,
and does not exceed 110 or even 120, while the temperature is moderately
raised, the outlook is hopeful; but when the pulse becomes small and
compressible, and reaches 130 or more, especially if at the same time
the temperature is low, a grave prognosis is indicated. The tongue is
often dry and coated with a black crust down the centre, while the sides
are red. It is a good omen when the tongue becomes moist again. Thirst
is most distressing, especially in septicæmia of intestinal origin.
Persistent vomiting of dark-brown material is often present, and
diarrhoea with blood-stained stools is not uncommon. The urine is small
in amount, and contains a large proportion of urates. As the poisons
accumulate, the respiration becomes shallow and laboured, the face of a
dull ashy grey, the nose pinched, and the skin cold and clammy.
Capillary hæmorrhages sometimes take place in the skin or mucous
membranes; and in a certain proportion of cases cutaneous eruptions
simulating those of scarlet fever or measles appear, and are apt to lead
to errors in diagnosis. In other cases there is slight jaundice. The
mental state is often one of complete apathy, the patient failing to
realise the gravity of his condition; sometimes there is delirium.

The _prognosis_ is always grave, and depends on the possibility of
completely eradicating the focus of infection, and on the reserve force
the patient has to carry him over the period during which he is
eliminating the poison already circulating in his blood.

The _treatment_ is carried out on the same lines as in sapræmia, but it
is less likely to be successful owing to the organisms having entered
the circulation. When possible, the primary focus of infection should be
dealt with.

#Pyæmia# is a form of blood-poisoning characterised by the development
of secondary foci of suppuration in different parts of the body. Toxins
are thus introduced into the blood, not only at the primary seat of
infection, but also from each of these metastatic collections. Like
septicæmia, this condition is due to pyogenic bacteria, the
_streptococcus pyogenes_ being the commonest organism found. The primary
infection is usually in a wound--for example, a compound fracture--but
cases occur in which the point of entrance of the bacteria is not
discoverable. The dissemination of the organisms takes place through the
medium of infected emboli which form in a thrombosed vein in the
vicinity of the original lesion, and, breaking loose, are carried
thence in the blood-stream. These emboli lodge in the minute vessels of
the lungs, spleen, liver, kidneys, pleura, brain, synovial membranes, or
cellular tissue, and the bacteria they contain give rise to secondary
foci of suppuration. Secondary abscesses are thus formed in those parts,
and these in turn may be the starting-point of new emboli which give
rise to fresh areas of pus formation. The organs above named are the
commonest situations of pyæmic abscesses, but these may also occur in
the bone marrow, the substance of muscles, the heart and pericardium,
lymph glands, subcutaneous tissue, or, in fact, in any tissue of the
body. Organisms circulating in the blood are prone to lodge on the
valves of the heart and give rise to endocarditis.

[Illustration: FIG. 13.--Chart of Pyæmia following on Acute
Osteomyelitis.]

_Clinical Features._--Before antiseptic surgery was practised, pyæmia
was a common complication of wounds. In the present day it is not only
infinitely less common, but appears also to be of a less severe type.
Its rarity and its mildness may be related as cause and effect, because
it was formerly found that pyæmia contracted from a pyæmic patient was
more virulent than that from other sources.

In contrast with sapræmia and septicæmia, pyæmia is late of developing,
and it seldom begins within a week of the primary infection. The first
sign is a feeling of chilliness, or a violent rigor lasting for perhaps
half an hour, during which time the temperature rises to 103°, 104°, or
105° F. In the course of an hour it begins to fall again, and the
patient breaks into a profuse sweat. The temperature may fall several
degrees, but seldom reaches the normal. In a few days there is a second
rigor with rise of temperature, and another remission, and such attacks
may be repeated at diminishing intervals during the course of the
illness (Figs. 12 and 13). The pulse is soft, and tends to remain
abnormally rapid even when the temperature falls nearly to normal.

The face is flushed, and wears a drawn, anxious expression, and the eyes
are bright. A characteristic sweetish odour, which has been compared to
that of new-mown hay, can be detected in the breath and may pervade the
patient. The appetite is lost; there may be sickness and vomiting and
profuse diarrhoea; and the patient emaciates rapidly. The skin is
continuously hot, and has often a peculiar pungent feel. Patches of
erythema sometimes appear scattered over the body. The skin may assume a
dull sallow or earthy hue, or a bright yellow icteric tint may appear.
The conjunctivæ also may be yellow. In the latter stages of the disease
the pulse becomes small and fluttering; the tongue becomes dry and
brown; sordes collect on the teeth; and a low muttering form of delirium
supervenes.

Secondary infection of the parotid gland frequently occurs, and gives
rise to a suppurative parotitis. This condition is associated with
severe pain, gradually extending from behind the angle of the jaw on to
the face. There is also swelling over the gland, and eventually
suppuration and sloughing of the gland tissue and overlying skin.

Secondary abscesses in the lymph glands, subcutaneous tissue, or joints
are often so insidious and painless in their development that they are
only discovered accidentally. When the abscess is evacuated, healing
often takes place with remarkable rapidity, and with little impairment
of function.

The general symptoms may be simulated by an attack of malaria.

_Prognosis._--The prognosis in acute pyæmia is much less hopeless than
it once was, a considerable proportion of the patients recovering. In
acute cases the disease proves fatal in ten days or a fortnight, death
being due to toxæmia. Chronic cases often run a long course, lasting for
weeks or even months, and prove fatal from exhaustion and waxy disease
following on prolonged suppuration.

_Treatment._--In such conditions as compound fractures and severe
lacerated wounds, much can be done to avert the conditions which lead to
pyæmia, by applying a Bier's constricting bandage as soon as there is
evidence of infection having taken place, or even if there is reason to
suspect that the wound is not aseptic.

If sepsis is already established, and evidence of general infection is
present, the wound should be opened up sufficiently to admit of thorough
disinfection and drainage, and the constricting bandage applied to aid
the defensive processes going on in the tissues. If these measures fail,
amputation of the limb may be the only means of preventing further
dissemination of infective material from the primary source of
infection.

Attempts have been made to interrupt the channel along which the
infective emboli spread, by ligating or resecting the main vein of the
affected part, but this is seldom feasible except in the case of the
internal jugular vein for infection of the transverse sinus.

Secondary abscesses must be aspirated or opened and drained whenever
possible.

The general treatment is conducted on the same lines as on other forms
of pyogenic infection.




CHAPTER V

ULCERATION AND ULCERS


Definitions--Clinical examination of an ulcer--The healing
sore.--Classification of ulcers--A. According to cause:
_Traumatism_, _Imperfect circulation_, _Imperfect nerve-supply_,
_Constitutional causes_--B. According to condition: _Healing_,
_Stationary_, _Spreading_.--Treatment.

The process of _ulceration_ may be defined as the molecular or cellular
death of tissue taking place on a free surface. It is essentially of the
same nature as the process of suppuration, only that the purulent
discharge, instead of collecting in a closed cavity and forming an
abscess, at once escapes on the surface.

An _ulcer_ is an open wound or sore in which there are present certain
conditions tending to prevent it undergoing the natural process of
repair. Of these, one of the most important is the presence of
pathogenic bacteria, which by their action not only prevent healing, but
so irritate and destroy the tissues as to lead to an actual increase in
the size of the sore. Interference with the nutrition of a part by oedema
or chronic venous congestion may impede healing; as may also induration
of the surrounding area, by preventing the contraction which is such an
important factor in repair. Defective innervation, such as occurs in
injuries and diseases of the spinal cord, also plays an important part
in delaying repair. In certain constitutional conditions, too--for
example, Bright's disease, diabetes, or syphilis--the vitiated state of
the tissues is an impediment to repair. Mechanical causes, such as
unsuitable dressings or ill-fitting appliances, may also act in the same
direction.

#Clinical Examination of an Ulcer.#--In examining any ulcer, we
observe--(1) Its _base_ or _floor_, noting the presence or absence of
granulations, their disposition, size, colour, vascularity, and whether
they are depressed or elevated in relation to the surrounding parts. (2)
The _discharge_ as to quantity, consistence, colour, composition, and
odour. (3) The _edges_, noting particularly whether or not the marginal
epithelium is attempting to grow over the surface; also their shape,
regularity, thickness, and whether undermined or overlapping, everted or
depressed. (4) The _surrounding tissues_, as to whether they are
congested, oedematous, inflamed, indurated, or otherwise. (5) Whether or
not there is _pain_ or tenderness in the raw surface or its
surroundings. (6) The _part of the body_ on which it occurs, because
certain ulcers have special seats of election--for example, the varicose
ulcer in the lower third of the leg, the perforating ulcer on the sole
of the foot, and so on.

#The Healing Sore.#--If a portion of skin be excised aseptically, and no
attempt made to close the wound, the raw surface left is soon covered
over with a layer of coagulated blood and lymph. In the course of a few
days this is replaced by the growth of _granulations_, which are of
uniform size, of a pinkish-red colour, and moist with a slight serous
exudate containing a few dead leucocytes. They grow until they reach the
level of the surrounding skin, and so fill the gap with a fine velvety
mass of granulation tissue. At the edges, the young epithelium may be
seen spreading in over the granulations as a fine bluish-white pellicle,
which gradually covers the sore, becoming paler in colour as it
thickens, and eventually forming the smooth, non-vascular covering of
the cicatrix. There is no pain, and the surrounding parts are healthy.

This may be used as a type with which to compare the ulcers seen at the
bedside, so that we may determine how far, and in what particulars,
these differ from the type; and that we may in addition recognise the
conditions that have to be counteracted before the characters of the
typical healing sore are assumed.

For purposes of contrast we may indicate the characters of an open sore
in which bacterial infection with pathogenic bacteria has taken place.
The layer of coagulated blood and lymph becomes liquefied and is thrown
off, and instead of granulations being formed, the tissues exposed on
the floor of the ulcer are destroyed by the bacterial toxins, with the
formation of minute sloughs and a quantity of pus.

The discharge is profuse, thin, acrid, and offensive, and consists of
pus, broken-down blood-clot, and sloughs. The edges are inflamed,
irregular, and ragged, showing no sign of growing epithelium--on the
contrary, the sore may be actually increasing in area by the
breaking-down of the tissues at its margins. The surrounding parts are
hot, red, swollen, and oedematous; and there is pain and tenderness both
in the sore itself and in the parts around.

#Classification of Ulcers.#--The nomenclature of ulcers is much involved
and gives rise to great confusion, chiefly for the reason that no one
basis of classification has been adopted. Thus some ulcers are named
according to the causes at work in producing or maintaining them--for
example, the traumatic, the septic, and the varicose ulcer; some from
the constitutional element present, as the gouty and the diabetic ulcer;
and others according to the condition in which they happen to be when
seen by the surgeon, such as the weak, the inflamed, and the callous
ulcer.

So long as we retain these names it will be impossible to find a single
basis for classification; and yet many of the terms are so descriptive
and so generally understood that it is undesirable to abolish them. We
must therefore remain content with a clinical arrangement of ulcers,--it
cannot be called a classification,--considering any given ulcer from two
points of view: first its _cause_, and second its _present condition_.
This method of studying ulcers has the practical advantage that it
furnishes us with the main indications for treatment as well as for
diagnosis: the cause must be removed, and the condition so modified as
to convert the ulcer into an aseptic healing sore.

A. #Arrangement of Ulcers according to their Cause.#--Although any given
ulcer may be due to a combination of causes, it is convenient to
describe the following groups:

_Ulcers due to Traumatism._--Traumatism in the form of a _crush_ or
_bruise_ is a frequent cause of ulcer formation, acting either by
directly destroying the skin, or by so diminishing its vitality that it
is rendered a suitable soil for bacteria. If these gain access, in the
course of a few days the damaged area of skin becomes of a greyish
colour, blebs form on it, and it undergoes necrosis, leaving an
unhealthy raw surface when the slough separates.

_Heat_ and _prolonged exposure to the Röntgen rays_ or _to radium
emanations_ act in a similar way.

The _pressure_ of improperly padded splints or other appliances may so
far interfere with the circulation of the part pressed upon, that the
skin sloughs, leaving an open sore. This is most liable to occur in
patients who suffer from some nerve lesion--such as anterior
poliomyelitis, or injury of the spinal cord or nerve-trunks.
Splint-pressure sores are usually situated over bony prominences, such
as the malleoli, the condyles of the femur or humerus, the head of the
fibula, the dorsum of the foot, or the base of the fifth metatarsal
bone. On removing the splint, the skin of the part pressed upon is found
to be of a red or pink colour, with a pale grey patch in the centre,
which eventually sloughs and leaves an ulcer. Certain forms of
_bed-sore_ are also due to prolonged pressure.

Pressure sores are also known to have been produced artificially by
malingerers and hysterical subjects.

[Illustration: FIG. 14.--Leg Ulcers associated with Varicose Veins and
Pigmentation of the Skin.]

_Ulcers due to Imperfect Circulation._--Imperfect circulation is an
important causative factor in ulceration, especially when it is the
_venous return_ that is defective. This is best illustrated in the
so-called _leg ulcer_, which occurs most frequently on the front and
medial aspect of the lower third of the leg. At this point the
anastomosis between the superficial and deep veins of the leg is less
free than elsewhere, so that the extra stress thrown upon the surface
veins interferes with the nutrition of the skin (Hilton). The importance
of imperfect venous return in the causation of such ulcers is evidenced
by the fact that as soon as the condition of the circulation is improved
by confining the patient to bed and elevating the limb, the ulcer begins
to heal, even although all methods of local treatment have hitherto
proved ineffectual. In a considerable number of cases, but by no means
in all, this form of ulcer is associated with the presence of varicose
veins, and in such cases it is spoken of as the _varicose ulcer_ (Fig. 14).
The presence of varicose veins is frequently associated with a
diffuse brownish or bluish pigmentation of the skin of the lower third
of the leg, or with an obstinate form of dermatitis (_varicose eczema_),
and the scratching or rubbing of the part is liable to cause a breach of
the surface and permit of infection which leads to ulceration. Varicose
ulcers may also originate from the bursting of a small peri-phlebitic
abscess.

Varicose veins in immediate relation to the base of a large chronic
ulcer usually become thrombosed, and in time are reduced to fibrous
cords, and therefore in such cases hæmorrhage is not a common
complication. In smaller and more superficial ulcers, however, the
destructive process is liable to implicate the wall of the vessel before
the occurrence of thrombosis, and to lead to profuse and it may be
dangerous bleeding.

These ulcers are at first small and superficial, but from want of care,
from continued standing or walking, or from injudicious treatment, they
gradually become larger and deeper. They are not infrequently multiple,
and this, together with their depth, may lead to their being mistaken
for ulcers due to syphilis. The base of the ulcer is covered with
imperfectly formed, soft, oedematous granulations, which give off a thin
sero-purulent discharge. The edges are slightly inflamed, and show no
evidence of healing. The parts around are usually pigmented and slightly
oedematous, and as a rule there is little pain. This variety of ulcer is
particularly prone to pass into the condition known as callous.

In _anæmic_ patients, especially young girls, ulcers are occasionally
met with which have many of the clinical characters of those associated
with imperfect venous return. They are slow to heal, and tend to pass
into the condition known as weak.

_Ulcers due to Interference with Nerve-Supply._--Any interference with
the nerve-supply of the superficial tissues predisposes to ulceration.
For example, _trophic_ ulcers are liable to occur in injuries or
diseases of the spinal cord, in cerebral paralysis, in limbs weakened by
poliomyelitis, in ascending or peripheral neuritis, or after injuries of
nerve-trunks.

The _acute bed-sore_ is a rapidly progressing form of ulceration, often
amounting to gangrene, of portions of skin exposed to pressure when
their trophic nerve-supply has been interfered with.

[Illustration: FIG. 15.--Perforating Ulcers of Sole of Foot.

(From Photograph lent by Sir Montagu Cotterill.)]

The _perforating ulcer of the foot_ is a peculiar type of sore which
occurs in association with the different forms of peripheral neuritis,
and with various lesions of the brain and spinal cord, such as general
paralysis, locomotor ataxia, or syringo-myelia (Fig. 15). It also occurs
in patients suffering from glycosuria, and is usually associated with
arterio-sclerosis--local or general. Perforating ulcer is met with most
frequently under the head of the metatarsal bone of the great toe. A
callosity forms and suppuration occurs under it, the pus escaping
through a small hole in the centre. The process slowly and gradually
spreads deeper and deeper, till eventually the bone or joint is reached,
and becomes implicated in the destructive process--hence the term
"perforating ulcer." The flexor tendons are sometimes destroyed, the toe
being dorsiflexed by the unopposed extensors. The depth of the track
being so disproportionate to its superficial area, the condition closely
simulates a tuberculous sinus, for which it is liable to be mistaken.
The raw surface is absolutely insensitive, so that the probe can be
freely employed without the patient even being aware of it or suffering
the least discomfort--a significant fact in diagnosis. The cavity is
filled with effete and decomposing epidermis, which has a most offensive
odour. The chronic and intractable character of the ulcer is due to
interference with the trophic nerve-supply of the parts, and to the fact
that the epithelium of the skin grows in and lines the track leading
down to the deepest part of the ulcer and so prevents closure. While
they are commonest on the sole of the foot and other parts subjected to
pressure, perforating ulcers are met with on the sides and dorsum of the
foot and toes, on the hands, and on other parts where no pressure has
been exerted.

The _tuberculous ulcer_, so often seen in the neck, in the vicinity of
joints, or over the ribs and sternum, usually results from the bursting
through the skin of a tuberculous abscess. The base is soft, pale, and
covered with feeble granulations and grey shreddy sloughs. The edges are
of a dull blue or purple colour, and gradually thin out towards their
free margins, and in addition are characteristically undermined, so that
a probe can be passed for some distance between the floor of the ulcer
and the thinned-out edges. Thin, devitalised tags of skin often stretch
from side to side of the ulcer. The outline is irregular; small
perforations often occur through the skin, and a thin, watery discharge,
containing grey shreds of tuberculous debris, escapes.

_Bazin's Disease._--This term is applied to an affection of the skin and
subcutaneous tissue which bears certain resemblances to tuberculosis. It
is met with almost exclusively between the knee and the ankle, and it
usually affects both legs. It is commonest in girls of delicate
constitution, in whose family history there is evidence of a tuberculous
taint. The patient often presents other lesions of a tuberculous
character, notably enlarged cervical glands, and phlyctenular
ophthalmia. The tubercle bacillus has rarely been found, but we have
always observed characteristic epithelioid cells and giant cells in
sections made from the edge or floor of the ulcer.

[Illustration: FIG. 16.--Bazin's Disease in a girl æt. 16.]

The condition begins by the formation in the skin and subcutaneous
tissue of dusky or livid nodules of induration, which soften and
ulcerate, forming small open sores with ragged and undermined edges, not
unlike those resulting from the breaking down of superficial syphilitic
gummata (Fig. 16). Fresh crops of nodules appear in the neighbourhood of
the ulcers, and in turn break down. While in the nodular stage the
affection is sometimes painful, but with the formation of the ulcer the
pain subsides.

The disease runs a chronic course, and may slowly extend over a wide
area in spite of the usual methods of treatment. After lasting for some
months, or even years, however, it may eventually undergo spontaneous
cure. The most satisfactory treatment is to excise the affected tissues
and fill the gap with skin-grafts.

[Illustration: FIG. 17.--Syphilitic Ulcers in region of Knee, showing
punched-out appearance and raised indurated edges.]

The _syphilitic ulcer_ is usually formed by the breaking down of a
cutaneous or subcutaneous gumma in the tertiary stage of syphilis. When
the gummatous tissue is first exposed by the destruction of the skin or
mucous membrane covering it, it appears as a tough greyish slough,
compared to "wash leather," which slowly separates and leaves a more or
less circular, deep, punched-out gap which shows a few feeble unhealthy
granulations and small sloughs on its floor. The edges are raised and
indurated; and the discharge is thick, glairy, and peculiarly offensive.
The parts around the ulcer are congested and of a dark brown colour.
There are usually several such ulcers together, and as they tend to heal
at one part while they spread at another, the affected area assumes a
sinuous or serpiginous outline. Syphilitic ulcers may be met with in any
part of the body, but are most frequent in the upper part of the leg
(Fig. 17), especially around the knee-joint in women, and over the ribs
and sternum. On healing, they usually leave a depressed and adherent
cicatrix.

The _scorbutic ulcer_ occurs in patients suffering from scurvy, and is
characterised by its prominent granulations, which show a marked
tendency to bleed, with the formation of clots, which dry and form a
spongy crust on the surface.

In _gouty_ patients small ulcers which are exceedingly irritable and
painful are liable to occur.

_Ulcers associated with Malignant Disease._--Cancer and sarcoma when
situated in the subcutaneous tissue may destroy the overlying skin so
that the substance of the tumour is exposed. The fungating masses thus
produced are sometimes spoken of as malignant ulcers, but as they are
essentially different in their nature from all other forms of ulcers,
and call for totally different treatment, it is best to consider them
along with the tumours with which they are associated. Rodent ulcer,
which is one form of cancer of the skin, will be discussed with new
growths of the skin.

B. #Arrangement of Ulcers according to their Condition.#--Having arrived
at an opinion as to the cause of a given ulcer, and placed it in one or
other of the preceding groups, the next question to ask is, In what
condition do I find this ulcer at the present moment?

Any ulcer is in one of three states--healing, stationary, or spreading;
although it is not uncommon to find healing going on at one part while
the destructive process is extending at another.

_The Healing Condition._--The process of healing in an ulcer has already
been studied, and we have learned that it takes place by the formation
of granulation tissue, which becomes converted into connective tissue,
and is covered over by epithelium growing in from the edges.

Those ulcers which are _stationary_--that is, neither healing nor
spreading--may be in one of several conditions.

_The Weak Condition._--Any ulcer may get into a weak state from
receiving a blood supply which is defective either in quantity or in
quality. The granulations are small and smooth, and of a pale yellow or
grey colour, the discharge is small in amount, and consists of thin
serum and a few pus cells, and as this dries on the edges it forms scabs
which interfere with the growth of epithelium.

Should the part become oedematous, either from general causes, such as
heart or kidney disease, or from local causes, such as varicose veins,
the granulations share in the oedema, and there is an abundant serous
discharge.

The excessive use of moist dressings leads to a third variety of weak
ulcer--namely, one in which the granulations become large, soft, pale,
and flabby, projecting beyond the level of the skin and overlapping the
edges, which become pale and sodden. The term "proud flesh" is popularly
applied to such redundant granulations.

[Illustration: FIG. 18.--Callous Ulcer, showing thickened edges and
indurated swelling of surrounding parts.]

_The Callous Condition._--This condition is usually met with in ulcers
on the lower third of the leg, and is often associated with the presence
of varicose veins. It is chiefly met with in hospital practice. The want
of healing is mainly due to impeded venous return and to oedema and
induration of the surrounding skin and cellular tissues (Fig. 18). The
induration results from coagulation and partial organisation of the
inflammatory effusion, and prevents the necessary contraction of the
sore. The base of a callous ulcer lies at some distance below the level
of the swollen, thickened, and white edges, and presents a glazed
appearance, such granulations as are present being unhealthy and
irregular. The discharge is usually watery, and cakes in the dressing.
When from neglect and want of cleanliness the ulcer becomes inflamed,
there is considerable pain, and the discharge is purulent and often
offensive.

The prolonged hyperæmia of the tissues in relation to a callous ulcer of
the leg often leads to changes in the underlying bones. The periosteum
is abnormally thick and vascular, the superficial layers of the bone
become injected and porous, and the bones, as a whole, are thickened. In
the macerated bone "the surface is covered with irregular,
stalactite-like processes or foliaceous masses, which, to a certain
extent, follow the line of attachment of the interosseous membrane and
of the intermuscular septa" (Cathcart) (Fig. 19). When the whole
thickness of the soft tissues is destroyed by the ulcerative process,
the area of bone that comes to form the base of the ulcer projects as a
flat, porous node, which in its turn may be eroded. These changes as
seen in the macerated specimen are often mistaken for disease
originating in the bone.

[Illustration: FIG. 19.--Tibia and Fibula, showing changes due to
chronic ulcer of leg.]

The _irritable condition_ is met with in ulcers which occur, as a rule,
just above the external malleolus in women of neurotic temperament. They
are small in size and have prominent granulations, and by the aid of a
probe points of excessive tenderness may be discovered. These, Hilton
believed, correspond to exposed nerve filaments.

_Ulcers which are spreading_ may be met with in one of several
conditions.

_The Inflamed Condition._--Any ulcer may become acutely inflamed from
the access of fresh organisms, aided by mechanical irritation from
trauma, ill-fitting splints or bandages, or want of rest, or from
chemical irritants, such as strong antiseptics. The best clinical
example of an inflamed ulcer is the venereal soft sore. The base of the
ulcer becomes red and angry-looking, the granulations disappear, and a
copious discharge of thin yellow pus, mixed with blood, escapes. Sloughs
of granulation tissue or of connective tissue may form. The edges become
red, ragged, and everted, and the ulcer increases in size by spreading
into the inflamed and oedematous surrounding tissues. Such ulcers are
frequently multiple. Pain is a constant symptom, and is often severe,
and there is usually some constitutional disturbance.

The _phagedænic condition_ is the result of an ulcer being infected with
specially virulent bacteria. It occurs in syphilitic ulcers, and rapidly
leads to a widespread destruction of tissue. It is also met with in the
throat in some cases of scarlet fever, and may give rise to fatal
hæmorrhage by ulcerating into large blood vessels. All the local and
constitutional signs of a severe septic infection are present.

#Treatment of Ulcers.#--An ulcer is not only an immediate cause of
suffering to the patient, crippling and incapacitating him for his work,
but is a distinct and constant menace to his health: the prolonged
discharge reduces his strength; the open sore is a possible source of
infection by the organisms of suppuration, erysipelas, or other specific
diseases; phlebitis, with formation of septic emboli, leading to pyæmia,
is liable to occur; and in old persons it is not uncommon for ulcers of
long standing to become the seat of cancer. In addition, the offensive
odour of many ulcers renders the patient a source of annoyance and
discomfort to others. The primary object of treatment in any ulcer is to
bring it into the condition of a healing sore. When this has been
effected, nature will do the rest, provided extraneous sources of
irritation are excluded.

Steps must be taken to facilitate the venous return from the ulcerated
part, and to ensure that a sufficient supply of fresh, healthy blood
reaches it. The septic element must be eliminated by disinfecting the
ulcer and its surroundings, and any other sources of irritation must be
removed.

If the patient's health is below par, good nourishing food, tonics, and
general hygienic treatment are indicated.

_Management of a Healing Sore._--Perhaps the best dressing for a healing
sore is a layer of Lister's perforated oiled-silk protective, which is
made to cover the raw surface and the skin for about a quarter of an
inch beyond the margins of the sore. Over this three or four thicknesses
of sterilised gauze, wrung out of eusol, creolin, or sterilised water,
are applied, and covered by a pad of absorbent wool. As far as possible
the part should be kept at rest, and the position should be adjusted so
as to favour the circulation in the affected area.

The dressing may be renewed at intervals, and care must be taken to
avoid any rough handling of the sore. Any discharge that lies on the
surface should be removed by a gentle stream of lotion rather than by
wiping. The area round the sore should be cleansed before the fresh
dressing is applied.

In some cases, healing goes on more rapidly under a dressing of weak
boracic ointment (one-quarter the strength of the pharmacopoeial
preparation). The growth of epithelium may be stimulated by a 6 to 8 per
cent. ointment of scarlet-red.

Dusting powders and poultice dressings are best avoided in the treatment
of healing sores.

In extensive ulcers resulting from recent burns, if the granulations are
healthy and aseptic, skin-grafts may safely be placed on them directly.
If, however, their asepticity cannot be relied upon, it is necessary to
scrape away the superficial layer of the granulations, the young fibrous
tissue underneath being conserved, as it is sufficiently vascular to
nourish the grafts placed on it.

#Treatment of Special Varieties of Ulcers.#--Before beginning to treat a
given ulcer, two questions have to be answered--first, What are the
causative conditions present? and second, In what condition do I find
the ulcer?--in other words, In what particulars does it differ from a
healthy healing sore?

If the cause is a local one, it must be removed; if a constitutional
one, means must be taken to counteract it. This done, the condition of
the ulcer must be so modified as to bring it into the state of a healing
sore, after which it will be managed on the lines already laid down.

#Treatment in relation to the Cause of the Ulcer.#--_Traumatic
Group._--The _prophylaxis_ of these ulcers consists in excluding
bacteria, by cleansing crushed or bruised parts, and applying sterilised
dressings and properly adjusted splints. If there is reason to fear that
the disinfection has not been complete, a Bier's constricting bandage
should be applied for some hours each day. These measures will often
prevent a grossly injured portion of skin dying, and will ensure
asepticity should it do so. In the event of the skin giving way, the
same form of dressing should be continued till the slough has separated
and a healthy granulating surface is formed. The protective dressing
appropriate to a healing sore is then substituted. _Pressure sores_ are
treated on the same lines.

The treatment of ulcers caused by _burns and scalds_ will be described
later.

In _ulcers of the leg due to interference with the venous return_, the
primary indication is to elevate the limb in order to facilitate the
flow of the blood in the veins, and so admit of fresh blood reaching the
part. The limb may be placed on pillows, or the foot of the bed raised
on blocks, so that the ulcer lies on a higher level than the heart.
Should varicose veins be present, the question of operative treatment
must be considered.

When an _imperfect nerve supply_ is the main factor underlying ulcer
formation, prophylaxis is the chief consideration. In patients suffering
from spinal injuries or diseases, cerebral paralysis, or affections of
the peripheral nerves, all sources of irritation, such as ill-fitting
splints, tight bandages, moist applications, and hot bottles, should be
avoided. Any part liable to pressure, from the position of the patient
or otherwise, must be carefully protected by pads of wool, air-cushions,
or water-bags, and must be kept absolutely dry. The skin should be
hardened by daily applications of methylated spirit.

Should an ulcer form in spite of these precautions, the mildest
antiseptics must be employed for bathing and dressing it, and as far as
possible all dressings should be dry.

The _perforating ulcer_ of the foot calls for special treatment. To
avoid pressure on the sole of the foot, the patient must be confined to
bed. As the main local obstacle to healing is the down-growth of
epithelium along the sides of the ulcer, this must be removed by the
knife or sharp spoon. The base also should be excised, and any bone
which may have become involved should be gouged away, so as to leave a
healthy and vascular surface. The cavity thus formed is stuffed with
bismuth or iodoform gauze and encouraged to heal from the bottom. As the
parts are insensitive an anæsthetic is not required. After the ulcer has
healed, the patient should wear in his boot a thick felt sole with a
hole cut out opposite the situation of the cicatrix. When a joint has
been opened into, the difficulty of thoroughly getting rid of all
unhealthy and infected granulations is so great that amputation may be
advisable, but it is to be remembered that ulceration may recur in the
stump if pressure is put upon it. The treatment of any nervous disease
or glycosuria which may coexist is, of course, indicated.

Exposure of the plantar nerves by an incision behind the medial
malleolus, and subjecting them to forcible stretching, has been employed
by Chipault and others in the treatment of perforating ulcers of the
foot.

The ulcer that forms in relation to callosities on the sole of the foot
is treated by paring away all the thickened skin, after softening it
with soda fomentations, removing the unhealthy granulations, and
applying stimulating dressings.

_Treatment of Ulcers due to Constitutional Causes._--When ulcers are
associated with such diseases as tuberculosis, syphilis, diabetes,
Bright's disease, scurvy, or gout, these must receive appropriate
treatment.

The local treatment of the _tuberculous ulcer_ calls for special
mention. If the ulcer is of limited extent and situated on an exposed
part of the body, the most satisfactory method is complete removal, by
means of the knife, scissors, or sharp spoon, of the ulcerated surface
and of all the infected area around it, so as to leave a healthy surface
from which granulations may spring up. Should the raw surface left be
likely to result in an unsightly scar or in cicatricial contraction,
skin-grafting should be employed.

For extensive ulcers on the limbs, the chest wall, or on other covered
parts, or when operative treatment is contra-indicated, the use of
tuberculin and exposure to the Röntgen rays have proved beneficial. The
induction of passive hyperæmia, by Bier's or by Klapp's apparatus,
should also be used, either alone or supplementary to other measures.

No ulcerative process responds so readily to medicinal treatment as the
_syphilitic ulcer_ does to the intra-venous administration of arsenical
preparations of the "606" or "914" groups or to full doses of iodide of
potassium and mercury, and the local application of black wash. When the
ulceration has lasted for a long time, however, and is widespread and
deep, the duration of treatment is materially shortened by a thorough
scraping with the sharp spoon.

#Treatment in relation to the Condition of the Ulcer.#--_Ulcers in a
weak condition._--If the weak condition of the ulcer is due to anæmia
or kidney disease, these affections must first be treated. Locally, the
imperfect granulations should be scraped away, and some stimulating
agent applied to the raw surface to promote the growth of healthy
granulations. For this purpose the sore may be covered with gauze
smeared with a 6 to 8 per cent. ointment of scarlet-red, the surrounding
parts being protected from the irritant action of the scarlet-red by a
layer of vaseline. A dressing of gauze moistened with eusol or of
boracic lint wrung out of red lotion (2 grains of sulphate of zinc, and
10 minims of compound tincture of lavender, to an ounce of water), and
covered with a layer of gutta-percha tissue, is also useful.

When the condition has resulted from the prolonged use of moist
dressings, these must be stopped, the redundant granulations clipped
away with scissors, the surface rubbed with silver nitrate or sulphate
of copper (blue-stone), and dry dressings applied.

When the ulcer has assumed the characters of a healing sore, skin-grafts
may be applied to hasten cicatrisation.

_Ulcers in a callous condition_ call for treatment in three
directions--(1) The infective element must be eliminated. When the ulcer
is foul, relays of charcoal poultices (three parts of linseed meal to
one of charcoal), maintained for thirty-six to forty-eight hours, are
useful as a preliminary step. The base of the ulcer and the thickened
edges should then be freely scraped with a sharp spoon, and the
resulting raw surface sponged over with undiluted carbolic acid or
iodine, after which an antiseptic dressing is applied, and changed daily
till healthy granulations appear. (2) The venous return must be
facilitated by elevation of the limb and massage. (3) The induration of
the surrounding parts must be got rid of before contraction of the sore
is possible. For this purpose the free application of blisters, as first
recommended by Syme, leaves little to be desired. Liquor epispasticus
painted over the parts, or a large fly-blister (emplastrum cantharidis)
applied all round the ulcer, speedily disperses the inflammatory
products which cause the induration. The use of elastic pressure or of
strapping, of hot-air baths, or the making of multiple incisions in the
skin around the ulcer, fulfils the same object.

As soon as the ulcer assumes the characters of a healing sore, it should
be covered with skin-grafts, which furnish a much better cicatrix than
that which forms when the ulcer is allowed to heal without such aid.

A more radical method of treatment consists in excising the whole
ulcer, including its edges and about a quarter of an inch of the
surrounding tissue, as well as the underlying fibrous tissue, and
grafting the raw surface.

_Ambulatory Treatment._--When the circumstances of the patient forbid
his lying up in bed, the healing of the ulcer is much delayed. He should
be instructed to take every possible opportunity of placing the limb in
an elevated position, and must constantly wear a firm bandage of
_elastic webbing_. This webbing is porous and admits of evaporation of
the skin and wound secretions--an advantage it has over Martin's rubber
bandage. The bandage should extend from the toes to well above the knee,
and should always be applied while the patient is in the recumbent
position with the leg elevated, preferably before getting out of bed in
the morning. Additional support is given to the veins if the bandage is
applied as a figure of eight.

We have found the following method satisfactory in out-patient
practice. The patient lying on a couch, the limb is raised about
eighteen inches and kept in this position for five minutes--till the
excess of blood has left it. With the limb still raised, the ulcer with
the surrounding skin is covered with a layer, about half an inch thick,
of finely powdered boracic acid, and the leg, from foot to knee,
excluding the sole, is enveloped in a thick layer of wood-wool wadding.
This is held in position by ordinary cotton bandages, painted over with
liquid starch; while the starch is drying the limb is kept elevated.
With this appliance the patient may continue to work, and the dressing
does not require to be changed oftener than once in three or four weeks
(W. G. Richardson).

When an ulcer becomes acutely _inflamed_ as a result of superadded
infection, antiseptic measures are employed to overcome the infection,
and ichthyol or other soothing applications may be used to allay the
pain.

The _phagedænic ulcer_ calls for more energetic means of disinfection;
the whole of the affected surface is touched with the actual cautery at
a white heat, or is painted with pure carbolic acid. Relays of charcoal
poultices are then applied until the spread of the disease is arrested.

For the _irritable ulcer_ the most satisfactory treatment is complete
excision and subsequent skin-grafting.




CHAPTER VI

GANGRENE


Definition--Types: _Dry_, _Moist_--Varieties--Gangrene primarily due to
interference with circulation: _Senile gangrene_; _Embolic
gangrene_; _Gangrene following ligation of arteries_; _Gangrene
from mechanical causes_; _Gangrene from heat, chemical agents, and
cold_; _Diabetic gangrene_; _Gangrene associated with spasm of
blood vessels_; _Raynaud's disease_; _Angio-sclerotic gangrene_;
_Gangrene from ergot_. Bacterial varieties of gangrene.
_Pathology_--clinical varieties--_Acute infective gangrene_;
_Malignant oedema_; _Acute emphysematous_ or _gas gangrene_;
_Cancrum oris_, _etc_. Bed-sores: _Acute_; _chronic_.

Gangrene or mortification is the process by which a portion of tissue
dies _en masse_, as distinguished from the molecular or cellular death
which constitutes ulceration. The dead portion is known as a _slough_.

In this chapter we shall confine our attention to the process as it
affects the limbs and superficial parts, leaving gangrene of the viscera
to be described in regional surgery.


TYPES OF GANGRENE

Two distinct types of gangrene are met with, which, from their most
obvious point of difference, are known respectively as _dry_ and
_moist_, and there are several clinical varieties of each type.

Speaking generally, it may be said that dry gangrene is essentially due
to a simple _interference with the blood supply_ of a part; while the
main factor in the production of moist gangrene is _bacterial
infection_.

The cardinal signs of gangrene are: change in the colour of the part,
coldness, loss of sensation and motor power, and, lastly, loss of
pulsation in the arteries.

#Dry Gangrene# or #Mummification# is a comparatively slow form of local
death due, as a rule, to a diminution in the arterial blood supply of
the affected part, resulting from such causes as the gradual narrowing
of the lumen of the arteries by disease of their coats, or the blocking
of the main vessel by an embolus.

As the fluids in the tissues are lost by evaporation the part becomes
dry and shrivelled, and as the skin is usually intact, infection does
not take place, or if it does, the want of moisture renders the part an
unsuitable soil, and the organisms do not readily find a footing. Any
spread of the process that may take place is chiefly influenced by the
anatomical distribution of the blocked arteries, and is arrested as soon
as it reaches an area rich in anastomotic vessels. The dead portion is
then cast off, the irritation resulting from the contact of the dead
with the still living tissue inducing the formation of granulations on
the proximal side of the junction, and these by slowly eating into the
dead portion produce a furrow--the _line of demarcation_--which
gradually deepens until complete separation is effected. As the muscles
and bones have a richer blood supply than the integument, the death of
skin and subcutaneous tissues extends higher than that of muscles and
bone, with the result that the stump left after spontaneous separation
is conical, the end of the bone projecting beyond the soft parts.

_Clinical Features._--The part undergoing mortification becomes colder
than normal, the temperature falling to that of the surrounding
atmosphere. In many instances, but not in all, the onset of the process
is accompanied by severe neuralgic pain in the part, probably due to
anæmia of the nerves, to neuritis, or to the irritation of the exposed
axis cylinders by the dead and dying tissues around them. This pain soon
ceases and gives place to a complete loss of sensation. The dead part
becomes dry, horny, shrivelled, and semi-transparent--at first of a dark
brown, but finally of a black colour, from the dissemination of blood
pigment throughout the tissues. There is no putrefaction, and therefore
no putrid odour; and the condition being non-infective, there is not
necessarily any constitutional disturbance. In itself, therefore, dry
gangrene does not involve immediate risk to life; the danger lies in the
fact that the breach of surface at the line of demarcation furnishes a
possible means of entrance for bacteria, which may lead to infective
complications.

#Moist Gangrene# is an acute process, the dead part retaining its fluids
and so affording a favourable soil for the development of bacteria. The
action of the organisms and their toxins on the adjacent tissues leads
to a rapid and wide spread of the process. The skin becomes moist and
macerated, and bullæ, containing dark-coloured fluid or gases, form
under the epidermis. The putrefactive gases evolved cause the skin to
become emphysematous and crepitant and produce an offensive odour. The
tissues assume a greenish-black colour from the formation in them of a
sulphide of iron resulting from decomposition of the blood pigment.
Under certain conditions the dead part may undergo changes resembling
more closely those of ordinary post-mortem decomposition. Owing to its
nature the spread of the gangrene is seldom arrested by the natural
protective processes, and it usually continues until the condition
proves fatal from the absorption of toxins into the circulation.

The _clinical features_ vary in the different varieties of moist
gangrene, but the local results of bacterial action and the
constitutional disturbance associated with toxin absorption are present
in all; the prognosis therefore is grave in the extreme.

From what has been said, it will be gathered that in dry gangrene there
is no urgent call for operation to save the patient's life, the primary
indication being to prevent the access of bacteria to the dead part, and
especially to the surface exposed at the line of demarcation. In moist
gangrene, on the contrary, organisms having already obtained a footing,
immediate removal of the dead and dying tissues, as a rule, offers the
only hope of saving life.


VARIETIES OF GANGRENE

#Varieties of Gangrene essentially due to Interference with the
Circulation#

While the varieties of gangrene included in this group depend primarily
on interference with the circulation, it is to be borne in mind that the
clinical course of the affection may be profoundly influenced by
superadded infection with micro-organisms. Although the bacteria do not
play the most important part in producing tissue necrosis, their
subsequent introduction is an accident of such importance that it may
change the whole aspect of affairs and convert a dry form of gangrene
into one of the moist type. Moreover, the low state of vitality of the
tissues, and the extreme difficulty of securing and maintaining asepsis,
make it a sequel of great frequency.

#Senile Gangrene.#--Senile gangrene is the commonest example of local
death produced by a _gradual_ diminution in the quantity of blood
passing through the parts, as a result of arterio-sclerosis or other
chronic disease of the arteries leading to diminution of their calibre.
It is the most characteristic example of the dry type of gangrene. As
the term indicates, it occurs in old persons, but the patient's age is
to be reckoned by the condition of his arteries rather than by the
number of his years. Thus the vessels of a comparatively young man who
has suffered from syphilis and been addicted to alcohol are more liable
to atheromatous degeneration leading to this form of gangrene than are
those of a much older man who has lived a regular and abstemious life.
This form of gangrene is much more common in men than in women. While it
usually attacks only one foot, it is not uncommon for the other foot to
be affected after an interval, and in some cases it is bilateral from
the outset. It must clearly be understood that any form of gangrene may
occur in old persons, the term senile being here restricted to that
variety which results from arterio-sclerosis.

[Illustration: FIG. 20.--Senile Gangrene of the Foot, showing line of
demarcation.]

_Clinical Features._--The commonest seat of the disease is in the toes,
especially the great toe, whence it spreads up the foot to the heel, or
even to the leg (Fig. 20). There is often a history of some slight
injury preceding its onset. The vitality of the tissues is so low that
the balance between life and death may be turned by the most trivial
injury, such as a cut while paring a toe-nail or a corn, a blister
caused by an ill-fitting shoe or the contact of a hot-bottle. In some
cases the actual gangrene is determined by thrombosis of the popliteal
or tibial arteries, which are already narrowed by obliterating
endarteritis.

It is common to find that the patient has been troubled for a long time
before the onset of definite signs of gangrene, with cold feet, with
tingling and loss of feeling, or a peculiar sensation as if walking on
cotton wool.

The first evidence of the death of the part varies in different cases.
Sometimes a dark-blue spot appears on the medial side of the great toe
and gradually increases in size; or a blister containing blood-stained
fluid may form. Streaks or patches of dark-blue mottling appear higher
up on the foot or leg. In other cases a small sore surrounded by a
congested areola forms in relation to the nail and refuses to heal. Such
sores on the toes of old persons are always to be looked upon with
suspicion and treated with the greatest care; and the urine should be
examined for sugar. There is often severe, deep-seated pain of a
neuralgic character, with cramps in the limb, and these may persist long
after a line of demarcation has formed. The dying part loses sensibility
to touch and becomes cold and shrivelled.

All the physical appearances and clinical symptoms associated with dry
gangrene supervene, and the dead portion is delimited by a line of
demarcation. If this forms slowly and irregularly it indicates a very
unsatisfactory condition of the circulation; while, if it forms quickly
and decidedly, the presumption is that the circulation in the parts
above is fairly good. The separation of the dead part is always attended
with the risk of infection taking place, and should this occur, the
temperature rises and other evidences of toxæmia appear.

_Prophylaxis._--The toes and feet of old people, the condition of whose
circulation predisposes them to gangrene, should be protected from
slight injuries such as may be received while paring nails, cutting
corns, or wearing ill-fitting boots. The patient should also be warned
of the risk of exposure to cold, the use of hot-bottles, and of placing
the feet near a fire. Attempts have been made to improve the peripheral
circulation by establishing an anastomosis between the main artery of a
limb and its companion vein, so that arterial blood may reach the
peripheral capillaries--reversal of the circulation--but the clinical
results have proved disappointing. (See _Op. Surg._, p. 29.)

_Treatment._--When there is evidence that gangrene has occurred, the
first indication is to prevent infection by purifying the part, and
after careful drying to wrap it in a thick layer of absorbent and
antiseptic wool, retained in place by a loosely applied bandage. A
slight degree of elevation of the limb is an advantage, but it must not
be sufficient to diminish the amount of blood entering the part.
Hot-bottles are to be used with the utmost caution. As absolute dryness
is essential, ointments or other greasy dressings are to be avoided, as
they tend to prevent evaporation from the skin. Opium should be given
freely to alleviate pain. Stimulation is to be avoided, and the patient
should be carefully dieted.

When the gangrene is limited to the toes in old and feeble patients,
some surgeons advocate the expectant method of treatment, waiting for a
line of demarcation to form and allowing the dead part to be separated.
This takes place so slowly, however, that it necessitates the patient
being laid up for many weeks, or even months; and we agree with the
majority in advising early amputation.

In this connection it is worthy of note that there are certain points at
which gangrene naturally tends to become arrested--namely, at the highly
vascular areas in the neighbourhood of joints. Thus gangrene of the
great toe often stops when it reaches the metatarso-phalangeal joint; or
if it trespasses this limit it may be arrested either at the
tarso-metatarsal or at the ankle joint. If these be passed, it usually
spreads up the leg to just below the knee before signs of arrestment
appear. Further, it is seen from pathological specimens that the spread
is greater on the dorsal than on the plantar aspect, and that the death
of skin and subcutaneous tissues extends higher than that of bone and
muscle.

These facts furnish us with indications as to the seat and method of
amputation. Experience has proved that in senile gangrene of the lower
extremity the most reliable and satisfactory results are obtained by
amputating in the region of the knee, care being taken to perform the
operation so as to leave the prepatellar anastomosis intact by retaining
the patella in the anterior flap. The most satisfactory operation in
these cases is Gritti's supra-condylar amputation. Hæmorrhage is easily
controlled by digital pressure, and the use of a tourniquet should be
dispensed with, as the constriction of the limb is liable to interfere
with the vitality of the flaps.

When the tibial vessels can be felt pulsating at the ankle it may be
justifiable, if the patient urgently desires it, to amputate lower than
the knee; but there is considerable risk of gangrene recurring in the
stump and necessitating a second operation.

That amputation for senile gangrene performed between the ankle and the
knee seldom succeeds, is explained by the fact that the vascular
obstruction is usually in the upper part of the posterior tibial artery,
and the operation is therefore performed through tissues with an
inadequate blood supply. It is not uncommon, indeed, on amputating above
the knee, to find even the popliteal artery plugged by a clot. This
should be removed at the amputation by squeezing the vessel from above
downward by a "milking" movement, or by "catheterising the artery" with
the aid of a cannula with a terminal aperture.

It is to be borne in mind that the object of amputation in these cases
is merely to remove the gangrenous part, and so relieve the patient of
the discomfort and the risks from infection which its presence involves.
While it is true that in many of these patients the operation is borne
remarkably well, it must be borne in mind that those who suffer from
senile gangrene are of necessity bad lives, and a guarded opinion should
be expressed as to the prospects of survival. The possibility of the
disease developing in the other limb has already been referred to.

[Illustration: FIG. 21.--Embolic Gangrene of Hand and Arm.]

#Embolic Gangrene# (Fig. 21).--This is the most typical form of gangrene
resulting from the _sudden_ occlusion of the main artery of a part,
whether by the impaction of an embolus or the formation of a thrombus in
its lumen, when the collateral circulation is not sufficiently free to
maintain the vitality of the tissues.

There is sudden pain at the site of impaction of the embolus, and the
pulses beyond are lost. The limb becomes cold, numb, insensitive, and
powerless. It is often pale at first--hence the term "white gangrene"
sometimes applicable to the early appearances, which closely resemble
those presented by the limb of a corpse.

If the part is aseptic it shrivels, and presents the ordinary features
of dry gangrene. It is liable, however, especially in the lower
extremity and when the veins also are obstructed, to become infected and
to assume the characters of the moist type.

The extent of the gangrene depends upon the site of impaction of the
embolus, thus if the _abdominal aorta_ becomes suddenly occluded by an
embolus at its bifurcation, the obstruction of the iliacs and femorals
induces symmetrical gangrene of both extremities as high as the inguinal
ligaments. When gangrene follows occlusion of the _external iliac_ or of
the _femoral artery_ above the origin of its deep branch, the death of
the limb extends as high as the middle or upper third of the thigh. When
the _femoral_ below the origin of its deep branch or the _popliteal
artery_ is obstructed, the veins remaining pervious, the anastomosis
through the profunda is sufficient to maintain the vascular supply, and
gangrene does not necessarily follow. The rupture of a popliteal
aneurysm, however, by compressing the vein and the articular branches,
usually determines gangrene. When an embolus becomes impacted at the
_bifurcation of the popliteal_, if gangrene ensues it usually spreads
well up the leg.

When the _axillary artery_ is the seat of embolic impaction, and
gangrene ensues, the process usually reaches the middle of the upper
arm. Gangrene following the blocking of the _brachial_ at its
bifurcation usually extends as far as the junction of the lower and
middle thirds of the forearm.

Gangrene due to thrombosis or embolism is sometimes met with in patients
recovering from typhus, typhoid, or other fevers, such as that
associated with child-bed. It occurs in peripheral parts, such as the
toes, fingers, nose, or ears.

_Treatment._--The general treatment of embolic gangrene is the same as
that for the senile form. Success has followed opening the artery and
removing the embolus. The artery is exposed at the seat of impaction
and, having been clamped above and below, a longitudinal opening is made
and the clot carefully extracted with the aid of forceps; it is
sometimes unexpectedly long (one recorded from the femoral artery
measured nearly 34 inches); the wound in the artery is then sewn up with
fine silk soaked in paraffin. When amputation is indicated, it must be
performed sufficiently high to ensure a free vascular supply to the
flaps.

#Gangrene following Ligation of Arteries.#--After the ligation of an
artery in its continuity--for example, in the treatment of aneurysm--the
limb may for some days remain in a condition verging on gangrene, the
distal parts being cold, devoid of sensation, and powerless. As the
collateral circulation is established, the vitality of the tissues is
gradually restored and these symptoms pass off. In some cases,
however,--and especially in the lower extremity--gangrene ensues and
presents the same characters as those resulting from embolism. It tends
to be of the dry type. The occlusion of the vein as well as the artery
is not found to increase the risk of gangrene.

#Gangrene from Mechanical Constriction of the Vessels of the part.#--The
application of a bandage or plaster-of-Paris case too tightly, or of a
tourniquet for too long a time, has been known to lead to death of the
part beyond; but such cases are rare, as are also those due to the
pressure of a fractured bone or of a tumour on a large artery or vein.
When gangrene occurs from such causes, it tends to be of the moist type.

Much commoner is it to meet with localised areas of necrosis due to the
excessive _pressure of splints_ over bony prominences, such as the
lateral malleolus, the medial condyle of the humerus, or femur, or over
the dorsum of the foot. This is especially liable to occur when the
nutrition of the skin is depressed by any interference with its
nerve-supply, such as follows injuries to the spine or peripheral
nerves, disease of the brain, or acute anterior poliomyelitis. When the
splint is removed the skin pressed upon is found to be of a pale yellow
or grey colour, and is surrounded by a ring of hyperæmia. If protected
from infection, the clinical course is that of dry gangrene.

Bed-sores, which are closely allied to pressure sores, will be described
at the end of this chapter.

When a localised portion of tissue, for example, a piece of skin, is so
severely _crushed_ or _bruised_ that its blood vessels are occluded and
its structure destroyed, it dies, and, if not infected with bacteria,
dries up, and the shrivelled brown skin is slowly separated by the
growth of granulation tissue beneath and around it.

Fingers, toes, or even considerable portions of limbs may in the same
way be suddenly destroyed by severe trauma, and undergo mummification.
If organisms gain access, typical moist gangrene may ensue, or changes
similar to those of ordinary post-mortem decomposition may take place.

_Treatment._--The first indication is to exclude bacteria by purifying
the damaged part and its surroundings, and applying dry, non-irritating
dressings.

When these measures are successful, dry gangrene ensues. The raw surface
left after the separation of the dead skin may be allowed to heal by
granulation, or may be covered by skin-grafts. In the case of a finger
or a limb it is not necessary to wait until spontaneous separation takes
place, as this is often a slow process. When a well-marked line of
demarcation has formed, amputation may be performed just sufficiently
far above it to enable suitable flaps to be made.

The end of a stump, after spontaneous separation of the gangrenous
portion, requires to be trimmed, sufficient bone being removed to permit
of the soft parts coming together.

If moist gangrene supervenes, amputation must be performed without
delay, and at a higher level.

#Gangrene from Heat, Chemical Agents, and Cold.#--Severe #burns# and
#scalds# may be followed by necrosis of tissue. So long as the parts are
kept absolutely dry--as, for example, by the picric acid method of
treatment--the grossly damaged portions of tissue undergo dry gangrene;
but when wet or oily dressings are applied and organisms gain access,
moist gangrene follows.

Strong #chemical agents#, such as caustic potash, nitric or sulphuric
acid, may also induce local tissue necrosis, the general appearances of
the lesions produced being like those of severe burns. The resulting
sloughs are slow to separate, and leave deep punched-out cavities which
are long of healing.

#Carbolic Gangrene.#--Carbolic acid, even in comparatively weak
solution, is liable to induce dry gangrene when applied as a fomentation
to a finger, especially in women and children. Thrombosis occurs in the
blood vessels of the part, which at first is pale and soft, but later
becomes dark and leathery. On account of the anæsthetic action of
carbolic acid, the onset of the process is painless, and the patient
does not realise his danger. A line of demarcation soon forms, but the
dead part separates very slowly.

#Gangrene from Frost-bite.#--It is difficult to draw the line between
the third degree of chilblain and the milder forms of true frost-bite;
the difference is merely one of degree. Frost-bite affects chiefly the
toes and fingers--especially the great toe and the little finger--the
ears, and the nose. In this country it is seldom seen except in members
of the tramp class, who, in addition to being exposed to cold by
sleeping in the open air, are ill-fed and generally debilitated. The
condition usually manifests itself after the parts, having been
subjected to extreme cold, are brought into warm surroundings. The first
symptom is numbness in the part, followed by a sense of weight,
tingling, and finally by complete loss of sensation. The part attacked
becomes white and bleached-looking, feels icy cold, and is insensitive
to touch. Either immediately, or, it may be, not for several days, it
becomes discoloured and swollen, and finally contracts and shrivels.
Above the dead area the limb may be the seat of excruciating pain. The
dead portion is cast off, as in other forms of dry gangrene, by the
formation of a line of demarcation.

To prevent the occurrence of gangrene from frost-bite it is necessary to
avoid the sudden application of heat. The patient should be placed in a
cold room, and the part rubbed with snow, or put in a cold bath, and
have light friction applied to it. As the circulation is restored the
general surroundings and the local applications are gradually made
warmer. Elevation of the part, wrapping it in cotton wool, and removal
to a warmer room, are then permissible, and stimulants and warm drinks
may be given with caution. When by these means the occurrence of
gangrene is averted, recovery ensues, its onset being indicated by the
white parts assuming a livid red hue and becoming the seat of an acute
burning sensation.

A condition known as _Trench feet_ was widely prevalent amongst the
troops in France during the European War. Although allied to frost-bite,
cold appears to play a less important part in its causation than
humidity and constriction of the limbs producing ischæmia of the feet.
Changes were found in the endothelium of the blood vessels, the axis
cylinders of nerves, and the muscles. The condition does not occur in
civil life.

#Diabetic Gangrene.#--This form of gangrene is prone to occur in persons
over fifty years of age who suffer from glycosuria. The arteries are
often markedly diseased. In some cases the existence of the glycosuria
is unsuspected before the onset of the gangrene, and it is only on
examining the urine that the cause of the condition is discovered. The
gangrenous process seldom begins as suddenly as that associated with
embolism, and, like senile gangrene, which it may closely simulate in
its early stages, it not infrequently begins after a slight injury to
one of the toes. It but rarely, however, assumes the dry, shrivelling
type, as a rule being attended with swelling, oedema, and dusky redness
of the foot, and severe pain. According to Paget, the dead part remains
warm longer than in other forms of senile gangrene; there is a greater
tendency for patches of skin at some distance from the primary seat of
disease to become gangrenous, and for the death of tissue to extend
upwards in the subcutaneous planes, leaving the overlying skin
unaffected. The low vitality of the tissues favours the growth of
bacteria, and if these gain access, the gangrene assumes the characters
of the moist type and spreads rapidly.

The rules for amputation are the same as those governing the treatment
of senile gangrene, the level at which the limb is removed depending
upon whether the gangrene is of the dry or moist type. The general
treatment for diabetes must, of course, be employed whether amputation
is performed or not. Paget recommended that the dietetic treatment
should not be so rigid as in uncomplicated diabetes, and that opium
should be given freely.

The _prognosis_ even after amputation is unfavourable. In many cases the
patient dies with symptoms of diabetic coma within a few days of the
operation; or, if he survives this, he may eventually succumb to
diabetes. In others there is sloughing of the flaps and death results
from toxæmia. Occasionally the other limb becomes gangrenous. On the
other hand, the glycosuria may diminish or may even disappear after
amputation.

#Gangrene associated with Spasm of Blood Vessels.#--#Raynaud's Disease#,
or symmetrical gangrene, is supposed to be due to spasm of the
arterioles, resulting from peripheral neuritis. It occurs oftenest in
women, between the ages of eighteen and thirty, who are the subjects of
uterine disorders, anæmia, or chlorosis. Cold is an aggravating factor,
as the disease is commonest during the winter months. The digits of both
hands or the toes of both feet are simultaneously attacked, and the
disease seldom spreads beyond the phalanges or deeper than the skin.

The first evidence is that the fingers become cold, white, and
insensitive to touch and pain. These attacks of _local syncope_ recur at
varying intervals for months or even years. They last for a few minutes
or even for some hours, and as they pass off the parts become hyperæmic
and painful.

A more advanced stage of the disease is known as _local asphyxia_. The
circulation through the fingers becomes exceedingly sluggish, and the
parts assume a dull, livid hue. There is swelling and burning or
shooting pain. This may pass off in a few days, or may increase in
severity, with the formation of bullæ, and end in dry gangrene. As a
rule, the slough which forms is comparatively small and superficial,
but it may take some months to separate. The condition tends to recur in
successive winters.

The _treatment_ consists in remedying any nervous or uterine disorder
that may be present, keeping the parts warm by wrapping them in cotton
wool, and in the use of hot-air or electric baths, the parts being
immersed in water through which a constant current is passed. When
gangrene occurs, it is treated on the same lines as other forms of dry
gangrene, but if amputation is called for it is only with a view to
removing the dead part.

#Angio-sclerotic Gangrene.#--A form of gangrene due to _angio-sclerosis_
is occasionally met with in young persons, even in children. It bears
certain analogies to Raynaud's disease in that spasm of the vessels
plays a part in determining the local death.

The main arteries are narrowed by hyperplastic endarteritis followed by
thrombosis, and similar changes are found in the veins. The condition is
usually met with in the feet, but the upper extremity may be affected,
and is attended with very severe pain, rendering sleep impossible.

The patient is liable to sudden attacks of numbness, tingling and
weakness of the limbs which pass off with rest--_intermittent
claudication_. During these attacks the large arteries--femoral,
brachial, and subclavian--can be felt as firm cords, while pulsation is
lost in the peripheral vessels. Gangrene eventually ensues, is attended
with great pain and runs a slow course. It is treated on the same lines
as Raynaud's disease.

#Gangrene from Ergot.#--Gangrene may occur from interference with blood
supply, the result of tetanic contraction of the minute vessels, such as
results in ill-nourished persons who eat large quantities of coarse rye
bread contaminated with the _claviceps purpurea_ and containing the
ergot of rye. It has also occurred in the fingers of patients who have
taken ergot medicinally over long periods. The gangrene, which attacks
the toes, fingers, ears, or nose, is preceded by formication, numbness,
and pains in the parts to be affected, and is of the dry variety.

In this country it is usually met with in sailors off foreign ships,
whose dietary largely consists of rye bread. Trivial injuries may be the
starting-point, the anæsthesia produced by the ergotin preventing the
patient taking notice of them. Alcoholism is a potent predisposing
cause.

As it is impossible to predict how far the process will spread, it is
advisable to wait for the formation of a line of demarcation before
operating, and then to amputate immediately above the dead part.


BACTERIAL VARIETIES OF GANGRENE

The acute bacillary forms of gangrene all assume the moist type from the
first, and, spreading rapidly, result in extensive necrosis of tissue,
and often end fatally.

The infection is usually a mixed one in which anaërobic bacteria
predominate. The anaërobe most constantly present is the _bacillus
ærogenes capsulatus_, usually in association with other anaërobes, and
sometimes with pyogenic diplo- and streptococci. According to the mode of
action of the associated organisms and the combined effects of their
toxins on the tissues, the gangrenous process presents different
pathological and clinical features. Some combinations, for example,
result in a rapidly spreading cellulitis with early necrosis of
connective tissue accompanied by thrombosis throughout the capillary and
venous circulation of the parts implicated; other combinations cause
great oedema of the part, and others again lead to the formation of gases
in the tissues, particularly in the muscles.

These different effects do not appear to be due to a specific action of
any one of the organisms present, but to the combined effect of a
particular group living in symbiosis.

According as the cellulitic, the oedematous, or the gaseous
characteristics predominate, the clinical varieties of bacillary
gangrene may be separately described, but it must be clearly understood
that they frequently overlap and cannot always be distinguished from one
another.

#Clinical Varieties of Bacillary Gangrene.#--#Acute infective gangrene#
is the form most commonly met with in civil practice. It may follow such
trivial injuries as a pin-prick or a scratch, the signs of acute
cellulitis rapidly giving place to those of a spreading gangrene. Or it
may ensue on a severe railway, machinery, or street accident, when
lacerated and bruised tissues are contaminated with gross dirt. Often
within a few hours of the injury the whole part rapidly becomes painful,
swollen, oedematous, and tense. The skin is at first glazed, and perhaps
paler than normal, but soon assumes a dull red or purplish hue, and
bullæ form on the surface. Putrefactive gases may be evolved in the
tissues, and their presence is indicated by emphysematous crackling when
the part is handled. The spread of the disease is so rapid that its
progress is quite visible from hour to hour, and may be traced by the
occurrence of red lines along the course of the lymphatics of the limb.
In the most acute cases the death of the affected part takes place so
rapidly that the local changes indicative of gangrene have not time to
occur, and the fact that the part is dead may be overlooked.

[Illustration: FIG. 22.--Gangrene of Terminal Phalanx of Index-Finger,
following cellulitis of hand resulting from a scratch on the palm of the
hand.]

Rigors may occur, but the temperature is not necessarily raised--indeed,
it is sometimes subnormal. The pulse is small, feeble, rapid, and
irregular. Unless amputation is promptly performed, death usually
follows within thirty-six or forty-eight hours. Even early operation
does not always avert the fatal issue, because the quantity of toxin
absorbed and its extreme virulence are often more than even a robust
subject can outlive.

_Treatment._--Every effort must be made to purify all such wounds as are
contaminated by earth, street dust, stable refuse, or other forms of
gross dirt. Devitalised and contaminated tissue is removed with the
knife or scissors and the wound purified with antiseptics of the
chlorine group or with hydrogen peroxide. If there is a reasonable
prospect that infection has been overcome, the wound may be at once
sutured, but if this is doubtful it is left open and packed or
irrigated.

When acute gangrene has set in no treatment short of amputation is of
any avail, and the sooner this is done, the greater is the hope of
saving the patient. The limb must be amputated well beyond the apparent
limits of the infected area, and stringent precautions must be taken to
avoid discharge from the already gangrenous area reaching the operation
wound. An assistant or nurse, who is to take no other part in the
operation, is told off to carry out the preliminary purification, and to
hold the limb during the operation.

#Malignant Oedema.#--This form of acute gangrene has been defined as
"a spreading inflammatory oedema attended with emphysema, and ultimately
followed by gangrene of the skin and adjacent parts." The predominant
organism is the _bacillus of malignant oedema_ or _vibrion septique_ of
Pasteur, which is found in garden soil, dung, and various putrefying
substances. It is anaërobic, and occurs as long, thick rods with
somewhat rounded ends and several laterally placed flagella. Spores,
which have a high power of resistance, form in the centre of the rods,
and bulge out the sides so as to give the organisms a spindle-shaped
outline. Other pathogenic organisms are also present and aid the
specific bacillus in its action.

At the bedside it is difficult, if not impossible, to distinguish it
from acute infective gangrene. Both follow on the same kinds of injury
and run an exceedingly rapid course. In malignant oedema, however, the
incidence of the disease is mainly on the superficial parts, which
become oedematous and emphysematous, and acquire a marbled appearance
with the veins clearly outlined. Early disappearance of sensation is a
particularly grave symptom. Bullæ form on the skin, and the tissues
have "a peculiar heavy but not putrid odour." The constitutional effects
are extremely severe, and death may ensue within a few hours.

#Acute Emphysematous# or #Gas Gangrene# was prevalent in certain areas
at various periods during the European War. It follows infection of
lacerated wounds with the _bacillus ærogenes capsulatus_, usually in
combination with other anaërobes, and its main incidence is on the
muscles, which rapidly become infiltrated with gas that spreads
throughout the whole extent of the muscle, disintegrating its fibres and
leading to necrosis. The gangrenous process spreads with appalling
rapidity, the limb becoming enormously swollen, painful, and crepitant
or even tympanitic. Patches of coppery or purple colour appear on the
skin, and bullæ containing blood-stained serum form on the surface. The
toxæmia is profound, and the face and lips assume a characteristic
cyanosis. The condition is attended with a high mortality. Only in the
early stages and when the infection is limited are local measures
successful in arresting the spread; in more severe cases amputation is
the only means of saving life.

#Cancrum Oris# or #Noma#.--This disease is believed to be due to a
specific bacillus, which occurs in long delicate rods, and is chiefly
found at the margin of the gangrenous area. It is prone to attack
unhealthy children from two to five years of age, especially during
their convalescence from such diseases as measles, scarlet fever, or
typhoid, but may attack adults when they are debilitated. It is most
common in the mouth, but sometimes occurs on the vulva. In the mouth it
begins as an ulcerative stomatitis, more especially affecting the gums
or inner aspect of the cheek. The child lies prostrated, and from the
open mouth foul-smelling saliva, streaked with blood, escapes; the face
is of an ashy-grey colour, the lips dark and swollen. On the inner
aspect of the cheek is a deeply ulcerated surface, with sloughy shreds
of dark-brown or black tissue covering its base; the edges are
irregular, firm, and swollen, and the surrounding mucous membrane is
infiltrated and oedematous. In the course of a few hours a dark spot
appears on the outer aspect of the cheek, and rapidly increases in size;
towards the centre it is black, shading off through blue and grey into a
dark-red area which extends over the cheek (Fig. 23). The tissue
implicated is at first firm and indurated, but as it loses its vitality
it becomes doughy and sodden. Finally a slough forms, and, when it
separates, the cheek is perforated.

Meanwhile the process spreads inside the mouth, and the gums, the floor
of the mouth, or even the jaws, may become gangrenous and the teeth fall
out. The constitutional disturbance is severe, the temperature raised,
and the pulse feeble and rapid.

The extremely foetid odour which pervades the room or even the house the
patient occupies, is usually sufficient to suggest the diagnosis of
cancrum oris. The odour must not be mistaken for that due to
decomposition of sordes on the teeth and gums of a debilitated patient.

The _prognosis_ is always grave in the extreme, the main risks being
general toxæmia and septic pneumonia. When recovery takes place there is
serious deformity, and considerable portions of the jaws may be lost by
necrosis.

[Illustration: FIG. 23.--Cancrum oris.

(From a photograph lent by Sir George T. Beatson.)]

_Treatment._--The only satisfactory treatment is thorough removal under
an anæsthetic of all the sloughy tissue, with the surrounding zone in
which the organisms are active. This is most efficiently accomplished by
the knife or scissors, cutting until the tissue bleeds freely, after
which the raw surface is painted with undiluted carbolic acid and
dressed with iodoform gauze. It may be necessary to remove large pieces
of bone when the necrotic process has implicated the jaws. The mouth
must be constantly sprayed with peroxide of hydrogen, and washed out
with a disinfectant and deodorant lotion, such as Condy's fluid. The
patient's general condition calls for free stimulation.

The deformity resulting from these necessarily heroic measures is not so
great as might be expected, and can be further diminished by plastic
operations, which should be undertaken before cicatricial contraction
has occurred.


BED-SORES

Bed-sores are most frequently met with in old and debilitated patients,
or in those whose tissues are devitalised by acute or chronic diseases
associated with stagnation of blood in the peripheral veins. Any
interference with the nerve-supply of the skin, whether from injury or
disease of the central nervous system or of the peripheral nerves,
strongly predisposes to the formation of bed-sores. Prolonged and
excessive pressure over a bony prominence, especially if the parts be
moist with skin secretions, urine, or wound discharges, determines the
formation of a sore. Excoriations, which may develop into true
bed-sores, sometimes form where two skin surfaces remain constantly
apposed, as in the region of the scrotum or labium, under pendulous
mammæ, or between fingers or toes confined in a splint.

[Illustration: FIG. 24.--Acute Bed-Sores over Right Buttock.]

_Clinical Features._--Two clinical varieties are met with--the acute
and the chronic bed-sore.

The _acute_ bed-sore usually occurs over the sacrum or buttock. It
develops rapidly after spinal injuries and in the course of certain
brain diseases. The part affected becomes red and congested, while the
surrounding parts are oedematous and swollen, blisters form, and the skin
loses its vitality (Fig. 24).

In advanced cases of general paralysis of the insane, a peculiar form of
acute bed-sore beginning as a blister, and passing on to the formation
of a black, dry eschar, which slowly separates, occurs on such parts as
the medial side of the knee, the angle of the scapula, and the heel.

The _chronic_ bed-sore begins as a dusky reddish purple patch, which
gradually becomes darker till it is almost black. The parts around are
oedematous, and a blister may form. This bursts and exposes the papillæ
of the skin, which are of a greenish hue. A tough greyish-black slough
forms, and is slowly separated. It is not uncommon for the gangrenous
area to continue to spread both in width and in depth till it reaches
the periosteum or bone. Bed-sores over the sacrum sometimes implicate
the vertebral canal and lead to spinal meningitis, which usually proves
fatal.

In old and debilitated patients the septic absorption taking place from
a bed-sore often proves a serious complication of other surgical
conditions. From this cause, for example, old people may succumb during
the treatment of a fractured thigh.

The granulating surface left on the separation of the slough tends to
heal comparatively rapidly.

_Prevention of Bed-sores._--The first essential in the prevention of
bed-sores is the regular changing of the patient's position, so that no
one part of the body is continuously pressed upon for any length of
time. Ring-pads of wool, air-cushions, or water-beds are necessary to
remove pressure from prominent parts. Absolute dryness of the skin is
all-important. At least once a day, the sacrum, buttocks,
shoulder-blades, heels, elbows, malleoli, or other parts exposed to
pressure, must be sponged with soap and water, thoroughly dried, and
then rubbed with methylated spirit, which is allowed to dry on the skin.
Dusting the part with boracic acid powder not only keeps it dry, but
prevents the development of bacteria in the skin secretions.

In operation cases, care must be taken that irritating chemicals used to
purify the skin do not collect under the patient and remain in contact
with the skin of the sacrum and buttocks during the time he is on the
operating-table. There is reason to believe that the so-called
"post-operation bed-sore" may be due to such causes. A similar result
has been known to follow soiling of the sheets by the escape of a
turpentine enema.

_Treatment._--Once a bed-sore has formed, every effort must be made to
prevent its spread. Alcohol is used to cleanse the broken surface, and
dry absorbent dressings are applied and frequently changed. It is
sometimes found necessary to employ moist or oily substances, such as
boracic poultices, eucalyptus ointment, or balsam of Peru, to facilitate
the separation of sloughs, or to promote the growth of granulations. In
patients who are not extremely debilitated the slough may be excised,
the raw surface scraped, and then painted with iodine.

Skin-grafting is sometimes useful in covering in the large raw surface
left after separation or removal of sloughs.




CHAPTER VII

BACTERIAL AND OTHER WOUND INFECTIONS


_Erysipelas_--_Diphtheria_--_Tetanus_--_Hydrophobia_--_Anthrax_--
_Glanders_--_Actinomycosis_--_Mycetoma_--_Delhi
boil_--_Chigoe_--_Poisoning by insects_--_Snake-bites_.


ERYSIPELAS

Erysipelas, popularly known as "rose," is an acute spreading infective
disease of the skin or of a mucous membrane due to the action of a
streptococcus. Infection invariably takes place through an abrasion of
the surface, although this may be so slight that it escapes observation
even when sought for. The streptococci are found most abundantly in the
lymph spaces just beyond the swollen margin of the inflammatory area,
and in the serous blebs which sometimes form on the surface.

#Clinical Features.#--_Facial erysipelas_ is the commonest clinical
variety, infection usually occurring through some slight abrasion in the
region of the mouth or nose, or from an operation wound in this area.
From this point of origin the inflammation may spread all over the face
and scalp as far back as the nape of the neck. It stops, however, at the
chin, and never extends on to the front of the neck. There is great
oedema of the face, the eyes becoming closed up, and the features
unrecognisable. The inflammation may spread to the meninges, the
intracranial venous sinuses, the eye, or the ear. In some cases the
erysipelas invades the mucous membrane of the mouth, and spreads to the
fauces and larynx, setting up an oedema of the glottis which may prove
dangerous to life.

Erysipelas occasionally attacks an operation wound that has become
septic; and it may accompany septic infection of the genital tract in
puerperal women, or the separation of the umbilical cord in infants
(_erysipelas neonatorum_). After an incubation period, which varies from
fifteen to sixty hours, the patient complains of headache, pains in the
back and limbs, loss of appetite, nausea, and frequently there is
vomiting. He has a chill or slight rigor, initiating a rise of
temperature to 103°, 104°, or 105° F.; and a full bounding pulse of
about 100 (Fig. 25). The tongue is foul, the breath heavy, and, as a
rule, the bowels are constipated. There is frequently albuminuria, and
occasionally nocturnal delirium. A moderate degree of leucocytosis
(15,000 to 20,000) is usually present.

Around the seat of inoculation a diffuse red patch forms, varying in hue
from a bright scarlet to a dull brick-red. The edges are slightly raised
above the level of the surrounding skin, as may readily be recognised by
gently stroking the part from the healthy towards the affected area. The
skin is smooth, tense, and glossy, and presents here and there blisters
filled with serous fluid. The local temperature is raised, and the part
is the seat of a burning sensation and is tender to the touch, the most
tender area being the actively spreading zone which lies about half an
inch beyond the red margin.

[Illustration: FIG. 25.--Chart of Erysipelas occurring in a wound.]

The disease tends to spread spasmodically and irregularly, and the
direction and extent of its progress may be recognised by mapping out
the peripheral zone of tenderness. Red streaks appear along the lines of
the superficial lymph vessels, and the deep lymphatics may sometimes be
palpated as firm, tender cords. The neighbouring glands, also, are
generally enlarged and tender.

The disease lasts for from two or three days to as many weeks, and
relapses are frequent. Spontaneous resolution usually takes place, but
the disease may prove fatal from absorption of toxins, involvement of
the brain or meninges, or from general streptococcal infection.

#Complications.#--_Diffuse suppurative cellulitis_ is the most serious
local complication, and results from a mixed infection with other
pyogenic bacteria. Small _localised superficial abscesses_ may form
during the convalescent stage. They are doubtless due to the action of
skin bacteria, which attack the tissues devitalised by the erysipelas. A
persistent form of _oedema_ sometimes remains after recurrent attacks of
erysipelas, especially when they affect the face or the lower extremity,
a condition which is referred to with elephantiasis.

#Treatment.#--The first indication is to endeavour to arrest the spread
of the process. We have found that by painting with linimentum iodi, a
ring half an inch broad, about an inch in front of the peripheral tender
zone--not the red margin--an artificial leucocytosis is produced, and
the advancing streptococci are thereby arrested. Several coats of the
iodine are applied, one after the other, and this is repeated daily for
several days, even although the erysipelas has not overstepped the ring.
Success depends upon using the liniment of iodine (the tincture is not
strong enough), and in applying it well in front of the disease. To
allay pain the most useful local applications are ichthyol ointment (1
in 6), or lead and opium fomentations.

The general treatment consists in attending to the emunctories, in
administrating quinine in small--two-grain--doses every four hours, or
salicylate of iron (2-5 gr. every three hours), and in giving plenty of
fluid nourishment. It is worthy of note that the anti-streptococcic
serum has proved of less value in the treatment of erysipelas than might
have been expected, probably because the serum is not made from the
proper strain of streptococcus.

It is not necessary to isolate cases of erysipelas, provided the usual
precautions against carrying infection from one patient to another are
rigidly carried out.


DIPHTHERIA

Diphtheria is an acute infective disease due to the action of a specific
bacterium, the _bacillus diphtheriæ_ or _Klebs-Löffler bacillus_. The
disease is usually transmitted from one patient to another, but it may
be contracted from cats, fowls, or through the milk of infected cows.
Cases have occurred in which the surgeon has carried the infection from
one patient to another through neglect of antiseptic precautions. The
incubation period varies from two to seven days.

#Clinical Features.#--In _pharyngeal diphtheria_, on the first or
second day of the disease, redness and swelling of the mucous membrane
of the pharynx, tonsils, and palate are well marked, and small, circular
greenish or grey patches of false membrane, composed of necrosed
epithelium, fibrin, leucocytes, and red blood corpuscles, begin to
appear. These rapidly increase in area and thickness, till they coalesce
and form a complete covering to the parts. In the pharynx the false
membrane is less adherent to the surface than it is when the disease
affects the air-passages. The diphtheritic process may spread from the
pharynx to the nasal cavities, causing blocking of the nares, with a
profuse ichorous discharge from the nostrils, and sometimes severe
epistaxis. The infection may spread along the nasal duct to the
conjunctiva. The middle ear also may become involved by spread along the
auditory (Eustachian) tube.

The lymph glands behind the angle of the jaw enlarge and become tender,
and may suppurate from superadded infection. There is pain on
swallowing, and often earache; and the patient speaks with a nasal
accent. He becomes weak and anæmic, and loses his appetite. There is
often albuminuria. Leucocytosis is usually well marked before the
injection of antitoxin; after the injection there is usually a
diminution in the number of leucocytes. The false membrane may separate
and be cast off, after which the patient gradually recovers. Death may
take place from gradual failure of the heart's action or from syncope
during some slight exertion.

_Laryngeal Diphtheria._--The disease may arise in the larynx, although,
as a rule, it spreads thence from the pharynx. It first manifests itself
by a short, dry, croupy cough, and hoarseness of the voice. The first
difficulty in breathing usually takes place during the night, and once
it begins, it rapidly gets worse. Inspiration becomes noisy, sometimes
stridulous or metallic or sibilant, and there is marked indrawing of the
epigastrium and lower intercostal spaces. The hoarseness becomes more
marked, the cough more severe, and the patient restless. The difficulty
of breathing occurs in paroxysms, which gradually increase in frequency
and severity, until at length the patient becomes asphyxiated. The
duration of the disease varies from a few hours to four or five days.

After the acute symptoms have passed off, various localised
paralyses may develop, affecting particularly the nerves of the palatal
and orbital muscles, less frequently the lower limbs.

#Diagnosis.#--The finding of the Klebs-Löffler bacillus is the only
conclusive evidence of the disease. The bacillus may be obtained by
swabbing the throat with a piece of aseptic--not antiseptic--cotton wool
or clean linen rag held in a pair of forceps, and rotated so as to
entangle portions of the false membrane or exudate. The swab thus
obtained is placed in a test-tube, previously sterilised by having had
some water boiled in it, and sent to a laboratory for investigation. To
identify the bacillus a piece of the membrane from the swab is rubbed on
a cover glass, dried, and stained with methylene blue or other basic
stain; or cultures may be made on agar or other suitable medium. When a
bacteriological examination is impossible, or when the clinical features
do not coincide with the results obtained, the patient should always be
treated on the assumption that he suffers from diphtheria. So much doubt
exists as to the real nature of membranous croup and its relationship to
true diphtheria, that when the diagnosis between the two is uncertain
the safest plan is to treat the case as one of diphtheria.

In children, diphtheria may occur on the vulva, vagina, prepuce, or
glans penis, and give rise to difficulty in diagnosis, which is only
cleared up by demonstration of the bacillus.

#Treatment.#--An attempt may be made to destroy or to counteract the
organisms by swabbing the throat with strong antiseptic solutions, such
as 1 in 1000 corrosive sublimate or 1 in 30 carbolic acid, or by
spraying with peroxide of hydrogen.

The antitoxic serum is our sheet-anchor in the treatment of diphtheria,
and recourse should be had to its use as early as possible.

Difficulty of swallowing may be met by the use of a stomach tube passed
either through the mouth or nose. When this is impracticable, nutrient
enemata are called for.

In laryngeal diphtheria, the interference with respiration may call for
intubation of the larynx, or tracheotomy, but the antitoxin treatment
has greatly diminished the number of cases in which it becomes necessary
to have recourse to these measures.

Intubation consists in introducing through the mouth into the larynx a
tube which allows the patient to breathe freely during the period while
the membrane is becoming separated and thrown off. This is best done
with the apparatus of O'Dwyer; but when this instrument is not
available, a simple gum-elastic catheter with a terminal opening (as
suggested by Macewen and Annandale) may be employed.

When intubation is impracticable, the operation of tracheotomy is
called for if the patient's life is endangered by embarrassment of
respiration. Unless the patient is in hospital with skilled assistance
available, tracheotomy is the safer of the two procedures.


TETANUS

Tetanus is a disease resulting from infection of a wound by a specific
micro-organism, the _bacillus tetani_, and characterised by increased
reflex excitability, hypertonus, and spasm of one or more groups of
voluntary muscles.

_Etiology and Morbid Anatomy._--The tetanus bacillus, which is a perfect
anaërobe, is widely distributed in nature and can be isolated from
garden earth, dung-heaps, and stable refuse. It is a slender rod-shaped
bacillus, with a single large spore at one end giving it the shape of a
drum-stick (Fig. 26). The spores, which are the active agents in
producing tetanus, are highly resistant to chemical agents, retain their
vitality in a dry condition, and even survive boiling for five minutes.

The organism does not readily establish itself in the human body, and
seems to flourish best when it finds a nidus in necrotic tissue and is
accompanied by aërobic organisms, which, by using up the oxygen in the
tissues, provide for it a suitable environment. The presence of a
foreign body in the wound seems to favour its action. The infection is
for all practical purposes a local one, the symptoms of the disease
being due to the toxins produced in the wound of infection acting upon
the central nervous system.

The toxin acts principally on the nerve centres in the spinal medulla,
to which it travels from the focus of infection by way of the nerve
fibres supplying the voluntary muscles. Its first effect on the motor
ganglia of the cord is to render them hypersensitive, so that they are
excited by mild stimuli, which under ordinary conditions would produce
no reaction. As the toxin accumulates the reflex arc is affected, with
the result that when a stimulus reaches the ganglia a motor discharge
takes place, which spreads by ascending and descending collaterals to
the reflex apparatus of the whole cord. As the toxin spreads it causes
both motor hyper-tonus and hyper-excitability, which accounts for the
tonic contraction and the clonic spasms characteristic of tetanus.

[Illustration: FIG. 26.--Bacillus of Tetanus from scraping of a wound of
finger, × 1000 diam. Basic fuchsin stain.]

#Clinical Varieties of Tetanus.#--_Acute_ or _Fulminating
Tetanus_.--This variety is characterised by the shortness of the
incubation period, the rapidity of its progress, the severity of its
symptoms, and its all but universally fatal issue in spite of
treatment, death taking place in from one to four days. The
characteristic symptoms may appear within three or four days of the
infliction of the wound, but the incubation period may extend to three
weeks, and the wound may be quite healed before the disease declares
itself--_delayed tetanus_. Usually, however, the wound is inflamed and
suppurating, with ragged and sloughy edges. A slight feverish attack may
mark the onset of the tetanic condition, or the patient may feel
perfectly well until the spasms begin. If careful observations be made,
it may be found that the muscles in the immediate neighbourhood of the
wound are the first to become contracted; but in the majority of
instances the patient's first complaint is of pain and stiffness in the
muscles of mastication, notably the masseter, so that he has difficulty
in opening the mouth--hence the popular name "lock-jaw." The muscles of
expression soon share in the rigidity, and the face assumes a taut,
mask-like aspect. The angles of the mouth may be retracted, producing a
grinning expression known as the _risus sardonicus_.

The next muscles to become stiff and painful are those of the neck,
especially the sterno-mastoid and trapezius. The patient is inclined to
attribute the pain and stiffness to exposure to cold or rheumatism. At
an early stage the diaphragm and the muscles of the anterior abdominal
wall become contracted; later the muscles of the back and thorax are
involved; and lastly those of the limbs. Although this is the typical
order of involvement of the different groups of muscles, it is not
always adhered to.

To this permanent tonic contraction of the muscles there are soon added
clonic spasms. These spasms are at first slight and transient, with
prolonged intervals between the attacks, but rapidly tend to become more
frequent, more severe, and of longer duration, until eventually the
patient simply passes out of one seizure into another.

The distribution of the spasms varies in different cases: in some it is
confined to particular groups of muscles, such as those of the neck,
back, abdominal walls, or limbs; in others all these groups are
simultaneously involved.

When the muscles of the back become spasmodically contracted, the body
is raised from the bed, sometimes to such an extent that the patient
rests only on his heels and occiput--the position of _opisthotonos_.
Lateral arching of the body from excessive action of the muscles on one
side--_pleurosthotonos_--is not uncommon, the arching usually taking
place towards the side on which the wound of infection exists. Less
frequently the body is bent forward so that the knees and chin almost
meet (_emprosthotonos_). Sometimes all the muscles simultaneously become
rigid, so that the body assumes a statuesque attitude (_orthotonos_).
When the thoracic muscles, including the diaphragm, are thrown into
spasm, the patient experiences a distressing sensation as if he were
gripped in a vice, and has extreme difficulty in getting breath. Between
the attacks the limbs are kept rigidly extended. The clonic spasms may
be so severe as to rupture muscles or even to fracture one of the long
bones.

As time goes on, the clonic exacerbations become more and more frequent,
and the slightest external stimulus, such as the feeling of the pulse, a
whisper in the room, a noise in the street, a draught of cold air, the
effort to swallow, a question addressed to the patient or his attempt to
answer, is sufficient to determine an attack. The movements are so
forcible and so continuous that the nurse has great difficulty in
keeping the bedclothes on the patient, or even in keeping him in bed.

The general condition of the patient is pitiful in the extreme. He is
fully conscious of the gravity of the disease, and his mind remains
clear to the end. The suffering induced by the cramp-like spasms of the
muscles keeps him in a constant state of fearful apprehension of the
next seizure, and he is unable to sleep until he becomes utterly
exhausted.

The temperature is moderately raised (100° to 102° F.), or may remain
normal throughout. Shortly before death very high temperatures (110° F.)
have been recorded, and it has been observed that the thermometer
sometimes continues to rise after death, and may reach as high as
112° F. or more.

The pulse corresponds with the febrile condition. It is accelerated
during the spasms, and may become exceedingly rapid and feeble before
death, probably from paralysis of the vagus. Sudden death from cardiac
paralysis or from cardiac spasm is not uncommon.

The respiration is affected in so far as the spasms of the respiratory
muscles produce dyspnoea, and a feeling of impending suffocation which
adds to the horrors of the disease.

One of the most constant symptoms is a copious perspiration, the patient
being literally bathed in sweat. The urine is diminished in quantity,
but as a rule is normal in composition; as in other acute infective
conditions, albumen and blood may be present. Retention of urine may
result from spasm of the urethral muscles, and necessitate the use of
the catheter.

The fits may cease some time before death, or, on the other hand, death
may occur during a paroxysm from fixation of the diaphragm and arrest of
respiration.

_Differential Diagnosis._--There is little difficulty, as a rule, in
diagnosing a case of fulminating tetanus, but there are several
conditions with which it may occasionally be confused. In _strychnin
poisoning_, for example, the spasms come on immediately after the
patient has taken a toxic dose of the drug; they are clonic in
character, but the muscles are relaxed between the fits. If the dose is
not lethal, the spasms soon cease. In _hydrophobia_ a history of having
been bitten by a rabid animal is usually forthcoming; the spasms, which
are clonic in character, affect chiefly the muscles of respiration and
deglutition, and pass off entirely in the intervals between attacks.
Certain cases of _hæmorrhage into the lateral ventricles_ of the brain
also simulate tetanus, but an analysis of the symptoms will prevent
errors in diagnosis. _Cerebro-spinal meningitis_ and _basal meningitis_
present certain superficial resemblances to tetanus, but there is no
trismus, and the spasms chiefly affect the muscles of the neck and
back. _Hysteria and catalepsy_ may assume characters resembling those
of tetanus, but there is little difficulty in distinguishing between
these diseases. Lastly, in the _tetany_ of children, or that following
operations on the thyreoid gland, the spasms are of a jerking character,
affect chiefly the hands and fingers, and yield to medicinal treatment.

#Chronic Tetanus.#--The difference between this and acute tetanus is
mainly one of degree. Its incubation period is longer, it is more slow
and insidious in its progress, and it never reaches the same degree of
severity. Trismus is the most marked and constant form of spasm; and
while the trunk muscles may be involved, those of respiration as a rule
escape. Every additional day the patient lives adds to the probability
of his ultimate recovery. When the disease does prove fatal, it is from
exhaustion, and not from respiratory or cardiac spasm. The usual
duration is from six to ten weeks.

#Delayed Tetanus.#--During the European War acute tetanus occasionally
developed many weeks or even months after a patient had been injured,
and when the original wound had completely healed. It usually followed
some secondary operation, _e.g._, for the removal of a foreign body, or
the breaking down of adhesions, which aroused latent organisms.

#Local Tetanus.#--This term is applied to a form of the disease in which
the hypertonus and spasms are localised to the muscles in the vicinity
of the wound. It usually occurs in patients who have had prophylactic
injections of anti-tetanic serum, the toxins entering the blood being
probably neutralised by the antibodies in circulation, while those
passing along the motor nerves are unaffected.

When it occurs in the _limbs_, attention is usually directed to the fact
by pain accompanying the spasms; the muscles are found to be hard and
there are frequent twitchings of the limb. A characteristic reflex is
present in the lower extremity, namely, extension of the foot and leg
when the sole is tickled.

_Cephalic Tetanus_ is another localised variety which follows injury in
the distribution of the facial nerve. It is characterised by the
occurrence on the same side as the injury, of facial spasm, rapidly
followed by more or less complete paralysis of the muscles of
expression, with unilateral trismus and difficulty in swallowing. Other
cranial nerves, particularly the oculomotor and the hypoglossal, may
also be implicated. A remarkable feature of this condition is that
although the muscles are irresponsive to ordinary physiological stimuli,
they are thrown into spasm by the abnormal impulses of tetanus.

_Trismus._--This term is used to denote a form of tetanic spasm limited
to the muscles of mastication. It is really a mild form of chronic
tetanus, and the prognosis is favourable. It must not be confused with
the fixation of the jaw sometimes associated with a wisdom-tooth
gumboil, with tonsillitis, or with affections of the temporo-mandibular
articulation.

_Tetanus neonatorum_ is a form of tetanus occurring in infants of about
a week old. Infection takes place through the umbilicus, and manifests
itself clinically by spasms of the muscles of mastication. It is almost
invariably fatal within a few days.

_Prophylaxis._--Experience in the European War has established the
fact that the routine injection of anti-tetanic serum to all patients
with lacerated and contaminated wounds greatly reduces the frequency of
tetanus. The sooner the serum is given after the injury, the more
certain is its effect; within twenty-four hours 1500 units injected
subcutaneously is sufficient for the initial dose; if a longer period
has elapsed, 2000 to 3000 units should be given intra-muscularly, as
this ensures more rapid absorption. A second injection is given a week
after the first.

The wound must be purified in the usual way, and all instruments and
appliances used for operations on tetanic patients must be immediately
sterilised by prolonged boiling.

_Treatment._--When tetanus has developed the main indications are to
prevent the further production of toxins in the wound, and to neutralise
those that have been absorbed into the nervous system. Thorough
purification with antiseptics, excision of devitalised tissues, and
drainage of the wound are first carried out. To arrest the absorption of
toxins intra-muscular injections of 10,000 units of serum are given
daily into the muscles of the affected limb, or directly into the nerve
trunks leading from the focus of infection, in the hope of "blocking"
the nerves with antitoxin and so preventing the passage of toxins
towards the spinal cord.

To neutralise the toxins that have already reached the spinal cord, 5000
units should be injected intra-thecally daily for four or five days, the
foot of the bed being raised to enable the serum to reach the upper
parts of the cord.

The quantity of toxin circulating in the blood is so small as to be
practically negligible, and the risk of anaphylactic shock attending
intra-venous injection outweighs any benefit likely to follow this
procedure.

Baccelli recommends the injection of 20 c.c. of a 1 in 100 solution of
carbolic acid into the subcutaneous tissues every four hours during the
period that the contractions persist. Opinions vary as to the
efficiency of this treatment. The intra-thecal injection of 10 c.c. of a
15 per cent. solution of magnesium sulphate has proved beneficial in
alleviating the severity of the spasms, but does not appear to have a
curative effect.

To conserve the patient's strength by preventing or diminishing the
severity of the spasms, he should be placed in a quiet room, and every
form of disturbance avoided. Sedatives, such as bromides, paraldehyde,
or opium, must be given in large doses. Chloral is perhaps the best, and
the patient should rarely have less than 150 grains in twenty-four
hours. When he is unable to swallow, it should be given by the rectum.
The administration of chloroform is of value in conserving the strength
of the patient, by abolishing the spasms, and enabling the attendants to
administer nourishment or drugs either through a stomach tube or by the
rectum. Extreme elevation of temperature is met by tepid sponging. It is
necessary to use the catheter if retention of urine occurs.


HYDROPHOBIA

Hydrophobia is an acute infective disease following on the bite of a
rabid animal. It most commonly follows the bite or lick of a rabid dog
or cat. The virus appears to be communicated through the saliva of the
animal, and to show a marked affinity for nerve tissues; and the disease
is most likely to develop when the patient is infected on the face or
other uncovered part, or in a part richly endowed with nerves.

A dog which has bitten a person should on no account be killed until its
condition has been proved one way or the other. Should rabies develop
and its destruction become necessary, the head and spinal cord should be
retained and forwarded, packed in ice, to a competent observer. Much
anxiety to the person bitten and to his friends would be avoided if
these rules were observed, because in many cases it will be shown that
the animal did not after all suffer from rabies, and that the patient
consequently runs no risk. If, on the other hand, rabies is proved to be
present, the patient should be submitted to the Pasteur treatment.

_Clinical Features._--There is almost always a history of the patient
having been bitten or licked by an animal supposed to suffer from
rabies. The incubation period averages about forty days, but varies from
a fortnight to seven or eight months, and is shorter in young than in
old persons. The original wound has long since healed, and beyond a
slight itchiness or pain shooting along the nerves of the part, shows no
sign of disturbance. A few days of general malaise, with chills and
giddiness precede the onset of the acute manifestations, which affect
chiefly the muscles of deglutition and respiration. One of the earliest
signs is that the patient has periodically a sudden catch in his
breathing "resembling what often occurs when a person goes into a cold
bath." This is due to spasm of the diaphragm, and is frequently
accompanied by a loud-sounding hiccough, likened by the laity to the
barking of a dog. Difficulty in swallowing fluids may be the first
symptom.

The spasms rapidly spread to all the muscles of deglutition and
respiration, so that the patient not only has the greatest difficulty in
swallowing, but has a constant sense of impending suffocation. To add to
his distress, a copious secretion of viscid saliva fills his mouth. Any
voluntary effort, as well as all forms of external stimuli, only serve
to aggravate the spasms which are always induced by the attempt to
swallow fluid, or even by the sound of running water.

The temperature is raised; the pulse is small, rapid, and intermittent;
and the urine may contain sugar and albumen.

The mind may remain clear to the end, or the patient may have delusions,
supposing himself to be surrounded by terrifying forms. There is always
extreme mental agitation and despair, and the sufferer is in constant
fear of his impending fate. Happily the inevitable issue is not long
delayed, death usually occurring in from two to four days from the
onset. The symptoms of the disease are so characteristic that there is
no difficulty in diagnosis. The only condition with which it is liable
to be confused is the variety of cephalic tetanus in which the muscles
of deglutition are specially involved--the so-called tetanus
hydrophobicus.

_Prophylaxis._--The bite of an animal suspected of being rabid should be
cauterised at once by means of the actual or Paquelin cautery, or by a
strong chemical escharotic such as pure carbolic acid, after which
antiseptic dressings are applied.

It is, however, to Pasteur's _preventive inoculation_ that we must look
for our best hope of averting the onset of symptoms. "It may now be
taken as established that a grave responsibility rests on those
concerned if a person bitten by a mad animal is not subjected to the
Pasteur treatment" (Muir and Ritchie).

This method is based on the fact that the long incubation period of the
disease admits of the patient being inoculated with a modified virus
producing a mild attack, which protects him from the natural disease.

_Treatment._--When the symptoms have once developed they can only be
palliated. The patient must be kept absolutely quiet and free from all
sources of irritation. The spasms may be diminished by means of chloral
and bromides, or by chloroform inhalation.


ANTHRAX

Anthrax is a comparatively rare disease, communicable to man from
certain of the lower animals, such as sheep, oxen, horses, deer, and
other herbivora. In animals it is characterised by symptoms of acute
general poisoning, and, from the fact that it produces a marked
enlargement of the spleen, is known in veterinary surgery as "splenic
fever."

The _bacillus anthracis_ (Fig. 27), the largest of the known pathogenic
bacteria, occurs in groups or in chains made up of numerous bacilli,
each bacillus measuring from 6 to 8 µ in length. The organisms are found
in enormous numbers throughout the bodies of animals that have died of
anthrax, and are readily recognised and cultivated. Sporulation only
takes place outside the body, probably because free oxygen is necessary
to the process. In the spore-free condition, the organisms are readily
destroyed by ordinary germicides, and by the gastric juice. The spores,
on the other hand, have a high degree of resistance. Not only do they
remain viable in the dry state for long periods, even up to a year, but
they survive boiling for five minutes, and must be subjected to dry heat
at 140° C. for several hours before they are destroyed.

[Illustration: FIG. 27.--Bacillus of Anthrax in section of skin, from a
case of malignant pustule; shows vesicle containing bacilli. × 400 diam.
Gram's stain.]

_Clinical Varieties of Anthrax._--In man, anthrax may manifest itself in
one of three clinical forms.

It may be transmitted by means of spores or bacilli directly from a
diseased animal to those who, by their occupation or otherwise, are
brought into contact with it--for example, shepherds, butchers,
veterinary surgeons, or hide-porters. Infection may occur on the face by
the use of a shaving-brush contaminated by spores. The path of infection
is usually through an abrasion of the skin, and the primary
manifestations are local, constituting what is known as _the malignant
pustule_.

In other cases the disease is contracted through the inhalation of the
dried spores into the respiratory passages. This occurs oftenest in
those who work amongst wool, fur, and rags, and a form of acute
pneumonia of great virulence ensues. This affection is known as
_wool-sorter's disease_, and is almost universally fatal.

There is reason to believe that infection may also take place by means
of spores ingested into the alimentary canal in meat or milk derived
from diseased animals, or in infected water.

#Clinical Features of Malignant Pustule.#--We shall here confine
ourselves to the consideration of the local lesion as it occurs in the
skin--_the malignant pustule_.

The point of infection is usually on an uncovered part of the body, such
as the face, hands, arms, or back of the neck, and the wound may be
exceedingly minute. After an incubation period varying from a few hours
to several days, a reddish nodule resembling a small boil appears at the
seat of inoculation, the immediately surrounding skin becomes swollen
and indurated, and over the indurated area there appear a number of
small vesicles containing serum, which at first is clear but soon
becomes blood-stained (Fig. 28). Coincidently the subcutaneous tissue
for a considerable distance around becomes markedly oedematous, and the
skin red and tense. Within a few hours, blood is extravasated in the
centre of the indurated area, the blisters burst, and a dark brown or
black eschar, composed of necrosed skin and subcutaneous tissue and
altered blood, forms (Fig. 29). Meanwhile the induration extends, fresh
vesicles form and in turn burst, and the eschar increases in size. The
neighbouring lymph glands soon become swollen and tender. The affected
part is hot and itchy, but the patient does not complain of great pain.
There is a moderate degree of constitutional disturbance, with headache,
nausea, and sometimes shivering.

If the infection becomes generalised--_anthracæmia_--the temperature
rises to 103° or 104° F., the pulse becomes feeble and rapid, and other
signs of severe blood-poisoning appear: vomiting, diarrhoea, pains in the
limbs, headache and delirium, and the condition proves fatal in from
five to eight days.

_Differential Diagnosis._--When the malignant pustule is fully
developed, the central slough with the surrounding vesicles and the
widespread oedema are characteristic. The bacillus can be obtained from
the peripheral portion of the slough, from the blisters, and from the
adjacent lymph vessels and glands. The occupation of the patient may
suggest the possibility of anthrax infection.

[Illustration: FIG. 28.--Malignant Pustule, third day after infection
with Anthrax, showing great oedema of upper extremity and pectoral region
(cf. Fig. 29).]

[Illustration: FIG. 29.--Malignant Pustule, fourteen days after
infection, showing black eschar in process of separation. The oedema has
largely disappeared. Treated by Sclavo's serum (cf. Fig. 28).]

_Prophylaxis._--Any wound suspected of being infected with anthrax
should at once be cauterised with caustic potash, the actual cautery, or
pure carbolic acid.

_Treatment._--The best results hitherto obtained have followed the use
of the anti-anthrax serum introduced by Sclavo. The initial dose is 40
c.c., and if the serum is given early in the disease, the beneficial
effects are manifest in a few hours. Favourable results have also
followed the use of pyocyanase, a vaccine prepared from the bacillus
pyocyaneus.

By some it is recommended that the local lesion should be freely
excised; others advocate cauterisation of the affected part with solid
caustic potash till all the indurated area is softened. Gräf has had
excellent results by the latter method in a large series of cases, the
oedema subsiding in about twenty-four hours and the constitutional
symptoms rapidly improving. Wolff and Wiewiorowski, on the other hand,
have had equally good results by simply protecting the local lesion with
a mild antiseptic dressing, and relying upon general treatment.

The general treatment consists in feeding and stimulating the patient as
freely as possible. Quinine, in 5 to 10 grain doses every four hours,
and powdered ipecacuanha, in 40 to 60 grain doses every four hours, have
also been employed with apparent benefit.


GLANDERS

Glanders is due to the action of a specific bacterium, the _bacillus
mallei_, which resembles the tubercle bacillus, save that it is somewhat
shorter and broader, and does not stain by Gram's method. It requires
higher temperatures for its cultivation than the tubercle bacillus, and
its growth on potato is of a characteristic chocolate-brown colour, with
a greenish-yellow ring at the margin of the growth. The bacillus mallei
retains its vitality for long periods under ordinary conditions, but is
readily killed by heat and chemical agents. It does not form spores.

_Clinical Features._--Both in the lower animals and in man the bacillus
gives rise to two distinct types of disease--_acute glanders_, and
_chronic glanders_ or _farcy_.

Acute Glanders is most commonly met with in the horse and in other
equine animals, horned cattle being immune. It affects the septum of the
nose and adjacent parts, firm, translucent, greyish nodules containing
lymphoid and epithelioid cells appearing in the mucous membrane. These
nodules subsequently break down in the centre, forming irregular
ulcers, which are attended with profuse discharge, and marked
inflammatory swelling. The cervical lymph glands, as well as the lungs,
spleen, and liver, may be the seat of secondary nodules.

_In man_, acute glanders is commoner than the chronic variety. Infection
always takes place through an abraded surface, and usually on one of the
uncovered parts of the body--most commonly the skin of the hands, arms,
or face; or on the mucous membrane of the mouth, nose, or eye. The
disease has been acquired by accidental inoculation in the course of
experimental investigations in the laboratory, and proved fatal. The
incubation period is from three to five days.

The _local_ manifestations are pain and swelling in the region of the
infected wound, with inflammatory redness around it and along the lines
of the superficial lymphatics. In the course of a week, small, firm
nodules appear, and are rapidly transformed into pustules. These may
occur on the face and in the vicinity of joints, and may be mistaken for
the eruption of small-pox.

After breaking down, these pustules give rise to irregular ulcers, which
by their confluence lead to extensive destruction of skin. Sometimes the
nasal mucous membrane becomes affected, and produces a discharge--at
first watery, but later sanious and purulent. Necrosis of the bones of
the nose may take place, in which case the discharge becomes peculiarly
offensive. In nearly every case metastatic abscesses form in different
parts of the body, such as the lungs, joints, or muscles.

During the development of the disease the patient feels ill, complains
of headache and pains in the limbs, the temperature rises to 104° or
even to 106° F., and assumes a pyæmic type. The pulse becomes rapid and
weak. The tongue is dry and brown. There is profuse sweating,
albuminuria, and often insomnia with delirium. Death may take place
within a week, but more frequently occurs during the second or third
week.

_Differential Diagnosis._--There is nothing characteristic in the site
of the primary lesion in man, and the condition may, during the early
stages, be mistaken for a boil or carbuncle, or for any acute
inflammatory condition. Later, the disease may simulate acute articular
rheumatism, or may manifest all the symptoms of acute septicæmia or
pyæmia. The diagnosis is established by the recognition of the bacillus.
Veterinary surgeons attach great importance to the mallein test as a
means of diagnosis in animals, but in the human subject its use is
attended with considerable risk and is not to be recommended.

_Treatment._--Excision of the primary nodule, followed by the
application of the thermo-cautery and sponging with pure carbolic acid,
should be carried out, provided the condition is sufficiently limited to
render complete removal practicable.

When secondary abscesses form in accessible situations, they must be
incised, disinfected, and drained. The general treatment is carried out
on the same lines as in other acute infective diseases.

#Chronic Glanders.#--_In the horse_ the chronic form of glanders is
known as _farcy_, and follows infection through an abrasion of the skin,
involving chiefly the superficial lymph vessels and glands. The
lymphatics become indurated and nodular, constituting what veterinarians
call _farcy pipes_ and _farcy buds_.

_In man_ also the clinical features of the chronic variety of the
disease are somewhat different from those of the acute form. Here, too,
infection takes place through a broken cutaneous surface, and leads to a
superficial lymphangitis with nodular thickening of the lymphatics
(_farcy buds_). The neighbouring glands soon become swollen and
indurated. The primary lesion meanwhile inflames, suppurates, and, after
breaking down, leaves a large, irregular ulcer with thickened edges and
a foul, purulent or bloody discharge. The glands break down in the same
way, and lead to wide destruction of skin, and the resulting sinuses and
ulcers are exceedingly intractable. Secondary deposits in the
subcutaneous tissue, the muscles, and other parts, are not uncommon, and
the nasal mucous membrane may become involved. The disease often runs a
chronic course, extending to four or five months, or even longer.
Recovery takes place in about 50 per cent. of cases, but the
convalescence is prolonged, and at any time the disease may assume the
characters of the acute variety and speedily prove fatal.

The _differential diagnosis_ is often difficult, especially in the
chronic nodules, in which it may be impossible to demonstrate the
bacillus. The ulcerated lesions of farcy have to be distinguished from
those of tubercle, syphilis, and other forms of infective granuloma.

_Treatment._--Limited areas of disease should be completely excised. The
general condition of the patient must be improved by tonics, good food,
and favourable hygienic surroundings. In some cases potassium iodide
acts beneficially.


ACTINOMYCOSIS

Actinomycosis is a chronic disease due to the action of an organism
somewhat higher in the vegetable scale than ordinary bacteria--the
_streptothrix actinomyces_ or _ray fungus_.

[Illustration: FIG. 30.--Section of Actinomycosis Colony in Pus from
Abscess of Liver, showing filaments and clubs of streptothrix
actinomyces. × 400 diam. Gram's stain.]

_Etiology and Morbid Anatomy._--The actinomyces, which has never been
met with outside the body, gives rise in oxen, horses, and other animals
to tumour-like masses composed of granulation tissue; and in man to
chronic suppurative processes which may result in a condition resembling
chronic pyæmia. The actinomyces is more complex in structure than other
pathogenic organisms, and occurs in the tissues in the form of small,
round, semi-translucent bodies, about the size of a pin-head or less,
and consisting of colonies of the fungus. On account of their yellow
tint they are spoken of as "sulphur grains." Each colony is made up of a
series of thin, interlacing, and branching _filaments_, some of which
are broken up so as to form masses or chains of _cocci_; and around the
periphery of the colony are elongated, pear-shaped, hyaline, _club-like
bodies_ (Fig. 30).

Infection is believed to be conveyed by the husks of cereals, especially
barley; and the organism has been found adhering to particles of grain
embedded in the tissues of animals suffering from the disease. In the
human subject there is often a history of exposure to infection from
such sources, and the disease is said to be most common during the
harvesting months.

Around each colony of actinomyces is a zone of granulation tissue in
which suppuration usually occurs, so that the fungus comes to lie in a
bath of greenish-yellow pus. As the process spreads these purulent foci
become confluent and form abscess cavities. When metastasis takes place,
as it occasionally does, the fungus is transmitted by the blood vessels,
as in pyæmia.

_Clinical features._--In man the disease may be met with in the skin,
the organisms gaining access through an abrasion, and spreading by the
formation of new nodules in the same way as tuberculosis.

The region of the mouth and jaws is one of the commonest sites of
surgical actinomycosis. Infection takes place, as a rule, along the side
of a carious tooth, and spreads to the lower jaw. A swelling is slowly
and insidiously developed, but when the loose connective tissue of the
neck becomes infiltrated, the spread is more rapid. The whole region
becomes infiltrated and swollen, and the skin ultimately gives way and
free suppuration occurs, resulting in the formation of sinuses. The
characteristic greenish-grey or yellow granules are seen in the pus, and
when examined microscopically reveal the colonies of actinomyces.

Less frequently the maxilla becomes affected, and the disease may spread
to the base of the skull and brain. The vertebræ may become involved by
infection taking place through the pharynx or oesophagus, and leading to
a condition simulating tuberculous disease of the spine. When it
implicates the intestinal canal and its accessory glands, the lungs,
pleura, and bronchial tubes, or the brain, the disease is not amenable
to surgical treatment.

_Differential Diagnosis._--The conditions likely to be mistaken for
surgical actinomycosis are sarcoma, tubercle, and syphilis. In the early
stages the differential diagnosis is exceedingly difficult. In many
cases it is only possible when suppuration has occurred and the fungus
can be demonstrated.

The slow destruction of the affected tissue by suppuration, the absence
of pain, tenderness, and redness, simulate tuberculosis, but the absence
of glandular involvement helps to distinguish it.

Syphilitic lesions are liable to be mistaken for actinomycosis, all the
more that in both diseases improvement follows the administration of
iodides. When it affects the lower jaw, in its early stages,
actinomycosis may closely simulate a periosteal sarcoma.

[Illustration: FIG. 31.--Actinomycosis of Maxilla. The disease spread to
opposite side; finally implicated base of skull, and proved fatal.
Treated by radium.

(Mr. D. P. D. Wilkie's case.)]

The recognition of the fungus is the crucial point in diagnosis.

_Prognosis._--Spontaneous cure rarely occurs. When the disease
implicates internal organs, it is almost always fatal. On external parts
the destructive process gradually spreads, and the patient eventually
succumbs to superadded septic infection. When, from its situation, the
primary focus admits of removal, the prognosis is more favourable.

_Treatment._--The surgical treatment is early and free removal of the
affected tissues, after which the wound is cauterised by the actual
cautery, and sponged over with pure carbolic acid. The cavity is packed
with iodoform gauze, no attempt being made to close the wound.

Success has attended the use of a vaccine prepared from cultures of the
organism; and the X-rays and radium, combined with the administration of
iodides in large doses, or with intra-muscular injections of a 10 per
cent. solution of cacodylate of soda, have proved of benefit.

MYCETOMA, OR MADURA FOOT.--Mycetoma is a chronic disease due to
an organism resembling that of actinomycosis, but not identical with it.
It is endemic in certain tropical countries, and is most frequently met
with in India. Infection takes place through an abrasion of the skin,
and the disease usually occurs on the feet of adult males who work
barefooted in the fields.

_Clinical Features._--The disease begins on the foot as an indurated
patch, which becomes discoloured and permeated by black or yellow
nodules containing the organism. These nodules break down by
suppuration, and numerous minute abscesses lined by granulation tissues
are thus formed. In the pus are found yellow particles likened to
fish-roe, or black pigmented granules like gunpowder. Sinuses form, and
the whole foot becomes greatly swollen and distorted by flattening of
the sole and dorsiflexion of the toes. Areas of caries or necrosis occur
in the bones, and the disease gradually extends up the leg (Fig. 32).
There is but little pain, and no glandular involvement or constitutional
disturbance. The disease runs a prolonged course, sometimes lasting for
twenty or thirty years. Spontaneous cure never takes place, and the risk
to life is that of prolonged suppuration.

If the disease is localised, it may be removed by the knife or sharp
spoon, and the part afterwards cauterised. As a rule, amputation well
above the disease is the best line of treatment. Unlike actinomycosis,
this disease does not appear to be benefited by iodides.

[Illustration: FIG. 32.--Mycetoma, or Madura Foot. (Museum of Royal
College of Surgeons, Edinburgh.)]

DELHI BOIL.--_Synonyms_--Aleppo boil, Biskra button, Furunculus
orientalis, Natal sore.

Delhi boil is a chronic inflammatory disease, most commonly met with in
India, especially towards the end of the wet season. The disease occurs
oftenest on the face, and is believed to be due to an organism, although
this has not been demonstrated. The infection is supposed to be conveyed
through water used for washing, or by the bites of insects.

_Clinical Features._--A red spot, resembling the mark of a mosquito
bite, appears on the affected part, and is attended with itching. After
becoming papular and increasing to the size of a pea, desquamation takes
place, leaving a dull-red surface, over which in the course of several
weeks there develops a series of small yellowish-white spots, from which
serum exudes, and, drying, forms a thick scab. Under this scab the skin
ulcerates, leaving small oval sores with sharply bevelled edges, and an
uneven floor covered with yellow or sanious pus. These sores vary in
number from one to forty or fifty. They may last for months and then
heal spontaneously, or may continue to spread until arrested by suitable
treatment. There is no enlargement of adjacent glands, and but little
inflammatory reaction in the surrounding tissues; nor is there any
marked constitutional disturbance. Recovery is often followed by
cicatricial contraction leading to deformity of the face.

The _treatment_ consists in destroying the original papule by the actual
cautery, acid nitrate of mercury, or pure carbolic acid. The ulcers
should be scraped with the sharp spoon, and cauterised.

CHIGOE.--Chigoe or jigger results from the introduction of the
eggs of the sand-flea (_Pulex penetrans_) into the tissues. It occurs in
tropical Africa, South America, and the West Indies. The impregnated
female flea remains attached to the part till the eggs mature, when by
their irritation they cause localised inflammation with pustules or
vesicles on the surface. Children are most commonly attacked,
particularly about the toe-nails and on the scrotum. The treatment
consists in picking out the insect with a blunt needle, special care
being taken not to break it up. The puncture is then cauterised. The
application of essential oils to the feet acts as a preventive.

POISONING BY INSECTS.--The bites of certain insects, such as
mosquitoes, midges, different varieties of flies, wasps, and spiders,
may be followed by serious complications. The effects are mainly due to
the injection of an irritant acid secretion, the exact nature of which
has not been ascertained.

The local lesion is a puncture, surrounded by a zone of hyperæmia,
wheals, or vesicles, and is associated with burning sensations and
itching which usually pass off in a few hours, but may recur at
intervals, especially when the patient is warm in bed. Scratching also
reproduces the local signs and symptoms. Where the connective tissue is
loose--for example, in the eyelid or scrotum--there is often
considerable swelling; and in the mouth and fauces this may lead to
oedema of the glottis, which may prove fatal.

The _treatment_ consists in the local application of dilute alkalies
such as ammonia water, solutions of carbonate or bicarbonate of soda, or
sal-volatile. Weak carbolic lotions, or lead and opium lotion, are
useful in allaying the local irritation. One of the best means of
neutralising the poison is to apply to the sting a drop of a mixture
containing equal parts of pure carbolic acid and liquor ammoniæ.

Free stimulation is called for when severe constitutional symptoms are
present.

SNAKE-BITES.--We are here only concerned with the injuries
inflicted by the venomous varieties of snakes, the most important of
which are the hooded snakes of India, the rattle-snakes of America, the
horned snakes of Africa, the viper of Europe, and the adder of the
United Kingdom.

While the virulence of these creatures varies widely, they are all
capable of producing in a greater or less degree symptoms of acute
poisoning in man and other animals. By means of two recurved fangs
attached to the upper jaw, and connected by a duct with poison-secreting
glands, they introduce into their prey a thick, transparent, yellowish
fluid, of acid reaction, probably of the nature of an albumose, and
known as the _venom_.

The _clinical features_ resulting from the injection of the venom vary
directly in intensity with the amount of the poison introduced, and the
rapidity with which it reaches the circulating blood, being most marked
when it immediately enters a large vein. The poison is innocuous when
taken into the stomach.

_Locally_ the snake inflicts a double wound, passing vertically into the
subcutaneous tissue; the edges of the punctures are ecchymosed, and the
adjacent vessels the seat of thrombosis. Immediately there is intense
pain, and considerable swelling with congestion, which tends to spread
towards the trunk. Extensive gangrene may ensue. There is no special
involvement of the lymphatics.

The _general symptoms_ may come on at once if the snake is a
particularly venomous one, or not for some hours if less virulent. In
the majority of viper or adder bites the constitutional disturbance is
slight and transient, if it appears at all. Snake-bites in children are
particularly dangerous.

The patient's condition is one of profound shock with faintness,
giddiness, dimness of sight, and a feeling of great terror. The pupils
dilate, the skin becomes moist with a clammy sweat, and nausea with
vomiting, sometimes of blood, ensues. High fever, cramps, loss of
sensation, hæmaturia, and melæna are among the other symptoms that may
be present. The pulse becomes feeble and rapid, the respiratory nerve
centres are profoundly depressed, and delirium followed by coma usually
precedes the fatal issue, which may take place in from five to
forty-eight hours. If the patient survives for two days the prognosis is
favourable.

_Treatment._--A broad ligature should be tied tightly round the limb
above the seat of infection, to prevent the poison passing into the
general circulation, and bleeding from the wound should be encouraged.
The application of an elastic bandage from above downward to empty the
blood out of the infected portion of the limb has been recommended. The
whole of the bite should at once be excised, and crystals of
permanganate of potash rubbed into the wound until it is black, or
peroxide of hydrogen applied with the object of destroying the poison by
oxidation.

The general treatment consists in free stimulation with whisky, brandy,
ammonia, digitalis, etc. Hypodermic injections of strychnin in doses
sufficiently large to produce a slight degree of poisoning by the drug
are particularly useful. The most rational treatment, when it is
available, is the use of the _antivenin_ introduced by Fraser and
Calmette.




CHAPTER VIII

TUBERCULOSIS


Tubercle bacillus--Methods of infection--Inherited and acquired
predisposition--Relationship of tuberculosis to injury--Human and
bovine tuberculosis--Action of the bacillus upon the
tissues--Tuberculous granulation tissue--Natural cure--Recrudescence
of the disease--THE TUBERCULOUS ABSCESS--Contents and wall of the
abscess--Tuberculous sinuses.

Tuberculosis occurs more frequently in some situations than in others;
it is common, for example, in lymph glands, in bones and joints, in the
peritoneum, the intestine, the kidney, prostate and testis, and in the
skin and subcutaneous cellular tissue; it is seldom met with in the
breast or in muscles, and it rarely affects the ovary, the pancreas, the
parotid, or the thyreoid.

_Tubercle bacilli_ vary widely in their virulence, and they are more
tenacious of life than the common pyogenic bacteria. In a dry state, for
example, they can retain their vitality for months; and they can also
survive immersion in water for prolonged periods. They resist the action
of the products of putrefaction for a considerable time, and are not
destroyed by digestive processes in the stomach and intestine. They may
be killed in a few minutes by boiling, or by exposure to steam under
pressure, or by immersion for less than a minute in 1 in 20 carbolic
lotion.

#Methods of Infection.#--In marked contrast to what obtains in the
infective diseases that have already been described, tuberculosis rarely
results from the _infection of a wound_. In exceptional instances,
however, this does occur, and in illustration of the fact may be cited
the case of a servant who cut her finger with a broken spittoon
containing the sputum of her consumptive master; the wound subsequently
showed evidence of tuberculous infection, which ultimately spread up
along the lymph vessels of the arm. Pathologists, too, whose hands,
before the days of rubber gloves, were frequently exposed to the contact
of tuberculous tissues and pus, were liable to suffer from a form of
tuberculosis of the skin of the finger, known as _anatomical tubercle_.
Slight wounds of the feet in children who go about barefoot in towns
sometimes become infected with tubercle. Operation wounds made with
instruments contaminated with tuberculous material have also been known
to become infected. It is highly probable that the common form of
tuberculosis of the skin known as "lupus" arises by direct infection
from without.

[Illustration: FIG. 33.--Tubercle Bacilli in caseous material
× 1000 diam. Z. Neilsen stain.]

In the vast majority of cases the tubercle bacillus gains entrance to
the body by way of the mucous surfaces, the organisms being either
inhaled or swallowed; those inhaled are mostly derived from the human
subject, those swallowed, from cattle. Bacilli, whether inhaled or
swallowed, are especially apt to lodge about the pharynx and pass to the
pharyngeal lymphoid tissue and tonsils, and by way of the lymph vessels
to the glands. The glands most frequently infected in this way are the
cervical glands, and those within the cavity of the chest--particularly
the bronchial glands at the root of the lung. From these, infection
extends at any later period in life to the bones, joints, and internal
organs.

There is reason to believe that the organisms may lie in a dormant
condition for an indefinite period in these glands, and only become
active long afterwards, when some depression of the patient's health
produces conditions which favour their growth. When the organisms become
active in this way, the tuberculous tissue undergoes softening and
disintegration, and the infective material, by bursting into an adjacent
vein, may enter the blood-stream, in which it is carried to distant
parts of the body. In this way a _general tuberculosis_ may be set up,
or localised foci of tuberculosis may develop in the tissues in which
the organisms lodge. Many tuberculous patients are to be regarded as
possessing in their bronchial glands, or elsewhere, an internal store of
bacilli, to which the disease for which advice is sought owes its
origin, and from which similar outbreaks of tuberculosis may originate
in the future.

_The alimentary mucous membrane_, especially that of the lower ileum and
cæcum, is exposed to infection by swallowed sputum and by food
materials, such as milk, containing tubercle bacilli. The organisms may
lodge in the mucous membrane and cause tuberculous ulceration, or they
may be carried through the wall of the bowel into the lacteals, along
which they pass to the mesenteric glands where they become arrested and
give rise to tuberculous disease.

#Relationship of Tuberculosis to Trauma.#--Any tissue whose vitality has
been lowered by injury or disease furnishes a favourable nidus for the
lodgment and growth of tubercle bacilli. The injury or disease, however,
is to be looked upon as determining the _localisation_ of the
tuberculous lesion rather than as an essential factor in its causation.
In a person, for example, in whose blood tubercle bacilli are
circulating and reaching every tissue and organ of the body, the
occurrence of tuberculous disease in a particular part may be determined
by the depression of the tissues resulting from an injury of that part.
There can be no doubt that excessive movement and jarring of a limb
aggravates tuberculous disease of a joint; also that an injury may light
up a focus that has been long quiescent, but we do not agree with
those--Da Costa, for example--who maintain that injury may be a
determining cause of tuberculosis. The question is not one of mere
academic interest, but one that may raise important issues in the law
courts.

#Human and Bovine Tuberculosis.#--The frequency of the bovine bacillus
in the abdominal and in the glandular and osseous tuberculous lesions of
children would appear to justify the conclusion that the disease is
transmissible from the ox to the human subject, and that the milk of
tuberculous cows is probably a common vehicle of transmission.

#Changes in the Tissues following upon the successful Lodgment of
Tubercle Bacilli.#--The action of the bacilli on the tissues results in
the formation of granulation tissue comprising characteristic tissue
elements and with a marked tendency to undergo caseation.

The recognition of the characteristic elements, with or without
caseation, is usually sufficient evidence of the tuberculous nature of
any portion of tissue examined for diagnostic purposes. The recognition
of the bacillus itself by appropriate methods of staining makes the
diagnosis a certainty; but as it is by no means easy to identify the
organism in many forms of surgical tuberculosis, it may be necessary to
have recourse to experimental inoculation of susceptible animals such as
guinea-pigs.

The changes subsequent to the formation of tuberculous granulation
tissue are liable to many variations. It must always be borne in mind
that although the bacilli have effected a lodgment and have inaugurated
disease, the relation between them and the tissues remains one of mutual
antagonism; which of them is to gain and keep the upper hand in the
conflict depends on their relative powers of resistance.

If the tissues prevail, there ensues a process of repair. In the
immediate vicinity of the area of infection young connective tissue, and
later, fibrous tissue, is formed. This may replace the tuberculous
tissue and bring about repair--a fibrous cicatrix remaining to mark the
scene of the previous contest. Scars of this nature are frequently
discovered at the apex of the lung after death in persons who have at
one time suffered from pulmonary phthisis. Under other circumstances,
the tuberculous tissue that has undergone caseation, or even
calcification, is only encapsulated by the new fibrous tissue, like a
foreign body. Although this may be regarded as a victory for the
tissues, the cure, if such it may be called, is not necessarily a
permanent one, for at any subsequent period, if the part affected is
disturbed by injury or through some other influence, the encapsulated
tubercle may again become active and get the upper hand of the tissues,
and there results a relapse or recrudescence of the disease. This
_tendency to relapse_ after apparent cure is a notable feature of
tuberculous disease as it is met with in the spine, or in the
hip-joint, and it necessitates a prolonged course of treatment to give
the best chance of a lasting cure.

If, however, at the inauguration of the tuberculous disease the bacilli
prevail, the infection tends to spread into the tissues surrounding
those originally infected, and more and more tuberculous granulation
tissue is formed. Finally the tuberculous tissue breaks down and
liquefies, resulting in the formation of a cold abscess. In their
struggle with the tissues, tubercle bacilli receive considerable support
and assistance from any pyogenic organisms that may be present. A
tuberculous infection may exhibit its aggressive qualities in a more
serious manner by sending off detachments of bacilli, which are carried
by the lymphatics to the nearest glands, or by the blood-stream to more
distant, and it may be to all, parts of the body. When the infection is
thus generalised, the condition is called _general tuberculosis_.
Considering the extraordinary frequency of localised forms of surgical
tuberculosis, general dissemination of the disease is rare.

#The clinical features# of surgical tuberculosis will be described with
the individual tissues and organs, as they vary widely according to the
situation of the lesion.

#The general treatment# consists in combating the adverse influences
that have been mentioned as increasing the liability to tuberculous
infection. Within recent years the value of the "open-air" treatment has
been widely recognised. An open-air life, even in the centre of a city,
may be followed by marked improvement, especially in the hospital class
of patient, whose home surroundings tend to favour the progress of the
disease. The purer air of places away from centres of population is
still better; and, according to the idiosyncrasies of the individual
patient, mountain air or that of the sea coast may be preferred. In view
of the possible discomforts and gastric disturbance which may attend a
sea-voyage, this should be recommended to patients suffering from
tuberculous lesions with more caution than has hitherto been exercised.
The diet must be a liberal one, and should include those articles which
are at the same time easily digested and nourishing, especially proteids
and fats; milk obtained from a reliable source and underdone
butcher-meat are among the best. When the ordinary nourishment taken is
insufficient, it may be supplemented by such articles as malt extract,
stout, and cod-liver oil. The last is specially beneficial in patients
who do not take enough fat in other forms. It is noteworthy that many
tuberculous patients show an aversion to fat.

For _the use of tuberculin in diagnosis_ and for _the vaccine treatment
of tuberculosis_ the reader is referred to text-books on medicine.

In addition to increasing the resisting power of the patient, it is
important to enable the fluids of the body, so altered, to come into
contact with the tuberculous focus. One of the obstacles to this is that
the focus is often surrounded by tissues or fluids which have been
almost entirely deprived of bactericidal substances. In the case of
caseated glands in the neck, for example, it is obvious that the removal
of this inert material is necessary before the tissues can be irrigated
with fluids of high bactericidal value. Again, in tuberculous ascites
the abdominal cavity is filled with a fluid practically devoid of
anti-bacterial substances, so that the bacilli are able to thrive and
work their will on the tissues. When the stagnant fluid is got rid of by
laparotomy, the parts are immediately douched with lymph charged with
protective substances, the bactericidal power of which may be many times
that of the fluid displaced.

It is probable that the beneficial influence of _counter-irritants_,
such as blisters, and exposure to the _Finsen light_ and other forms of
_rays_, is to be attributed in part to the increased flow of blood to
the infected tissues.

_Artificial Hyperæmia._--As has been explained, the induction of
hyperæmia by the method devised by Bier, constitutes one of our most
efficient means of combating bacterial infection. The treatment of
tuberculosis on this plan has been proved by experience to be a valuable
addition to our therapeutic measures, and the simplicity of its
application has led to its being widely adopted in practice. It results
in an increase in the reactive changes around the tuberculous focus, an
increase in the immigration of leucocytes, and infiltration with the
lymphocytes.

The constricting bandage should be applied at some distance above the
seat of infection; for instance, in disease of the wrist, it is put on
above the elbow, and it must not cause pain either where it is applied
or in the diseased part. The bandage is only applied for a few hours
each day, either two hours at a time or twice a day for one hour, and,
while it is on, all dressings are removed save a piece of sterile gauze
over any wound or sinus that may be present. The process of cure takes a
long time--nine or even twelve months in the case of a severe joint
affection.

In cases in which a constricting bandage is inapplicable, for example,
in cold abscesses, tuberculous glands or tendon sheaths, Klapp's suction
bell is employed. The cup is applied for five minutes at a time and then
taken off for three minutes, and this is repeated over a period of
about three-quarters of an hour. The pus is allowed to escape by a small
incision, and no packing or drain should be introduced.

It has been found that tuberculous lesions tend to undergo cure
when the infected tissues are exposed to the rays of the
sun--_heliotherapy_--therefore whenever practicable this therapeutic
measure should be had recourse to.

Since the introduction of the methods of treatment described above, and
especially by their employment at an early stage in the disease, the
number of cases of tuberculosis requiring operative interference has
greatly diminished. There are still circumstances, however, in which an
operation is required; for example, in disease of the lymph glands for
the removal of inert masses of caseous material, in disease of bone for
the removal of sequestra, or in disease of joints to improve the
function of the limb. It is to be understood, however, that operative
treatment must always be preceded by and combined with other therapeutic
measures.


TUBERCULOUS ABSCESS

The caseation of tuberculous granulation tissue and its liquefaction is
a slow and insidious process, and is unattended with the classical signs
of inflammation--hence the terms "cold" and "chronic" applied to the
tuberculous abscess.

In a cold abscess, such as that which results from tuberculous disease
of the vertebræ, the clinical appearances are those of a soft, fluid
swelling without heat, redness, pain, or fever. When toxic symptoms are
present, they are usually due to a mixed infection.

A tuberculous abscess results from the disintegration and liquefaction
of tuberculous granulation tissue which has undergone caseation. Fluid
and cells from the adjacent blood vessels exude into the cavity, and
lead to variations in the character of its contents. In some cases the
contents consist of a clear amber-coloured fluid, in which are suspended
fragments of caseated tissue; in others, of a white material like
cream-cheese. From the addition of a sufficient number of leucocytes,
the contents may resemble the pus of an ordinary abscess.

The wall of the abscess is lined with tuberculous granulation tissue,
the inner layers of which are undergoing caseation and disintegration,
and present a shreddy appearance; the outer layers consist of
tuberculous tissue which has not yet undergone caseation. The abscess
tends to increase in size by progressive liquefaction of the inner
layers, caseation of the outer layers, and the further invasion of the
surrounding tissues by tubercle bacilli. In this way a tuberculous
abscess is capable of indefinite extension and increase in size until it
reaches a free surface and ruptures externally. The direction in which
it spreads is influenced by the anatomical arrangement of the tissues,
and possibly to some extent by gravity, and the abscess may reach the
surface at a considerable distance from its seat of origin. The best
illustration of this is seen in the psoas abscess, which may originate
in the dorsal vertebræ, extend downwards within the sheath of the psoas
muscle, and finally appear in the thigh.

#Clinical Features.#--The insidious development of the tuberculous
abscess is one of its characteristic features. The swelling may attain a
considerable size without the patient being aware of its existence, and,
as a matter of fact, it is often discovered accidentally. The absence of
toxæmia is to be associated with the incapacity of the wall of the
abscess to permit of absorption; this is shown also by the fact that
when even a large quantity of iodoform is inserted into the cavity of
the abscess, there are no symptoms of poisoning. The abscess varies in
size from a small cherry to a cavity containing several pints of pus.
Its shape also varies; it is usually that of a flattened sphere, but it
may present pockets or burrows running in various directions. Sometimes
it is hour-glass or dumb-bell shaped, as is well illustrated in the
region of the groin in disease of the spine or pelvis, where there may
be a large sac occupying the venter ilii, and a smaller one in the
thigh, the two communicating by a narrow channel under Poupart's
ligament. By pressing with the fingers the pus may be displaced from one
compartment to the other. The usual course of events is that the abscess
progresses slowly, and finally reaches a free surface--generally the
skin. As it does so there may be some pain, redness, and local elevation
of temperature. Fluctuation becomes evident and superficial, and the
skin becomes livid and finally gives way. If the case is left to nature,
the discharge of pus continues, and the track opening on the skin
remains as a _sinus_. The persistence of suppuration is due to the
presence in the wall of the abscess and of the sinus, of tuberculous
granulation tissue, which, so long as it remains, continues to furnish
discharge, and so prevents healing. Sooner or later pyogenic organisms
gain access to the sinus, and through it to the wall of the abscess.
They tend further to depress the resisting power of the tissues, and
thereby aggravate and perpetuate the tuberculous disease. This
superadded infection with pyogenic organisms exposes the patient to the
further risks of septic intoxication, especially in the form of hectic
fever and septicæmia, and increases the liability to general
tuberculosis, and to waxy degeneration of the internal organs. The mixed
infection is chiefly responsible for the pyrexia, sweating, and
emaciation which the laity associate with consumptive disease. A
tuberculous abscess may in one or other of these ways be a cause of
death.

_Residual abscess_ is the name given to an abscess that makes its
appearance months, or even years, after the apparent cure of tuberculous
disease--as, for example, in the hip-joint or spine. It is called
residual because it has its origin in the remains of the original
disease.

[Illustration: FIG. 34.--Tuberculous Abscess in right lumbar region in a
woman aged thirty.]

#Diagnosis.#--A cold abscess is to be diagnosed from a syphilitic gumma,
a cyst, and from lipoma and other soft tumours. The differential
diagnosis of these affections will be considered later; it is often made
easier by recognising the presence of a lesion that is likely to cause a
cold abscess, such as tuberculous disease of the spine or of the
sacro-iliac joint. When it is about to burst externally, it may be
difficult to distinguish a tuberculous abscess from one due to infection
with pyogenic organisms. Even when the abscess is opened, the
appearances of the pus may not supply the desired information, and it
may be necessary to submit it to bacteriological examination. When the
pus is found to be sterile, it is usually safe to assume that the
condition is tuberculous, as in other forms of suppuration the causative
organisms can usually be recognised. Experimental inoculation will
establish a definite diagnosis, but it implies a delay of two to three
weeks.

#Treatment.#--The tuberculous abscess may recede and disappear under
general treatment. Many surgeons advise that so long as the abscess is
quiescent it should be left alone. All agree, however, that if it shows
a tendency to spread, to increase in size, or to approach the skin or a
mucous membrane, something should be done to avoid the danger of its
bursting and becoming infected with pyogenic organisms. Simple
evacuation of the abscess by a hollow needle may suffice, or bismuth or
iodoform may be introduced after withdrawal of the contents.

_Evacuation of the Abscess and Injection of Iodoform._--The iodoform is
employed in the form of a 10 per cent. solution in ether or the same
proportion suspended in glycerin. Either form becomes sterile soon after
it is prepared. Its curative effects would appear to depend upon the
liberation of iodine, which restrains the activity of the bacilli, and
upon its capacity for irritating the tissues and so inducing a
protective leucocytosis, and also of stimulating the formation of scar
tissue. An anæsthetic is rarely called for, except in children. The
abscess is first evacuated by means of a large trocar and cannula
introduced obliquely through the overlying soft parts, avoiding any part
where the skin is thin or red. If the cannula becomes blocked with
caseous material, it may be cleared with a probe, or a small quantity of
saline solution is forced in by the syringe. The iodoform is injected by
means of a glass-barrelled syringe, which is firmly screwed on to the
cannula. The amount injected varies with the size of the abscess and the
age of the patient; it may be said to range from two or three drams in
the case of children to several ounces in large abscesses in adults. The
cannula is withdrawn, the puncture is closed by a Michel's clip, and a
dressing applied so as to exert a certain amount of compression. If the
abscess fills up again, the procedure should be repeated; in doing so,
the contents show the coloration due to liberated iodine. When the
contents are semi-solid, and cannot be withdrawn even through a large
cannula, an incision must be made, and, after the cavity has been
emptied, the iodoform is introduced through a short rubber tube attached
to the syringe. Experience has shown that even large abscesses, such as
those associated with spinal disease, may be cured by iodoform
injection, and this even when rupture of the abscess on the skin surface
has appeared to be imminent.

Another method of treatment which is less popular now than it used to
be, and which is chiefly applicable in abscesses of moderate size, is by
_incision of the abscess and removal of the tuberculous tissue in its
wall_ with the sharp spoon. An incision is made which will give free
access to the interior of the abscess, so that outlying pockets or
recesses may not be overlooked. After removal of the pus, the wall of
the abscess is scraped with the Volkmann spoon or with Barker's flushing
spoon, to get rid of the tuberculous tissue with which it is lined. In
using the spoon, care must be taken that its sharp edge does not
perforate the wall of a vein or other important structure. Any debris
which may adhere to the walls is removed by rubbing with dry gauze. The
oozing of blood is arrested by packing the cavity for a few minutes with
gauze. After the packing is removed, iodoform powder is rubbed into the
raw surface. The soft parts divided by the incision are sutured in
layers so as to ensure primary union. If, on the other hand, there is
fear of a mixed infection, especially in abscesses near the rectum or
anus, it is safer to treat it by the open method, packing the cavity
with iodoform worsted or bismuth gauze, which is renewed at intervals of
a week or ten days as the cavity heals from the bottom.

Another method is to incise the abscess, cleanse the cavity with gauze,
irrigate with Carrel-Dakin solution and pack with gauze smeared with the
dilute non-toxic B.I.P.P. (bismuth and iodoform 2 parts, vaseline 12
parts, hard paraffin, sufficient to give the consistence of butter). The
wound is closed with "bipped" silk sutures; one of these--the "waiting
suture"--is left loose to permit of withdrawal of the gauze after
forty-eight hours; the waiting suture is then tied, and delayed primary
union is thus effected.

When the skin over the abscess is red, thin, and about to give way, as
is frequently the case when the abscess is situated in the subcutaneous
cellular tissue, any skin which is undermined and infected with tubercle
should be removed with the scissors at the same time that the abscess is
dealt with.

In abscesses treated by the open method, when the cavity has become
lined with healthy granulations, it may be closed by secondary suture,
or, if the granulating surface is flush with the skin, healing may be
hastened by skin-grafting.

If the tuberculous abscess has burst and left a _sinus_, this is apt to
persist because of the presence of tuberculous tissue in its wall, and
of superadded pyogenic infection, or because it serves as an avenue for
the escape of discharge from a focus of tubercle in a bone or a lymph
gland.

[Illustration: FIG. 35.--Tuberculous Sinus injected through its opening
in the forearm with bismuth paste.

(Mr. Pirie Watson's case--Radiogram by Dr. Hope Fowler.)]

The treatment varies with the conditions present, and must include
measures directed to the lesion from which the sinus has originated. The
extent and direction of any given sinus may be demonstrated by the use
of the probe, or, more accurately, by injecting the sinus with a paste
consisting of white vaseline containing 10 to 30 per cent. of bismuth
subcarbonate, and following its track with the X-rays (Fig. 35).

It was found by Beck of Chicago that the injection of bismuth paste is
frequently followed by healing of the sinus, and that, if one injection
fails to bring about a cure, repeating the injection every second day
may be successful. Some caution must be observed in this treatment, as
symptoms of poisoning have been observed to follow its use. If they
manifest themselves, an injection of warm olive oil should be given; the
oil, left in for twelve hours or so, forms an emulsion with the bismuth,
which can be withdrawn by aspiration. Iodoform suspended in glycerin may
be employed in a similar manner. When these and other non-operative
measures fail, and the whole track of the sinus is accessible, it should
be laid open, scraped, and packed with bismuth or iodoform gauze until
it heals from the bottom.

The _tuberculous ulcer_ is described in the chapter on ulcers.




CHAPTER IX

SYPHILIS


Definition.--Virus.--ACQUIRED SYPHILIS--Primary period:
_Incubation, primary chancre, glandular enlargement_;
_Extra-genital chancres_--Treatment--Secondary period: _General
symptoms, skin affections, mucous patches, affections of bones,
joints, eyes_, etc.--Treatment: _Salvarsan_--_Methods of
administering mercury_--Syphilis and marriage--Intermediate
stage--_Reminders_--Tertiary period: _General symptoms_,
_gummata_, _tertiary ulcers_, _tertiary lesions of skin, mucous
membrane, bones, joints_, etc.--Second attacks.--INHERITED
SYPHILIS--Transmission--_Clinical features in infancy, in later
life_--Contagiousness--Treatment.

Syphilis is an infective disease due to the entrance into the body of a
specific virus. It is nearly always communicated from one individual to
another by contact infection, the discharge from a syphilitic lesion
being the medium through which the virus is transmitted, and the seat of
inoculation is almost invariably a surface covered by squamous
epithelium. The disease was unknown in Europe before the year 1493, when
it was introduced into Spain by Columbus' crew, who were infected in
Haiti, where the disease had been endemic from time immemorial (Bloch).

The granulation tissue which forms as a result of the reaction of the
tissues to the presence of the virus is chiefly composed of lymphocytes
and plasma cells, along with an abundant new formation of capillary
blood vessels. Giant cells are not uncommon, but the endothelioid cells,
which are so marked a feature of tuberculous granulation tissue, are
practically absent.

When syphilis is communicated from one individual to another by contact
infection, the condition is spoken of as _acquired syphilis_, and the
first visible sign of the disease appears at the site of inoculation,
and is known as _the primary lesion_. Those who have thus acquired the
disease may transmit it to their offspring, who are then said to suffer
from _inherited syphilis_.

#The Virus of Syphilis.#--The cause of syphilis, whether acquired or
inherited, is the organism, described by Schaudinn and Hoffman, in 1905,
under the name of _spirochæta pallida_ or _spironema pallidum_. It is a
delicate, thread-like spirilla, in length averaging from 8 to 10 µ and
in width about 0.25 µ, and is distinguished from other spirochætes by
its delicate shape, its dead-white appearance, together with its closely
twisted spiral form, with numerous undulations (10 to 26), which are
perfectly regular, and are characteristic in that they remain the same
during rest and in active movement (Fig. 36). In a fresh specimen, such
as a scraping from a hard chancre suspended in a little salt solution,
it shows active movements. The organism is readily destroyed by heat,
and perishes in the absence of moisture. It has been proved
experimentally that it remains infective only up to six hours after its
removal from the body. Noguchi has succeeded in obtaining pure cultures
from the infected tissues of the rabbit.

[Illustration: FIG. 36.--Spirochæta pallida from scraping of hard
Chancre of Prepuce. × 1000 diam. Burri method.]

The spirochæte may be recognised in films made by scraping the deeper
parts of the primary lesion, from papules on the skin, or from blisters
artificially raised on lesions of the skin or on the immediately
adjacent portion of healthy skin. It is readily found in the mucous
patches and condylomata of the secondary period. It is best stained by
Giemsa's method, and its recognition is greatly aided by the use of the
ultra-microscope.

The spirochæte has been demonstrated in every form of syphilitic lesion,
and has been isolated from the blood--with difficulty--and from lymph
withdrawn by a hollow needle from enlarged lymph glands. The saliva of
persons suffering from syphilitic lesions of the mouth also contains the
organism.

[Illustration: FIG. 37.--Spirochæta refrigerans from scraping of Vagina.
× 1000 diam. Burri method.]

In tertiary lesions there is greater difficulty in demonstrating the
spirochæte, but small numbers have been found in the peripheral parts of
gummata and in the thickened patches in syphilitic disease of the aorta.
Noguchi and Moore have discovered the spirochæte in the brain in a
number of cases of general paralysis of the insane. The spirochæte may
persist in the body for a long time after infection; its presence has
been demonstrated as long as sixteen years after the original
acquisition of the disease.

In inherited syphilis the spirochæte is present in enormous numbers
throughout all the organs and fluids of the body.

Considerable interest attaches to the observations of Metchnikoff, Roux,
and Neisser, who have succeeded in conveying syphilis to the chimpanzee
and other members of the ape tribe, obtaining primary and secondary
lesions similar to those observed in man, and also containing the
spirochæte. In animals the disease has been transmitted by material from
all kinds of syphilitic lesions, including even the blood in the
secondary and tertiary stages of the disease. The primary lesion is in
the form of an indurated papule, in every respect resembling the
corresponding lesion in man, and associated with enlargement and
induration of the lymph glands. The primary lesion usually appears about
thirty days after inoculation, to be followed, in about half the cases,
by secondary manifestations, which are usually of a mild character; in
no instance has any tertiary lesion been observed. The severity of the
affection amongst apes would appear to be in proportion to the nearness
of the relationship of the animal to the human subject. The eye of the
rabbit is also susceptible to inoculation from syphilitic lesions; the
material in a finely divided state is introduced into the anterior
chamber of the eye.

Attempts to immunise against the disease have so far proved negative,
but Metchnikoff has shown that the inunction of the part inoculated with
an ointment containing 33 per cent. of calomel, within one hour of
infection, suffices to neutralise the virus in man, and up to eighteen
hours in monkeys. He recommends the adoption of this procedure in the
prophylaxis of syphilis.

Noguchi has made an emulsion of dead spirochætes which he calls
_luetin_, and which gives a specific reaction resembling that of
tuberculin in tuberculosis, a papule or a pustule forming at the site of
the intra-dermal injection. It is said to be most efficacious in the
tertiary and latent forms of syphilis, which are precisely those forms
in which the diagnosis is surrounded with difficulties.


ACQUIRED SYPHILIS

In the vast majority of cases, infection takes place during the congress
of the sexes. Delicate, easily abraded surfaces are then brought into
contact, and the discharge from lesions containing the virus is placed
under favourable conditions for conveying the disease from one person to
the other. In the male the possibility of infection taking place is
increased if the virus is retained under cover of a long and tight
prepuce, and if there are abrasions on the surface with which it comes
in contact. The frequency with which infection takes place on the
genitals during sexual intercourse warrants syphilis being considered a
venereal disease, although there are other ways in which it may be
contracted.

Some of these imply direct contact--such, for example, as kissing, the
digital examination of syphilitic patients by doctors or nurses, or
infection of the surgeon's fingers while operating upon a syphilitic
patient. In suckling, a syphilitic wet nurse may infect a healthy
infant, or a syphilitic infant may infect a healthy wet nurse. In other
cases the infection is by indirect contact, the virus being conveyed
through the medium of articles contaminated by a syphilitic
patient--such, for example, as surgical instruments, tobacco pipes, wind
instruments, table utensils, towels, or underclothing. Physiological
secretions, such as saliva, milk, or tears, are not capable of
communicating the disease unless contaminated by discharge from a
syphilitic sore. While the saliva itself is innocuous, it can be, and
often is, contaminated by the discharge from mucous patches or other
syphilitic lesions in the mouth and throat, and is then a dangerous
medium of infection. Unless these extra-genital sources of infection are
borne in mind, there is a danger of failing to recognise the primary
lesion of syphilis in unusual positions, such as the lip, finger, or
nipple. When the disease is thus acquired by innocent transfer, it is
known as _syphilis insontium_.

#Stages or Periods of Syphilis.#--Following the teaching of Ricord, it
is customary to divide the life-history of syphilis into three periods
or stages, referred to, for convenience, as primary, secondary, and
tertiary. This division is to some extent arbitrary and artificial, as
the different stages overlap one another, and the lesions of one stage
merge insensibly into those of another. Wide variations are met with in
the manifestations of the secondary stage, and histologically there is
no valid distinction to be drawn between secondary and tertiary lesions.

_The primary period_ embraces the interval that elapses between the
initial infection and the first constitutional manifestations,--roughly,
from four to eight weeks,--and includes the period of incubation, the
development of the primary sore, and the enlargement of the nearest
lymph glands.

_The secondary period_ varies in duration from one to two years, during
which time the patient is liable to suffer from manifestations which are
for the most part superficial in character, affecting the skin and its
appendages, the mucous membranes, and the lymph glands.

_The tertiary period_ has no time-limit except that it follows upon the
secondary, so that during the remainder of his life the patient is
liable to suffer from manifestations which may affect the deeper tissues
and internal organs as well as the skin and mucous membranes.

#Primary Syphilis.#--_The period of incubation_ represents the interval
that elapses between the occurrence of infection and the appearance of
the primary lesion at the site of inoculation. Its limits may be stated
as varying from two to six weeks, with an average of from twenty-one to
twenty-eight days. While the disease is incubating, there is nothing to
show that infection has occurred.

_The Primary Lesion._--The incubation period having elapsed, there
appears at the site of inoculation a circumscribed area of infiltration
which represents the reaction of the tissues to the entrance of the
virus. The first appearance is that of a sharply defined papule, rarely
larger than a split pea. Its surface is at first smooth and shiny, but
as necrosis of the tissue elements takes place in the centre, it becomes
concave, and in many cases the epithelium is shed, and an ulcer is
formed. Such an ulcer has an elevated border, sharply cut edges, an
indurated base, and exudes a scanty serous discharge; its surface is at
first occupied by yellow necrosed tissue, but in time this is replaced
by smooth, pale-pink granulation tissue; finally, epithelium may spread
over the surface, and the ulcer heals. As a rule, the patient suffers
little discomfort, and may even be ignorant of the existence of the
lesion, unless, as a result of exposure to mechanical or septic
irritation, ulceration ensues, and the sore becomes painful and tender,
and yields a purulent discharge. The primary lesion may persist until
the secondary manifestations make their appearance, that is, for several
weeks.

It cannot be emphasised too strongly that the induration of the primary
lesion, which has obtained for it the name of "hard chancre," is its
most important characteristic. It is best appreciated when the sore is
grasped from side to side between the finger and thumb. The sensation on
grasping it has been aptly compared to that imparted by a nodule of
cartilage, or by a button felt through a layer of cloth. The evidence
obtained by touch is more valuable than that obtained by inspection, a
fact which is made use of in the recognition of _concealed
chancres_--that is, those which are hidden by a tight prepuce. The
induration is due not only to the dense packing of the connective-tissue
spaces with lymphocytes and plasma cells, but also to the formation of
new connective-tissue elements. It is most marked in chancres situated
in the furrow between the glans and the prepuce.

_In the male_, the primary lesion specially affects certain
_situations_, and the appearances vary with these: (1) On the inner
aspect of the prepuce, and in the fold between the prepuce and the
glans; in the latter situation the induration imparts a "collar-like"
rigidity to the prepuce, which is most apparent when it is rolled back
over the corona. (2) At the orifice of the prepuce the primary lesion
assumes the form of multiple linear ulcers or fissures, and as each of
these is attended with infiltration, the prepuce cannot be pulled
back--a condition known as _syphilitic phimosis_. (3) On the glans penis
the infiltration may be so superficial that it resembles a layer of
parchment, but if it invades the cavernous tissue there is a dense mass
of induration. (4) On the external aspect of the prepuce or on the skin
of the penis itself. (5) At either end of the torn frænum, in the form
of a diamond-shaped ulcer raised above the surroundings. (6) In relation
to the meatus and canal of the urethra, in either of which situations
the swelling and induration may lead to narrowing of the urethra, so
that the urine is passed with pain and difficulty and in a minute
stream; stricture results only in the exceptional cases in which the
chancre has ulcerated and caused destruction of tissue. A chancre within
the orifice of the urethra is rare, and, being concealed from view, it
can only be recognised by the discharge from the meatus and by the
induration felt between the finger and thumb on palpating the urethra.

_In the female_, the primary lesion is not so typical or so easily
recognised as in men; it is usually met with on the labia; the
induration is rarely characteristic and does not last so long. The
primary lesion may take the form of condylomata. Indurated oedema, with
brownish-red or livid discoloration of one or both labia, is diagnostic
of syphilis.

The hard chancre is usually solitary, but sometimes there are two or
more; when there are several, they are individually smaller than the
solitary chancre.

It is the exception for a hard chancre to leave a visible scar, hence,
in examining patients with a doubtful history of syphilis, little
reliance can be placed on the presence or absence of a scar on the
genitals. When the primary lesion has taken the form of an open ulcer
with purulent discharge, or has sloughed, there is a permanent scar.

_Infection of the adjacent lymph glands_ is usually found to have taken
place by the time the primary lesion has acquired its characteristic
induration. Several of the glands along Poupart's ligament, on one or on
both sides, become enlarged, rounded, and indurated; they are usually
freely movable, and are rarely sensitive unless there is superadded
septic infection. The term _bullet-bubo_ has been applied to them, and
their presence is of great value in diagnosis. In a certain number of
cases, one of the main _lymph vessels_ on the dorsum of the penis is
transformed into a fibrous cord easily recognisable on palpation, and
when grasped between the fingers appears to be in size and consistence
not unlike the vas deferens.

_Concealed chancre_ is the term applied when one or more chancres are
situated within the sac of a prepuce which cannot be retracted. If the
induration is well marked, the chancre can be palpated through the
prepuce, and is tender on pressure. As under these conditions it is
impossible for the patient to keep the parts clean, septic infection
becomes a prominent feature, the prepuce is oedematous and inflamed, and
there is an abundant discharge of pus from its orifice. It occasionally
happens that the infection assumes a virulent character and causes
sloughing of the prepuce--a condition known as _phagedæna_. The
discharge is then foul and blood-stained, and the prepuce becomes of a
dusky red or purple colour, and may finally slough, exposing the glans.

_Extra-genital or Erratic Chancres_ (Fig. 38).--Erratic chancre is the
term applied by Jonathan Hutchinson to the primary lesion of syphilis
when it appears on parts of the body other than the genitals. It differs
in some respects from the hard chancre as met with on the penis; it is
usually larger, the induration is more diffused, and the enlarged glands
are softer and more sensitive. The glands in nearest relation to the
sore are those first affected, for example, the epitrochlear or axillary
glands in chancre of the finger; the submaxillary glands in chancre of
the lip or mouth; or the pre-auricular gland in chancre of the eyelid or
forehead. In consequence of their divergence from the typical chancre,
and of their being often met with in persons who, from age,
surroundings, or moral character, are unlikely subjects of venereal
disease, the true nature of erratic chancres is often overlooked until
the persistence of the lesion, its want of resemblance to anything else,
or the onset of constitutional symptoms, determines the diagnosis of
syphilis. A solitary, indolent sore occurring on the lip, eyelid,
finger, or nipple, which does not heal but tends to increase in size,
and is associated with induration and enlargement of the adjacent
glands, is most likely to be the primary lesion of syphilis.

[Illustration: FIG. 38.--Primary Lesion on Thumb, with Secondary
Eruption on Forearm.[1]]

[1] From _A System of Syphilis_, vol. ii., edited by D'Arcy Power and
J. Keogh Murphy, Oxford Medical Publications.

#The Soft Sore, Soft Chancre, or Chancroid.#--The differential diagnosis
of syphilis necessitates the consideration of the _soft sore_, _soft
chancre_, or _chancroid_, which is also a common form of venereal
disease, and is due to infection with a virulent pus-forming bacillus,
first described by Ducrey in 1889. Ducrey's bacillus occurs in the form
of minute oval rods measuring about 1.5 µ in length, which stain readily
with any basic aniline dye, but are quickly decolorised by Gram's
method. They are found mixed with other organisms in the purulent
discharge from the sore, and are chiefly arranged in small groups or in
short chains. Soft sores are always contracted by direct contact from
another individual, and the incubation period is a short one of from two
to five days. They are usually situated in the vicinity of the frænum,
and, in women, about the labia minora or fourchette; they probably
originate in abrasions in these situations. They appear as pustules,
which are rapidly converted into small, acutely inflamed ulcers with
sharply cut, irregular margins, which bleed easily and yield an abundant
yellow purulent discharge. They are devoid of the induration of
syphilis, are painful, and nearly always multiple, reproducing
themselves in successive crops by auto-inoculation. Soft sores are often
complicated by phimosis and balanitis, and they frequently lead to
infection of the glands in the groin. The resulting bubo is ill-defined,
painful, and tender, and suppuration occurs in about one-fourth of the
cases. The overlying skin becomes adherent and red, and suppuration
takes place either in the form of separate foci in the interior of the
individual glands, or around them; in the latter case, on incision, the
glands are found lying bathed in pus. Ducrey's bacillus is found in pure
culture in the pus. Sometimes other pyogenic organisms are superadded.
After the bubo has been opened the wound may take on the characters of a
soft sore.

_Treatment._--Soft sores heal rapidly when kept clean. If concealed
under a tight prepuce, an incision should be made along the dorsum to
give access to the sores. They should be washed with eusol, and dusted
with a mixture of one part iodoform and two parts boracic or salicylic
acid, or, when the odour of iodoform is objected to, of equal parts of
boracic acid and carbonate of zinc. Immersion of the penis in a bath of
eusol for some hours daily is useful. The sore is then covered with a
piece of gauze kept in position by drawing the prepuce over it, or by a
few turns of a narrow bandage. Sublimed sulphur frequently rubbed into
the sore is recommended by C. H. Mills. If the sores spread in spite of
this, they should be painted with cocaine and then cauterised. When the
glands in the groin are infected, the patient must be confined to bed,
and a dressing impregnated with ichthyol and glycerin (10 per cent.)
applied; the repeated use of a suction bell is of great service.
Harrison recommends aspiration of a bubonic abscess, followed by
injection of 1 in 20 solution of tincture of iodine into the cavity;
this is in turn aspirated, and then 1 or 2 c.c. of the solution injected
and left in. This is repeated as often as the cavity refills. It is
sometimes necessary to let the pus out by one or more small incisions
and continue the use of the suction bell.

_Diagnosis of Primary Syphilis._--In cases in which there is a history
of an incubation period of from three to five weeks, when the sore is
indurated, persistent, and indolent, and attended with bullet-buboes in
the groin, the diagnosis of primary syphilis is not difficult. Owing,
however, to the great importance of instituting treatment at the
earliest possible stage of the infection, an effort should be made to
establish the diagnosis without delay by demonstrating the spirochæte.
Before any antiseptic is applied, the margin of the suspected sore is
rubbed with gauze, and the serum that exudes on pressure is collected
in a capillary tube and sent to a pathologist for microscopical
examination. A better specimen can sometimes be obtained by puncturing
an enlarged lymph gland with a hypodermic needle, injecting a few minims
of sterile saline solution and then aspirating the blood-stained fluid.

The Wassermann test must not be relied upon for diagnosis in the early
stage, as it does not appear until the disease has become generalised
and the secondary manifestations are about to begin. The practice of
waiting in doubtful cases before making a diagnosis until secondary
manifestations appear is to be condemned.

Extra-genital chancres, _e.g._ sores on the fingers of doctors or
nurses, are specially liable to be overlooked, if the possibility of
syphilis is not kept in mind.

It is important to bear in mind _the possibility of a patient having
acquired a mixed infection_ with the virus of soft chancre, which will
manifest itself a few days after infection, and the virus of syphilis,
which shows itself after an interval of several weeks. This occurrence
was formerly the source of much confusion in diagnosis, and it was
believed at one time that syphilis might result from soft sores, but it
is now established that syphilis does not follow upon soft sores unless
the virus of syphilis has been introduced at the same time. The
practitioner must be on his guard, therefore, when a patient asks his
advice concerning a venereal sore which has appeared within a few days
of exposure to infection. Such a patient is naturally anxious to know
whether he has contracted syphilis or not, but neither a positive nor a
negative answer can be given--unless the spirochæte can be identified.

Syphilis is also to be diagnosed from _epithelioma_, the common form of
cancer of the penis. It is especially in elderly patients with a tight
prepuce that the induration of syphilis is liable to be mistaken for
that associated with epithelioma. In difficult cases the prepuce must be
slit open.

Difficulty may occur in the diagnosis of primary syphilis from _herpes_,
as this may appear as late as ten days after connection; it commences as
a group of vesicles which soon burst and leave shallow ulcers with a
yellow floor; these disappear quickly on the use of an antiseptic
dusting powder.

Apprehensive patients who have committed sexual indiscretions are apt to
regard as syphilitic any lesion which happens to be located on the
penis--for example, acne pustules, eczema, psoriasis papules, boils,
balanitis, or venereal warts.

_The local treatment_ of the primary sore consists in attempting to
destroy the organisms _in situ_. An ointment made up of calomel 33
parts, lanoline 67 parts, and vaseline 10 parts (Metchnikoff's cream) is
rubbed into the sore several times a day. If the surface is unbroken, it
may be dusted lightly with a powder composed of equal parts of calomel
and carbonate of zinc. A gauze dressing is applied, and the penis and
scrotum should be supported against the abdominal wall by a triangular
handkerchief or bathing-drawers; if there is inflammatory oedema the
patient should be confined to bed.

In _concealed chancres_ with phimosis, the sac of the prepuce should be
slit up along the dorsum to admit of the ointment being applied. If
phagedæna occurs, the prepuce must be slit open along the dorsum, or if
sloughing, cut away, and the patient should have frequent sitz baths of
weak sublimate lotion. When the chancre is within the meatus, iodoform
bougies are inserted into the urethra, and the urine should be rendered
bland by drinking large quantities of fluid.

General treatment is considered on p. 149.

#Secondary Syphilis.#--The following description of secondary syphilis
is based on the average course of the disease in untreated cases. The
onset of constitutional symptoms occurs from six to twelve weeks after
infection, and the manifestations are the result of the entrance of the
virus into the general circulation, and its being carried to all parts
of the body. The period during which the patient is liable to suffer
from secondary symptoms ranges from six months to two years.

In some cases the general health is not disturbed; in others the patient
is feverish and out of sorts, losing appetite, becoming pale and anæmic,
complaining of lassitude, incapacity for exertion, headache, and pains
of a rheumatic type referred to the bones. There is a moderate degree of
leucocytosis, but the increase is due not to the polymorpho-nuclear
leucocytes but to lymphocytes. In isolated cases the temperature rises
to 101° or 102° F. and the patient loses flesh. The lymph glands,
particularly those along the posterior border of the sterno-mastoid,
become enlarged and slightly tender. The hair comes out, eruptions
appear on the skin and mucous membranes, and the patient may suffer from
sore throat and affections of the eyes. The local lesions are to be
regarded as being of the nature of reactions against accumulations of
the parasite, lymphocytes and plasma cells being the elements chiefly
concerned in the reactive process.

_Affections of the Skin_ are among the most constant manifestations. An
evanescent macular rash, not unlike that of measles--_roseola_--is the
first to appear, usually in from six to eight weeks from the date of
infection; it is widely diffused over the trunk, and the original dull
rose-colour soon fades, leaving brownish stains, which in time
disappear. It is usually followed by a _papular eruption_, the
individual papules being raised above the surface of the skin, smooth or
scaly, and as they are due to infiltration of the skin they are more
persistent than the roseoles. They vary in size and distribution, being
sometimes small, hard, polished, and closely aggregated like lichen,
sometimes as large as a shilling-piece, with an accumulation of scales
on the surface like that seen in psoriasis. The co-existence of scaly
papules and faded roseoles is very suggestive of syphilis.

Other types of eruption are less common, and are met with from the third
month onwards. A _pustular_ eruption, not unlike that of acne, is
sometimes a prominent feature, but is not characteristic of syphilis
unless it affects the scalp and forehead and is associated with the
remains of the papular eruption. The term _ecthyma_ is applied when the
pustules are of large size, and, after breaking on the surface, give
rise to superficial ulcers; the discharge from the ulcer often dries up
and forms a scab or crust which is continually added to from below as
the ulcer extends in area and depth. The term _rupia_ is applied when
the crusts are prominent, dark in colour, and conical in shape, roughly
resembling the shell of a limpet. If the crust is detached, a sharply
defined ulcer is exposed, and when this heals it leaves a scar which is
usually circular, thin, white, shining like satin, and the surrounding
skin is darkly pigmented; in the case of deep ulcers, the scar is
depressed and adherent (Fig. 39).

[Illustration: FIG. 39.--Syphilitic Rupia, showing the limpet-shaped
crusts or scabs.]

In the later stages there may occur a form of creeping or _spreading
ulceration of the skin_ of the face, groin, or scrotum, healing at one
edge and spreading at another like tuberculous lupus, but distinguished
from this by its more rapid progress and by the pigmentation of the
scar.

_Condylomata_ are more characteristic of syphilis than any other type of
skin lesion. They are papules occurring on those parts of the body where
the skin is habitually moist, and especially where two skin surfaces are
in contact. They are chiefly met with on the external genitals,
especially in women, around the anus, beneath large pendulous mammæ,
between the toes, and at the angles of the mouth, and in these
situations their development is greatly favoured by neglect of
cleanliness. They present the appearance of well-defined circular or
ovoid areas in which the skin is thickened and raised above the surface;
they are covered with a white sodden epidermis, and furnish a scanty but
very infective discharge. Under the influence of irritation and want of
rest, as at the anus or at the angle of the mouth, they are apt to
become fissured and superficially ulcerated, and the discharge then
becomes abundant and may crust on the surface, forming yellow scabs. At
the angle of the mouth the condylomatous patches may spread to the
cheek, and when they ulcerate may leave fissure-like scars radiating
from the mouth--an appearance best seen in inherited syphilis (Fig. 44).

_The Appendages of the Skin._--The _hair_ loses its gloss, becomes dry
and brittle, and readily falls out, either as an exaggeration of the
normal shedding of the hair, or in scattered areas over the scalp
(_syphilitic alopoecia_). The hair is not re-formed in the scars which
result from ulcerated lesions of the scalp. The _nail-folds_
occasionally present a pustular eruption and superficial ulceration, to
which the name _syphilitic onychia_ has been applied; more commonly the
nails become brittle and ragged, and they may even be shed.

_The Mucous Membranes_, and especially those of the _mouth_ and
_throat_, suffer from lesions similar to those met with on the skin. On
a mucous surface the papular eruption assumes the form of _mucous
patches_, which are areas with a congested base covered with a thin
white film of sodden epithelium like wet tissue-paper. They are best
seen on the inner aspect of the cheeks, the soft palate, uvula, pillars
of the fauces, and tonsils. In addition to mucous patches, there may be
a number of small, _superficial, kidney-shaped ulcers_, especially along
the margins of the tongue and on the tonsils. In the absence of mucous
patches and ulcers, the sore throat may be characterised by a bluish
tinge of the inflamed mucous membrane and a thin film of shed epithelium
on the surface. Sometimes there is an elongated sinuous film which has
been likened to the track of a snail. In the _larynx_ the presence of
congestion, oedema, and mucous patches may be the cause of persistent
hoarseness. The _tongue_ often presents a combination of lesions,
including ulcers, patches where the papillæ are absent, fissures, and
raised white papules resembling warts, especially towards the centre of
the dorsum. These lesions are specially apt to occur in those who smoke,
drink undiluted alcohol or spirits, or eat hot condiments to excess, or
who have irregular, sharp-cornered teeth. At a later period, and in
those who are broken down in health from intemperance or other cause,
the sore throat may take the form of rapidly spreading, penetrating
ulcers in the soft palate and pillars of the fauces, which may lead to
extensive destruction of tissue, with subsequent scars and deformity
highly characteristic of previous syphilis.

In the _Bones_, lesions occur which assume the clinical features of an
evanescent periostitis, the patient complaining of nocturnal pains over
the frontal bone, sternum, tibiæ, and ulnæ, and localised tenderness on
tapping over these bones.

In the _Joints_, a serous synovitis or hydrops may occur, chiefly in the
knee, on one or on both sides.

_The Affections of the Eyes_, although fortunately rare, are of great
importance because of the serious results which may follow if they are
not recognised and treated. _Iritis_ is the commonest of these, and may
occur in one or in both eyes, one after the other, from three to eight
months after infection. The patient complains of impairment of sight and
of frontal or supraorbital pain. The eye waters and is hypersensitive,
the iris is discoloured and reacts sluggishly to light, and there is a
zone of ciliary congestion around the cornea. The appearance of minute
white nodules or flakes of lymph at the margin of the pupil is
especially characteristic of syphilitic iritis. When adhesions have
formed between the iris and the structures in relation to it, the pupil
dilates irregularly under atropin. Although complete recovery is to be
expected under early and energetic treatment, if neglected, _iritis_ may
result in occlusion of the pupil and permanent impairment or loss of
sight.

The other lesions of the eye are much rarer, and can only be discovered
on ophthalmoscopic examination.

The virus of syphilis exerts a special influence upon the _Blood
Vessels_, exciting a proliferation of the endothelial lining which
results in narrowing of their lumen, _endarteritis_, and a perivascular
infiltration in the form of accumulations of plasma cells around the
vessels and in the lymphatics that accompany them.

In the _Brain_, in the later periods of secondary and in tertiary
syphilis, changes occur as a result of the narrowing of the lumen of the
arteries, or of their complete obliteration by thrombosis. By
interfering with the nutrition of those parts of the brain supplied by
the affected arteries, these lesions give rise to clinical features of
which severe headache and paralysis are the most prominent.

Affections of the _Spinal Cord_ are extremely rare, but paraplegia from
myelitis has been observed.

Lastly, attention must be directed to the remarkable variations observed
in different patients. Sometimes the virulent character of the disease
can only be accounted for by an idiosyncrasy of the patient.
Constitutional symptoms, particularly pyrexia and anæmia, are most often
met with in young women. Patients over forty years of age have greater
difficulty in overcoming the infection than younger adults. Malarial and
other infections, and the conditions attending life in tropical
countries, from the debility which they cause, tend to aggravate and
prolong the disease, which then assumes the characters of what has been
called _malignant syphilis_. All chronic ailments have a similar
influence, and alcoholic intemperance is universally regarded as a
serious aggravating factor.

_Diagnosis of Secondary Syphilis._--A routine examination should be made
of the parts of the body which are most often affected in this
disease--the scalp, mouth, throat, posterior cervical glands, and the
trunk, the patient being stripped and examined by daylight. Among the
_diagnostic features of the skin affections_ the following may be
mentioned: They are frequently, and sometimes to a marked degree,
symmetrical; more than one type of eruption--papules and pustules, for
example--are present at the same time; there is little itching; they are
at first a dull-red colour, but later present a brown pigmentation which
has been likened to the colour of raw ham; they exhibit a predilection
for those parts of the forehead and neck which are close to the roots of
the hair; they tend to pass off spontaneously; and they disappear
rapidly under treatment.

#Serum Diagnosis--Wassermann Reaction.#--Wassermann found that if an
extract of syphilitic liver rich in spirochætes is mixed with the serum
from a syphilitic patient, a large amount of complement is fixed. The
application of the test is highly complicated and can only be carried
out by an expert pathologist. For the purpose he is supplied with from 5
c.c. to 10 c.c. of the patient's blood, withdrawn under aseptic
conditions from the median basilic vein by means of a serum syringe, and
transferred to a clean and dry glass tube. There is abundant evidence
that the Wassermann test is a reliable means of establishing a diagnosis
of syphilis.

A definitely positive reaction can usually be obtained between the
fifteenth and thirtieth day after the appearance of the primary lesion,
and as time goes on it becomes more marked. During the secondary period
the reaction is practically always positive. In the tertiary stage also
it is positive except in so far as it is modified by the results of
treatment. In para-syphilitic lesions such as general paralysis and
tabes a positive reaction is almost always present. In inherited
syphilis the reaction is positive in every case. A positive reaction may
be present in other diseases, for example, frambesia, trypanosomiasis,
and leprosy.

As the presence of the reaction is an evidence of the activity of the
spirochætes, repeated applications of the test furnish a valuable means
of estimating the efficacy of treatment. The object aimed at is to
change a persistently positive reaction to a permanently negative one.

#Treatment of Syphilis.#--In the treatment of syphilis the two main
objects are to maintain the general health at the highest possible
standard, and to introduce into the system therapeutic agents which will
inhibit or destroy the invading parasite.

The second of these objects has been achieved by the researches of
Ehrlich, who, in conjunction with his pupil, Hata, has built up a
compound, the dihydrochloride of dioxydiamido-arseno-benzol, popularly
known as salvarsan or "606." Other preparations, such as kharsivan,
arseno-billon, and diarsenol, are chemically equivalent to salvarsan,
containing from 27 to 31 per cent. of arsenic, and are equally
efficient. The full dose is 0.6 grm. All these members of the "606"
group form an acid solution when dissolved in water, and must be
rendered alkaline before being injected. As subcutaneous and
intra-muscular injections cause considerable pain, and may cause
sloughing of the tissues, "606" preparations must be injected
intravenously. Ehrlich has devised a preparation--neo-salvarsan, or
"914," which is more easily prepared and forms a neutral solution. It
contains from 18 to 20 per cent. of arsenic. Neo-kharsivan,
novo-arseno-billon, and neo-diarsenol belong to the "914" group, the
full dosage of which is 0.9 grm. As subcutaneous and intra-muscular
injections of the "914" group are not painful, and even more efficient
than intravenous injections, the administration is simpler.

Galyl, luargol, and other preparations act in the same way as the "606"
and "914" groups.

The "606" preparations may be introduced into the veins by injection or
by means of an apparatus which allows the solution to flow in by
gravity. The left median basilic vein is selected, and a platino-iridium
needle with a short point and a bore larger than that of the ordinary
hypodermic syringe is used. The needle is passed for a few millimetres
along the vein, and the solution is then slowly introduced; before
withdrawing the needle some saline is run in to diminish the risk of
thrombosis.

The "914" preparations may be injected either into the subcutaneous
tissue of the buttock or into the substance of the gluteus muscle. The
part is then massaged for a few minutes, and the massage is repeated
daily for a few days.

No hard-and-fast rules can be laid down as to what constitutes a
complete course of treatment. Harrison recommends as a _minimum_ course
of one of the "914" preparations in _early primary cases_ an initial
dose of 0.45 grm. given intra-muscularly or into the deep subcutaneous
tissue; the same dose a week later; 0.6 grm. the following week; then
miss a week and give 9.6 grms. on two successive weeks; then miss two
weeks and give 0.6 grm. on two more successive weeks.

When a _positive Wassermann reaction_ is present before treatment is
commenced, the above course is prolonged as follows: for three weeks is
given a course of potassium iodide, after which four more weekly
injections of 0.6 grm. of "914" are given.

With each injection of "914" after the first, throughout the whole
course 1 grain of mercury is injected intra-muscularly.

In the course of a few hours, there is usually some indisposition, with
a feeling of chilliness and slight rise of temperature; these symptoms
pass off within twenty-four hours, and in a few days there is a decided
improvement of health. Three or four days after an intra-muscular
injection there may be pain and stiffness in the gluteal region.

These preparations are the most efficient therapeutic agents that have
yet been employed in the treatment of syphilis.

The manifestations of the disease disappear with remarkable rapidity.
Observations show that the spirochætes lose their capacity for movement
within an hour or two of the administration, and usually disappear
altogether in from twenty-four to thirty-six hours. Wassermann's
reaction usually yields a negative result in from three weeks to two
months, but later may again become positive. Subsequent doses of the
arsenical preparation are therefore usually indicated, and should be
given in from 7 to 21 days according to the dose.

When syphilis occurs in a _pregnant woman_, she should be given in the
early months an ordinary course of "914," followed by 10-grain doses of
potassium iodide twice daily. The injections may be repeated two months
later, and during the remainder of the pregnancy 2-grain mercury pills
are given twice daily (A. Campbell). The presence of albumen in the
urine contra-indicates arsenical treatment.

It need scarcely be pointed out that the use of powerful drugs like
"606" and "914" is not free from risk; it may be mentioned that each
dose contains nearly three grains of arsenic. Before the administration
the patient must be overhauled; its administration is contra-indicated
in the presence of disease of the heart and blood vessels, especially a
combination of syphilitic aortitis and sclerosis of the coronary
arteries, with degeneration of the heart muscle; in affections of the
central nervous system, especially advanced paralysis, and in such
disturbances of metabolism as are associated with diabetes and Bright's
disease. Its use is not contra-indicated in any lesion of active
syphilis.

The administration is controlled by the systematic examination of the
urine for arsenic.

_The Administration of Mercury._--The success of the arsenical
preparations has diminished the importance of mercury in the treatment
of syphilis, but it is still used to supplement the effect of the
injections. The amount of mercury to be given in any case must be
proportioned to the idiosyncrasies of the patient, and it is advisable,
before commencing the treatment, to test his urine and record his
body-weight. The small amount of mercury given at the outset is
gradually increased. If the body-weight falls, or if the gums become
sore and the breath foul, the mercury should be stopped for a time. If
salivation occurs, the drinking of hot water and the taking of hot baths
should be insisted upon, and half-dram doses of the alkaline sulphates
prescribed.

_Methods of Administering Mercury._--(1) _By the Mouth._--This was for
long the most popular method in this country, the preparation usually
employed being grey powder, in pills or tablets, each of which contains
one grain of the powder. Three of these are given daily in the first
instance, and the daily dose is increased to five or even seven grains
till the standard for the individual patient is arrived at. As the grey
powder alone sometimes causes irritation of the bowels, it should be
combined with iron, as in the following formula: Hydrarg. c. cret. gr. 1;
ferri sulph. exsiccat. gr. 1 or 2.

(2) _By Inunction._--Inunction consists in rubbing into the pores of the
skin an ointment composed of equal parts of 20 per cent. oleate of
mercury and lanolin. Every night after a hot bath, a dram of the
ointment (made up by the chemist in paper packets) is rubbed for fifteen
minutes into the skin where it is soft and comparatively free from
hairs. When the patient has been brought under the influence of the
mercury, inunction may be replaced by one of the other methods, of
administering the drug.

(3) _By Intra-muscular Injection._--This consists in introducing the
drug by means of a hypodermic syringe into the substance of the gluteal
muscles. The syringe is made of glass, and has a solid glass piston; the
needle of platino-iridium should be 5 cm. long and of a larger calibre
than the ordinary hypodermic needle. The preparation usually employed
consists of: metallic mercury or calomel 1 dram, lanolin and olive oil
each 2 drams; it must be warmed to allow of its passage through the
needle. Five minims--containing one grain of metallic mercury--represent
a dose, and this is injected into the muscles above and behind the great
trochanter once a week. The contents of the syringe are slowly
expressed, and, after withdrawing the needle, gentle massage of the
buttock should be employed. Four courses each of ten injections are
given the first year, three courses of the same number during the second
and third years, and two courses during the fourth year (Lambkin).

_The General Health._--The patient must lead a regular life and
cultivate the fresh-air habit, which is as beneficial in syphilis as in
tuberculosis. Anæmia, malaria, and other sources of debility must
receive appropriate treatment. The diet should be simple and easily
digested, and should include a full supply of milk. Alcohol is
prohibited. The excretory organs are encouraged to act by the liberal
drinking of hot water between meals, say five or six tumblerfuls in the
twenty-four hours. The functions of the skin are further aided by
frequent hot baths, and by the wearing of warm underclothing. While the
patient should avoid exposure to cold, and taxing his energies by undue
exertion, he should be advised to take exercise in the open air. On
account of the liability to lesions of the mouth and throat, he should
use tobacco in moderation, his teeth should be thoroughly overhauled by
the dentist, and he should brush them after every meal, using an
antiseptic tooth powder or wash. The mouth and throat should be rinsed
out night and morning with a solution of chlorate of potash and alum, or
with peroxide of hydrogen.

_Treatment of the Local Manifestations._--_The skin lesions_ are treated
on the same lines as similar eruptions of other origin. As local
applications, preparations of mercury are usually selected, notably the
ointments of the red oxide of mercury, ammoniated mercury, or oleate of
mercury (5 per cent.), or the mercurial plaster introduced by Unna. In
the treatment of condylomata the greatest attention must be paid to
cleanliness and dryness. After washing and drying the affected patches,
they are dusted with a powder consisting of equal parts of calomel and
carbonate of zinc; and apposed skin surfaces, such as the nates or
labia, are separated by sublimate wool. In the ulcers of later secondary
syphilis, crusts are got rid of in the first instance by means of a
boracic poultice, after which a piece of lint or gauze cut to the size
of the ulcer and soaked in black wash is applied and covered with
oil-silk. If the ulcer tends to spread in area or in depth, it should be
scraped with a sharp spoon, and painted over with acid nitrate of
mercury, or a local hyperæmia may be induced by Klapp's suction
apparatus.

_In lesions of the mouth and throat_, the teeth should be attended to;
the best local application is a solution of chromic acid--10 grains to
the ounce--painted on with a brush once daily. If this fails, the
lesions may be dusted with calomel the last thing at night. For deep
ulcers of the throat the patient should gargle frequently with chlorine
water or with perchloride of mercury (1 in 2000); if the ulcer continues
to spread it should be painted with acid nitrate of mercury.

In the treatment of _iritis_ the eyes are shaded from the light and
completely rested, and the pupil is well dilated by atropin to prevent
adhesions. If there is much pain, a blister may be applied to the
temple.

_The Relations of Syphilis to Marriage._--Before the introduction of the
Ehrlich-Hata treatment no patient was allowed to marry until three years
had elapsed after the disappearance of the last manifestation. While
marriage might be entered upon under these conditions without risk of
the husband infecting the wife, the possibility of his conveying the
disease to the offspring cannot be absolutely excluded. It is
recommended, as a precautionary measure, to give a further mercurial
course of two or three months' duration before marriage, and an
intravenous injection of an arsenical preparation.

#Intermediate Stage.#--After the dying away of the secondary
manifestations and before the appearance of tertiary lesions, the
patient may present certain symptoms which Hutchinson called
_reminders_. These usually consist of relapses of certain of the
affections of the skin, mouth, or throat, already described. In the
skin, they may assume the form of peeling patches in the palms, or may
appear as spreading and confluent circles of a scaly papular eruption,
which if neglected may lead to the formation of fissures and superficial
ulcers. Less frequently there is a relapse of the eye affections, or of
paralytic symptoms from disease of the cerebral arteries.

#Tertiary Syphilis.#--While the manifestations of primary and secondary
syphilis are common, those of the tertiary period are by comparison
rare, and are observed chiefly in those who have either neglected
treatment or who have had their powers of resistance lowered by
privation, by alcoholic indulgence, or by tropical disease.

It is to be borne in mind that in a certain proportion of men and in a
larger proportion of women, the patient has no knowledge of having
suffered from syphilis. Certain slight but important signs may give the
clue in a number of cases, such as irregularity of the pupils or failure
to react to light, abnormality of the reflexes, and the discovery of
patches of leucoplakia on the tongue, cheek, or palate.

The _general character of tertiary manifestations_ may be stated as
follows: They attack by preference the tissues derived from the
mesoblastic layer of the embryo--the cellular tissue, bones, muscles,
and viscera. They are often localised to one particular tissue or organ,
such, for example, as the subcutaneous cellular tissue, the bones, or
the liver, and they are rarely symmetrical. They are usually aggressive
and persistent, with little tendency to natural cure, and they may be
dangerous to life, because of the destructive changes produced in such
organs as the brain or the larynx. They are remarkably amenable to
treatment if instituted before the stage which is attended with
destruction of tissue is reached. Early tertiary lesions may be
infective, and the disease may be transmitted by the discharges from
them; but the later the lesions the less is the risk of their containing
an infective virus.

The most prominent feature of tertiary syphilis consists in the
formation of granulation tissue, and this takes place on a scale
considerably larger than that observed in lesions of the secondary
period. The granulation tissue frequently forms a definite swelling or
tumour-like mass (syphiloma), which, from its peculiar elastic
consistence, is known as a _gumma_. In its early stages a gumma is a
firm, semi-translucent greyish or greyish-red mass of tissue; later it
becomes opaque, yellow, and caseous, with a tendency to soften and
liquefy. The gumma does harm by displacing and replacing the normal
tissue elements of the part affected, and by involving these in the
degenerative changes, of the nature of caseation and necrosis, which
produce the destructive lesions of the skin, mucous membranes, and
internal organs. This is true not only of the circumscribed gumma, but
of the condition known as _gummatous infiltration_ or _syphilitic
cirrhosis_, in which the granulation tissue is diffused throughout the
connective-tissue framework of such organs as the tongue or liver. Both
the gummatous lesions and the fibrosis of tertiary syphilis are directly
excited by the spirochætes.

The life-history of an untreated gumma varies with its environment. When
protected from injury and irritation in the substance of an internal
organ such as the liver, it may become encapsulated by fibrous tissue,
and persist in this condition for an indefinite period, or it may be
absorbed and leave in its place a fibrous cicatrix. In the interior of a
long bone it may replace the rigid framework of the shaft to such an
extent as to lead to pathological fracture. If it is near the surface of
the body--as, for example, in the subcutaneous or submucous cellular
tissue, or in the periosteum of a superficial bone, such as the palate,
the skull, or the tibia--the tissue of which it is composed is apt to
undergo necrosis, in which the overlying skin or mucous membrane
frequently participates, the result being an ulcer--the tertiary
syphilitic ulcer (Figs. 40 and 41).

_Tertiary Lesions of the Skin and Subcutaneous Cellular Tissue._--The
clinical features of a _subcutaneous gumma_ are those of an indolent,
painless, elastic swelling, varying in size from a pea to an almond or
walnut. After a variable period it usually softens in the centre, the
skin over it becomes livid and dusky, and finally separates as a slough,
exposing the tissue of the gumma, which sometimes appears as a mucoid,
yellowish, honey-like substance, more frequently as a sodden, caseated
tissue resembling wash-leather. The caseated tissue of a gumma differs
from that of a tuberculous lesion in being tough and firm, of a buff
colour like wash-leather, or whitish, like boiled fish. The degenerated
tissue separates slowly and gradually, and in untreated cases may be
visible for weeks in the floor of the ulcer.

[Illustration: FIG. 40.--Ulcerating Gumma of Lips.

(From a photograph lent by Dr. Stopford Taylor and Dr. R. W. Mackenna.)]

_The tertiary ulcer_ may be situated anywhere, but is most frequently
met with on the leg, especially in the region of the knee (Fig. 42) and
over the calf. There may be one or more ulcers, and also scars of
antecedent ulcers. The edges are sharply cut, as if punched out; the
margins are rounded in outline, firm, and congested; the base is
occupied by gummatous tissue, or, if this has already separated and
sloughed out, by unhealthy granulations and a thick purulent discharge.
When the ulcer has healed it leaves a scar which is depressed, and if
over a bone, is adherent to it. The features of the tertiary ulcer,
however, are not always so characteristic as the above description would
imply. It is to be diagnosed from the "leg ulcer," which occurs almost
exclusively on the lower third of the leg; from Bazin's disease (p. 74);
from the ulcers that result from certain forms of malignant disease,
such as rodent cancer, and from those met with in chronic glanders.

_Gummatous Infiltration of the Skin_ ("Syphilitic Lupus").--This is a
lesion, met with chiefly on the face and in the region of the external
genitals, in which the skin becomes infiltrated with granulation tissue
so that it is thickened, raised above the surface, and of a brownish-red
colour. It appears as isolated nodules, which may fuse together; the
epidermis becomes scaly and is shed, giving rise to superficial ulcers
which are usually covered by crusted discharge. The disease tends to
spread, creeping over the skin with a serpiginous, crescentic, or
horse-shoe margin, while the central portion may heal and leave a scar.
From the fact of its healing in the centre while it spreads at the
margin, it may resemble tuberculous disease of the skin. It can usually
be differentiated by observing that the infiltration is on a larger
scale; the progress is much more rapid, involving in the course of
months an area which in the case of tuberculosis would require as many
years; the scars are sounder and are less liable to break down again;
and the disease rapidly yields to anti-syphilitic treatment.

[Illustration: FIG. 41.--Ulceration of nineteen year's duration
in a woman æt. 24, the subject of inherited syphilis, showing active
ulceration, cicatricial contraction, and sabre-blade deformity of
tibiæ.]

_Tertiary lesions of mucous membrane and of the submucous cellular
tissue_ are met with chiefly in the tongue, nose, throat, larynx, and
rectum. They originate as gummata or as gummatous infiltrations, which
are liable to break down and lead to the formation of ulcers which may
prove locally destructive, and, in such situations as the larynx, even
dangerous to life. In the tongue the tertiary ulcer may prove the
starting-point of cancer; and in the larynx or rectum the healing of the
ulcer may lead to cicatricial stenosis.

Tertiary lesions of the _bones and joints_, of the _muscles_, and of the
_internal organs_, will be described under these heads. The part played
by syphilis in the production of disease of arteries and of aneurysm
will be referred to along with diseases of blood vessels.

[Illustration: FIG. 42.--Tertiary Syphilitic Ulceration in region of
Knee and on both Thumbs of woman æt. 37.]

_Treatment._--The most valuable drugs for the treatment of the
manifestations of the tertiary period are the arsenical preparations and
the iodides of sodium and potassium. On account of their depressing
effects, the latter are frequently prescribed along with carbonate of
ammonium. The dose is usually a matter of experiment in each individual
case; 5 grains three times a day may suffice, or it may be necessary to
increase each dose to 20 or 25 grains. The symptoms of iodism which may
follow from the smaller doses usually disappear on giving a larger
amount of the drug. It should be taken after meals, with abundant water
or other fluid, especially if given in tablet form. It is advisable to
continue the iodides for from one to three months after the lesions for
which they are given have cleared up. If the potassium salt is not
tolerated, it may be replaced by the ammonium or sodium iodide.

_Local Treatment._--The absorption of a subcutaneous gumma is often
hastened by the application of a fly-blister. When a gumma has broken on
the surface and caused an ulcer, this is treated on general principles,
with a preference, however, for applications containing mercury or
iodine, or both. If a wet dressing is required to cleanse the ulcer,
black wash may be used; if a powder to promote dryness, one containing
iodoform; if an ointment is indicated, the choice lies between the red
oxide of mercury or the dilute nitrate of mercury ointment, and one
consisting of equal parts of lanolin and vaselin with 2 per cent. of
iodine. Deep ulcers, and obstinate lesions of the bones, larynx, and
other parts may be treated by excision or scraping with the sharp spoon.

#Second Attacks of Syphilis.#--Instances of re-infection of syphilis
have been recorded with greater frequency since the more general
introduction of arsenical treatment. A remarkable feature in such cases
is the shortness of the interval between the original infection and the
alleged re-infection; in a recent series of twenty-eight cases, this
interval was less than a year. Another feature of interest is that when
patients in the tertiary stage of syphilis are inoculated with the virus
from lesions from these in the primary and secondary stage lesions of
the tertiary type are produced.

Reference may be made to the #relapsing false indurated chancre#,
described by Hutchinson and by Fournier, as it may be the source of
difficulty in diagnosis. A patient who has had an infecting chancre one
or more years before, may present a slightly raised induration on the
penis at or close to the site of his original sore. This relapsed
induration is often so like that of a primary chancre that it is
impossible to distinguish between them, except by the history. If there
has been a recent exposure to venereal infection, it is liable to be
regarded as the primary lesion of a second attack of syphilis, but the
further progress shows that neither bullet-buboes nor secondary
manifestations develop. These facts, together with the disappearance of
the induration under treatment, make it very likely that the lesion is
really gummatous in character.


INHERITED SYPHILIS

One of the most striking features of syphilis is that it may be
transmitted from infected parents to their offspring, the children
exhibiting the manifestations that characterise the acquired form of the
disease.

The more recent the syphilis in the parent, the greater is the risk of
the disease being communicated to the offspring; so that if either
parent suffers from secondary syphilis the infection is almost
inevitably transmitted.

While it is certain that either parent may be responsible for
transmitting the disease to the next generation, the method of
transmission is not known. In the case of a syphilitic mother it is most
probable that the infection is conveyed to the foetus by the placental
circulation. In the case of a syphilitic father, it is commonly believed
that the infection is conveyed to the ovum through the seminal fluid at
the moment of conception. If a series of children, one after the other,
suffer from inherited syphilis, it is almost invariably the case that
the mother has been infected.

In contrast to the acquired form, inherited syphilis is remarkable for
the absence of any primary stage, the infection being a general one from
the outset. The spirochæte is demonstrated in incredible numbers in the
liver, spleen, lung, and other organs, and in the nasal secretion, and,
from any of these, successful inoculations in monkeys can readily be
made. The manifestations differ in degree rather than in kind from those
of the acquired disease; the difference is partly due to the fact that
the virus is attacking developing instead of fully formed tissues.

The virus exercises an injurious influence on the foetus, which in many
cases dies during the early months of intra-uterine life, so that
miscarriage results, and this may take place in repeated pregnancies,
the date at which the miscarriage occurs becoming later as the virus in
the mother becomes attenuated. Eventually a child is carried to full
term, and it may be still-born, or, if born alive, may suffer from
syphilitic manifestations. It is difficult to explain such vagaries of
syphilitic inheritance as the infection of one twin and the escape of
the other.

_Clinical Features._--We are not here concerned with the severe forms of
the disease which prove fatal, but with the milder forms in which the
infant is apparently healthy when born, but after from two to six weeks
begins to show evidence of the syphilitic taint.

The usual phenomena are that the child ceases to thrive, becomes thin
and sallow, and suffers from eruptions on the skin and mucous membranes.
There is frequently a condition known as _snuffles_, in which the nasal
passages are obstructed by an accumulation of thin muco-purulent
discharge which causes the breathing to be noisy. It usually begins
within a month after birth and before the eruptions on the skin appear.
When long continued it is liable to interfere with the development of
the nasal bones, so that when the child grows up there results a
condition known as the "saddle-nose" deformity (Figs. 43 and 44).

[Illustration: FIG. 43.--Facies of Inherited Syphilis.

(From Dr. Byrom Bramwell's _Atlas of Clinical Medicine_.)]

_Affections of the Skin._--Although all types of skin affection are met
with in the inherited disease, the most important is a _papular_
eruption, the papules being of large size, with a smooth shining top and
of a reddish-brown colour. It affects chiefly the buttocks and thighs,
the genitals, and other parts which are constantly moist. It is
necessary to distinguish this specific eruption from a form of eczema
which occurs in these situations in non-syphilitic children, the points
that characterise the syphilitic condition being the infiltration of the
skin and the coppery colour of the eruption. At the anus the papules
acquire the characters of _condylomata_, also at the angles of the
mouth, where they often ulcerate and leave radiating scars.

David Castor said...

Hey Craig,

It's great to see you back on this blog and commenting again!

Messy Christian said...

How odd ... I was writing a post about criticisms against Hillsongs today! I applaud you for recommending that site. True, you may not have been directly involved with it, but you're concerned enough to demand transparency, and I think that's a-ok. Aren't we, as Christians, suppose to keep each other accountable? Christian megachurch juggernaut or not, Hillsongs needs that too. Thanks for the link btw.

PastorD said...

David,

Thanks for visiting my blog. Just today I received an email with an article from THE BULLETIN (march 207)"JESUS LOVES MONEY: The Gospel according to Hillsong Church)

I have nothing against Hillsong per say. To borrow from Yaconelli, I guess, church too can be messy and still be used by God, just like us.

Still, I agree with you and Messy Christian. There's nothing wrong (in fact, it's good) to ask for accountability

Anonymous said...

I'm in love with Zombie Steamer over at the Hillsong blog! lol

emblazoned said...

Zombie Steamer is pretty funny...

Reductio in absurdum in it's finest form....