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Title: Manual of Surgery Volume First: General Surgery. Sixth Edition.
Author: Thomson, Alexis, Miles, Alexander
Language: English
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Copyright Status: Not copyrighted in the United States. If you live elsewhere check the laws of your country before downloading this ebook. See comments about copyright issues at end of book.

*** Start of this Doctrine Publishing Corporation Digital Book "Manual of Surgery Volume First: General Surgery. Sixth Edition." ***

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                     OXFORD MEDICAL PUBLICATIONS



                          MANUAL OF SURGERY



                                  BY

                     ALEXIS THOMSON, F.R.C.S.Ed.
           _PROFESSOR OF SURGERY, UNIVERSITY OF EDINBURGH_
                  SURGEON EDINBURGH ROYAL INFIRMARY

                                 AND

                     ALEXANDER MILES, F.R.C.S.Ed.
                  SURGEON EDINBURGH ROYAL INFIRMARY


                             VOLUME FIRST
                           GENERAL SURGERY


                       _SIXTH EDITION REVISED_
                       _WITH 169 ILLUSTRATIONS_



                                LONDON
                 HENRY FROWDE and HODDER & STOUGHTON
                        THE _LANCET_ BUILDING
                 1 & 2 BEDFORD STREET, STRAND, W.C.2



    First Edition                                             1904
    Second Edition                                            1907
    Third Edition                                             1909
    Fourth Edition                                            1911
      "       "    Second Impression                          1913
    Fifth Edition                                             1915
      "       "    Second Impression                          1919
    Sixth Edition                                             1921



                     PRINTED IN GREAT BRITAIN BY
                  MORRISON AND GIBB LTD., EDINBURGH



PREFACE TO SIXTH EDITION


Much has happened since this Manual was last revised, and many surgical
lessons have been learned in the hard school of war. Some may yet have
to be unlearned, and others have but little bearing on the problems
presented to the civilian surgeon. Save in its broadest principles, the
surgery of warfare is a thing apart from the general surgery of civil
life, and the exhaustive literature now available on every aspect of it
makes it unnecessary that it should receive detailed consideration in a
manual for students. In preparing this new edition, therefore, we have
endeavoured to incorporate only such additions to our knowledge and
resources as our experience leads us to believe will prove of permanent
value in civil practice.

For the rest, the text has been revised, condensed, and in places
rearranged; a number of old illustrations have been discarded, and a
greater number of new ones added. Descriptions of operative procedures
have been omitted from the _Manual_, as they are to be found in the
companion volume on _Operative Surgery_, the third edition of which
appeared some months ago.

We have retained the Basle anatomical nomenclature, as extended
experience has confirmed our preference for it. For the convenience of
readers who still employ the old terms, these are given in brackets
after the new.

This edition of the _Manual_ appears in three volumes; the first being
devoted to General Surgery, the other two to Regional Surgery. This
arrangement has enabled us to deal in a more consecutive manner than
hitherto with the surgery of the Extremities, including Fractures and
Dislocations.

We have once more to express our thanks to colleagues in the Edinburgh
School and to other friends for aiding us in providing new
illustrations, and for other valuable help, as well as to our publishers
for their generosity in the matter of illustrations.

EDINBURGH,
    _March_ 1921.



CONTENTS


                                                                   PAGE
    CHAPTER I
    REPAIR                                                            1

    CHAPTER II
    CONDITIONS WHICH INTERFERE WITH REPAIR                           17

    CHAPTER III
    INFLAMMATION                                                     31

    CHAPTER IV
    SUPPURATION                                                      45

    CHAPTER V
    ULCERATION AND ULCERS                                            68

    CHAPTER VI
    GANGRENE                                                         86

    CHAPTER VII
    BACTERIAL AND OTHER WOUND INFECTIONS                            107

    CHAPTER VIII
    TUBERCULOSIS                                                    133

    CHAPTER IX
    SYPHILIS                                                        146

    CHAPTER X
    TUMOURS                                                         181

    CHAPTER XI
    INJURIES                                                        218

    CHAPTER XII
    METHODS OF WOUND TREATMENT                                      241

    CHAPTER XIII
    CONSTITUTIONAL EFFECTS OF INJURIES                              249

    CHAPTER XIV
    THE BLOOD VESSELS                                               258

    CHAPTER XV
    THE LYMPH VESSELS AND GLANDS                                    321

    CHAPTER XVI
    THE NERVES                                                      342

    CHAPTER XVII
    SKIN AND SUBCUTANEOUS TISSUES                                   376

    CHAPTER XVIII
    THE MUSCLES, TENDONS, AND TENDON SHEATHS                        405

    CHAPTER XIX
    THE BURSÆ                                                       426

    CHAPTER XX
    DISEASES OF BONE                                                434

    CHAPTER XXI
    DISEASES OF JOINTS                                              501

    INDEX                                                           547



LIST OF ILLUSTRATIONS


  FIG.                                                             PAGE

    1. Ulcer of Back of Hand grafted from Abdominal Wall             15

    2. Staphylococcus aureus in Pus from case of Osteomyelitis       25

    3. Streptococci in Pus from case of Diffuse Cellulitis           26

    4. Bacillus coli communis in Pus from Abdominal Abscess          27

    5. Fraenkel's Pneumococci in Pus from Empyema following          28
       Pneumonia

    6. Passive Hyperæmia of Hand and Forearm induced by Bier's       37
       Bandage

    7. Passive Hyperæmia of Finger induced by Klapp's Suction        38
       Bell

    8. Passive Hyperæmia induced by Klapp's Suction Bell for         39
       Inflammation of Inguinal Gland

    9. Diagram of various forms of Whitlow                           56

   10. Charts of Acute Sapræmia                                      61

   11. Chart of Hectic Fever                                         62

   12. Chart of Septicæmia followed by Pyæmia                        63

   13. Chart of Pyæmia following on Acute Osteomyelitis              65

   14. Leg Ulcers associated with Varicose Veins                     71

   15. Perforating Ulcers of Sole of Foot                            74

   16. Bazin's Disease in a girl æt. 16                              75

   17. Syphilitic Ulcers in region of Knee                           76

   18. Callous Ulcer showing thickened edges                         78

   19. Tibia and Fibula, showing changes due to Chronic Ulcer of     80
       Leg

   20. Senile Gangrene of the Foot                                   89

   21. Embolic Gangrene of Hand and Arm                              92

   22. Gangrene of Terminal Phalanx of Index-Finger                 100

   23. Cancrum Oris                                                 103

   24. Acute Bed Sores over right Buttock                           104

   25. Chart of Erysipelas occurring in a wound                     108

   26. Bacillus of Tetanus                                          113

   27. Bacillus of Anthrax                                          120

   28. Malignant Pustule third day after infection                  122

   29. Malignant Pustule fourteen days after infection              122

   30. Colony of Actinomyces                                        126

   31. Actinomycosis of Maxilla                                     128

   32. Mycetoma, or Madura Foot                                     130

   33. Tubercle bacilli                                             134

   34. Tuberculous Abscess in Lumbar Region                         141

   35. Tuberculous Sinus injected through its opening in the        144
       Forearm with Bismuth Paste

   36. Spirochæte pallida                                           147

   37. Spirochæta refrigerans from scraping of Vagina               148

   38. Primary Lesion on Thumb, with Secondary Eruption on          154
       Forearm

   39. Syphilitic Rupia                                             159

   40. Ulcerating Gumma of Lips                                     169

   41. Ulceration in inherited Syphilis                             170

   42. Tertiary Syphilitic Ulceration in region of Knee and on      171
       both Thumbs

   43. Facies of Inherited Syphilis                                 174

   44. Facies of Inherited Syphilis                                 175

   45. Subcutaneous Lipoma                                          185

   46. Pedunculated Lipoma of Buttock                               186

   47. Diffuse Lipomatosis of Neck                                  187

   48. Zanthoma of Hands                                            188

   49. Zanthoma of Buttock                                          189

   50. Chondroma growing from Infra-Spinous Fossa of Scapula        190

   51. Chondroma of Metacarpal Bone of Thumb                        190

   52. Cancellous Osteoma of Lower End of Femur                     192

   53. Myeloma of Shaft of Humerus                                  195

   54. Fibro-myoma of Uterus                                        196

   55. Recurrent Sarcoma of Sciatic Nerve                           198

   56. Sarcoma of Arm fungating                                     199

   57. Carcinoma of Breast                                          206

   58. Epithelioma of Lip                                           209

   59. Dermoid Cyst of Ovary                                        213

   60. Carpal Ganglion in a woman æt. 25                            215

   61. Ganglion on lateral aspect of Knee                           216

   62. Radiogram showing pellets embedded in Arm                    228

   63. Cicatricial Contraction following Severe Burn                236

   64. Genealogical Tree of Hæmophilic Family                       278

   65. Radiogram showing calcareous degeneration of Arteries        284

   66. Varicose Vein with Thrombosis                                289

   67. Extensive Varix of Internal Saphena System on Left Leg       291

   68. Mixed Nævus of Nose                                          296

   69. Cirsoid Aneurysm of Forehead                                 299

   70. Cirsoid Aneurysm of Orbit and Face                           300

   71. Radiogram of Aneurysm of Aorta                               303

   72. Sacculated Aneurysm of Abdominal Aorta                       304

   73. Radiogram of Innominate Aneurysm after Treatment by          309
       Moore-Corradi method

   74. Thoracic Aneurysm threatening to rupture                     313

   75. Innominate Aneurysm in a woman                               315

   76. Congenital Cystic Tumour or Hygroma of Axilla                328

   77. Tuberculous Cervical Gland with Abscess formation            331

   78. Mass of Tuberculous Glands removed from Axilla               333

   79. Tuberculous Axillary Glands                                  335

   80. Chronic Hodgkin's Disease in boy æt. 11                      337

   81. Lymphadenoma in a woman æt. 44                               338

   82. Lympho Sarcoma removed from Groin                            339

   83. Cancerous Glands in Neck, secondary to Epithelioma of Lip    341

   84. Stump Neuromas of Sciatic Nerve                              345

   85. Stump Neuromas, showing changes at ends of divided Nerves    354

   86. Diffuse Enlargement of Nerves in generalised                 356
       Neuro-Fibromatosis

   87. Plexiform Neuroma of small Sciatic Nerve                     357

   88. Multiple Neuro-Fibromas of Skin (Molluscum fibrosum)         358

   89. Elephantiasis Neuromatosa in a woman æt. 28                  359

   90. Drop-Wrist following Fracture of Shaft of Humerus            365

   91. To illustrate the Loss of Sensation produced by Division     367
       of the Median Nerve

   92. To illustrate Loss of Sensation produced by Complete         368
       Division of Ulnar Nerve

   93. Callosities and Corns on Sole of Foot                        377

   94. Ulcerated Chilblains on Fingers                              378

   95. Carbuncle on Back of Neck                                    381

   96. Tuberculous Elephantiasis                                    383

   97. Elephantiasis in a woman æt. 45                              387

   98. Elephantiasis of Penis and Scrotum                           388

   99. Multiple Sebaceous Cysts or Wens                             390

  100. Sebaceous Horn growing from Auricle                          392

  101. Paraffin Epithelioma                                         394

  102. Rodent Cancer of Inner Canthus                               395

  103. Rodent Cancer with destruction of contents of Orbit          396

  104. Diffuse Melanotic Cancer of Lymphatics of Skin               398

  105. Melanotic Cancer of Forehead with Metastasis in Lymph        399
       Glands

  106. Recurrent Keloid                                             401

  107. Subungual Exostosis                                          403

  108. Avulsion of Tendon                                           410

  109. Volkmann's Ischæmic Contracture                              414

  110. Ossification in Tendon of Ilio-psoas Muscle                  417

  111. Radiogram of Calcification and Ossification in Biceps and    418
       Triceps

  112. Ossification in Muscles of Trunk in generalised Ossifying    419
       Myositis

  113. Hydrops of Prepatellar Bursa                                 427

  114. Section through Gouty Bursa                                  428

  115. Tuberculous Disease of Sub-Deltoid Bursa                     429

  116. Great Enlargement of the Ischial Bursa                       431

  117. Gouty Disease of Bursæ                                       432

  118. Shaft of the Femur after Acute Osteomyelitis                 444

  119. Femur and Tibia showing results of Acute Osteomyelitis       445

  120. Segment of Tibia resected for Brodie's Abscess               449

  121. Radiogram of Brodie's Abscess in Lower End of Tibia          451

  122. Sequestrum of Femur after Amputation                         453

  123. New Periosteal Bone on Surface of Femur from Amputation      454
       Stump

  124. Tuberculous Osteomyelitis of Os Magnum                       456

  125. Tuberculous Disease of Tibia                                 457

  126. Diffuse Tuberculous Osteomyelitis of Right Tibia             458

  127. Advanced Tuberculous Disease in Region of Ankle              459

  128. Tuberculous Dactylitis                                       460

  129. Shortening of Middle Finger of Adult, the result of          461
       Tuberculous Dactylitis in Childhood

  130. Syphilitic Disease of Skull                                  463

  131. Syphilitic Hyperostosis and Sclerosis of Tibia               464

  132. Sabre-blade Deformity of Tibia                               467

  133. Skeleton of Rickety Dwarf                                    470

  134. Changes in the Skull resulting from Ostitis Deformans        474

  135. Cadaver, illustrating the alterations in the Lower Limbs     475
       resulting from Ostitis Deformans

  136. Osteomyelitis Fibrosa affecting Femora                       476

  137. Radiogram of Upper End of Femur in Osteomyelitis Fibrosa     478

  138. Radiogram of Right Knee showing Multiple Exostoses           482

  139. Multiple Exostoses of Limbs                                  483

  140. Multiple Cartilaginous Exostoses                             484

  141. Multiple Cartilaginous Exostoses                             486

  142. Multiple Chondromas of Phalanges and Metacarpals             488

  143. Skiagram of Multiple Chondromas                              489

  144. Multiple Chondromas in Hand                                  490

  145. Radiogram of Myeloma of Humerus                              492

  146. Periosteal Sarcoma of Femur                                  493

  147. Periosteal Sarcoma of Humerus                                493

  148. Chondro-Sarcoma of Scapula                                   494

  149. Central Sarcoma of Femur invading Knee Joint                 495

  150. Osseous Shell of Osteo-Sarcoma of Femur                      495

  151. Radiogram of Osteo-Sarcoma of Femur                          496

  152. Radiogram of Chondro-Sarcoma of Humerus                      497

  153. Epitheliomatus Ulcer of Leg invading Tibia                   499

  154. Osseous Ankylosis of Femur and Tibia                         503

  155. Osseous Ankylosis of Knee                                    504

  156. Caseating focus in Upper End of Fibula                       513

  157. Arthritis Deformans of Elbow                                 525

  158. Arthritis Deformans of Knee                                  526

  159. Hypertrophied Fringes of Synovial Membrane of Knee           527

  160. Arthritis Deformans of Hands                                 529

  161. Arthritis Deformans of several Joints                        530

  162. Bones of Knee in Charcot's Disease                           533

  163. Charcot's Disease of Left Knee                               534

  164. Charcot's Disease of both Ankles: front view                 535

  165. Charcot's Disease of both Ankles: back view                  536

  166. Radiogram of Multiple Loose Bodies in Knee-joint             540

  167. Loose Body from Knee-joint                                   541

  168. Multiple partially ossified Chondromas of Synovial           542
       Membrane from Shoulder-joint

  169. Multiple Cartilaginous Loose Bodies from Knee-joint          543



MANUAL OF SURGERY



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 amœboid 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.


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 œsophagus 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 gonorrhœa 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 fœtid, 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 œdema_, 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 œdema_. The more open the structure of the tissue
of the part, the greater is the amount of swelling--witness the marked
degree of œdema 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. Diarrhœa 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 œdematous, 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 œdema 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 amœboid 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
œdematous 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, œdema 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 œdema 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 œdematous. 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 gonorrhœal 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,
œdematous, 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 œdema, 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 œdema 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 fœtal 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 diarrhœa 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, œdema of the lower limbs, clubbing of the
fingers, and diarrhœa 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
diarrhœa 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 diarrhœa; 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 œdema
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, œdematous, 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 œdematous; 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, œdematous 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
œdematous, 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 œdematous, either from general causes, such as
heart or kidney disease, or from local causes, such as varicose veins,
the granulations share in the œdema, 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 œdema 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 œdematous 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 pharmacopœial
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 œdema_; _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, œdema, 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 œdema 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 œdematous, 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, œdematous, 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 Œdema.#--This form of acute gangrene has been defined as
"a spreading inflammatory œdema attended with emphysema, and ultimately
followed by gangrene of the skin and adjacent parts." The predominant
organism is the _bacillus of malignant œdema_ 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 œdema, however, the
incidence of the disease is mainly on the superficial parts, which
become œdematous 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 œdematous. 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 fœtid 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 œdematous 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
œdematous, 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
œdema 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 œdema 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 _œdema_ 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 dyspnœa, 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 œdematous, 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, diarrhœa, 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 œdema 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 œdema 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 œdema 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
œdema 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 œsophagus, 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
œdema 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 œdema, 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 œdematous 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 œdema 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 alopœcia_). 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, œdema, 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 fœtus 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 fœtus, 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.

_Affections of the Mucous Membranes._--The inflammation of the nasal
mucous membrane that causes snuffles has already been referred to. There
may be mucous patches in the mouth, or a stomatitis which is of
importance, because it results in interference with the development of
the permanent teeth. The mucous membrane of the larynx may be the seat
of mucous patches or of catarrh, and as a result the child's cry is
hoarse.

_Affections of the Bones._--Swellings at the ends of the long bones, due
to inflammation at the epiphysial junctions, are most often observed at
the upper end of the humerus and in the bones in the region of the
elbow. Partial displacement and mobility at the ossifying junction may
be observed. The infant cries when the part is touched; and as it does
not move the limb voluntarily, the condition is spoken of as _the
pseudo-paralysis of syphilis_. Recovery takes place under
anti-syphilitic treatment and immobilisation of the limb.

Diffuse thickening of the shafts of the long bones, due to a deposit of
new bone by the periosteum, is sometimes met with.

[Illustration: FIG. 44.--Facies of Inherited Syphilis.]

The conditions of the skull known as Parrot's nodes or bosses, and
craniotabes, were formerly believed to be characteristic of inherited
syphilis, but they are now known to occur, particularly in rickety
children, from other causes. The _bosses_ result from the heaping up of
new spongy bone beneath the pericranium, and they may be grouped
symmetrically around the anterior fontanelle, or may extend along either
side of the sagittal suture, which appears as a deep groove--the
"natiform skull." The bosses disappear in time, but the skull may remain
permanently altered in shape, the frontal and parietal eminences
appearing unduly prominent. The term _craniotabes_ is applied when the
bone becomes thin and soft, reverting to its original membranous
condition, so that the affected areas dimple under the finger like
parchment or thin cardboard; its localisation in the posterior parts of
the skull suggests that the disappearance of the osseous tissue is
influenced by the pressure of the head on the pillow. Craniotabes is
recovered from as the child improves in health.

Between the ages of three and six months, certain other phenomena may be
met with, such as _effusion into the joints_, especially the knees;
_iritis_, in one or in both eyes, and enlargement of the spleen and
liver.

In the majority of cases the child recovers from these early
manifestations, especially when efficiently treated, and may enjoy an
indefinite period of good health. On the other hand, when it attains the
age of from two to four years, it may begin to manifest lesions which
correspond to those of the tertiary period of acquired syphilis.

#Later Lesions.#--In the skin and subcutaneous tissue, the later
manifestations may take the form of localised gummata, which tend to
break down and form ulcers, on the leg for example, or of a spreading
gummatous infiltration which is also liable to ulcerate, leaving
disfiguring scars, especially on the face. The palate and fauces may be
destroyed by ulceration. In the nose, especially when the ulcerative
process is associated with a putrid discharge--ozæna--the destruction of
tissue may be considerable and result in unsightly deformity. The entire
palatal portions of the upper jaws, the vomer, turbinate, and other
bones bounding the nasal and oral cavities, may disappear, so that on
looking into the mouth the base of the skull is readily seen. Gummatous
disease is frequently observed also in the flat bones of the skull, in
the bones of the hand, as syphilitic dactylitis, and in the bones of the
forearm and leg. When the tibia is affected the disease is frequently
bilateral, and may assume the form of gummatous ulcers and sinuses. In
later years the tibia may present alterations in shape resulting from
antecedent gummatous disease--for example, nodular thickenings of the
shaft, flattening of the crest, or a more uniform increase in thickness
and length of the shaft of the bone, which, when it is curved in
addition, is described as the "sabre-blade" deformity. Among lesions of
the viscera, mention should be made of gumma of the testis, which causes
the organ to become enlarged, uneven, and indurated. This has even been
observed in infants a few months old.

Occasionally a syphilitic child suffers from a succession of these
gummatous lesions with resulting ill-health, and, it may be, waxy
disease of the internal organs; on the other hand, it may recover and
present no further manifestations of the inherited taint.

_Affections of the Eyes._--At or near puberty there is frequently
observed an affection of the eyes, known as _chronic interstitial
keratitis_, the relationship of which to inherited syphilis was first
established by Hutchinson. It occurs between the ages of six and sixteen
years, and usually affects one eye before the other. It commences as a
diffuse haziness or steaminess near the centre of the cornea, and as it
spreads the entire cornea assumes the appearance of ground glass. The
chief complaint is of dimness of sight, which may almost amount to
blindness, but there is little pain or photophobia; a certain amount of
conjunctival and ciliary congestion is usually present, and there may be
_iritis_ in addition. The cornea, or parts of it, may become of a deep
pink or salmon colour from the formation in it of new blood vessels. The
affection may last for from eighteen months to two years. Complete
recovery usually takes place, but slight opacities, especially in the
site of former salmon patches, may persist, and the disease occasionally
relapses. _Choroiditis_ and _retinitis_ may also occur, and leave
permanent changes easily recognised on examination with the
ophthalmoscope.

Among the rarer and more serious lesions of the inherited disease may be
mentioned gummatous disease in the _larynx and trachea_, attended with
ulceration and resulting in stenosis; and lesions of the _nervous
system_ which may result in convulsions, paralysis, or dementia.

In a limited number of cases, about the period of puberty there may
develop _deafness_, which is usually bilateral and may become absolute.

_Changes in the Permanent Teeth._--These affect specially the upper
central incisors, which are dwarfed and stand somewhat apart in the gum,
with their free edges converging towards one another. They are tapering
or peg-shaped, and present at their cutting margin a deep semilunar
notch. These appearances are commonly associated with the name of
Hutchinson, who first described them. Affecting as they do the
permanent teeth, they are not available for diagnosis until the child is
over eight years of age. Henry Moon drew attention to a change in the
first molars; these are reduced in size and dome-shaped through dwarfing
of the central tubercle of each cusp.

#Diagnosis of Inherited Syphilis.#--When there is a typical eruption on
the buttocks and snuffles there is no difficulty in recognising the
disease. When, however, the rash is scanty or is obscured by co-existing
eczema, most reliance should be placed on the distribution of the
eruption, on the brown stains which are left after it has passed off, on
the presence of condylomata, and of fissuring and scarring at the angles
of the mouth. The history of the mother relative to repeated
miscarriages and still-born children may afford confirmatory evidence.
In doubtful cases, the diagnosis may be aided by the Wassermann test and
by noting the therapeutic effects of grey powder, which, in syphilitic
infants, usually effects a marked and rapid improvement both in the
symptoms and in the general health.

While a considerable number of syphilitic children grow up without
showing any trace of their syphilitic inheritance, the majority retain
throughout life one or more of the following characteristics, which may
therefore be described as _permanent signs of the inherited disease_:
Dwarfing of stature from interference with growth at the epiphysial
junctions; the forehead low and vertical, and the parietal and frontal
eminences unduly prominent; the bridge of the nose sunken and rounded;
radiating scars at the angles of the mouth; perforation or destruction
of the hard palate; Hutchinson's teeth; opacities of the cornea from
antecedent keratitis; alterations in the fundus oculi from choroiditis;
deafness; depressed scars or nodes on the bones from previous gummata;
"sabre-blade" or other deformity of the tibiæ.

#The Contagiousness of Inherited Syphilis.#--In 1837, Colles of Dublin
stated his belief that, while a syphilitic infant may convey the disease
to a healthy wet nurse, it is incapable of infecting its own mother if
nursed by her, even although she may never have shown symptoms of the
disease. This doctrine, which is known as _Colles' law_, is generally
accepted in spite of the alleged occurrence of occasional exceptions.
The older the child, the less risk there is of its communicating the
disease to others, until eventually the tendency dies out altogether, as
it does in the tertiary period of acquired syphilis. It should be
added, however, that the contagiousness of inherited syphilis is denied
by some observers, who affirm that, when syphilitic infants prove
infective, the disease has been really acquired at or soon after birth.

There is general agreement that the subjects of inherited syphilis
cannot transmit the disease by inheritance to their offspring, and that,
although they very rarely acquire the disease _de novo_, it is possible
for them to do so.

#Prognosis of Inherited Syphilis.#--Although inherited syphilis is
responsible for a large but apparently diminishing mortality in infancy,
the subjects of this disease may grow up to be as strong and healthy as
their neighbours. Hutchinson insisted on the fact that there is little
bad health in the general community that can be attributed to inherited
syphilis.

#Treatment.#--Arsenical injections are as beneficial in the inherited as
in the acquired disease. An infant the subject of inherited syphilis
should, if possible, be nursed by its mother, and failing this it should
be fed by hand. In infants at the breast, the drug may be given to the
mother; in others, it is administered in the same manner as already
described--only in smaller doses. On the first appearance of syphilitic
manifestations it should be given 0.05 grm, novarsenbillon, injected
into the deep subcutaneous tissues every week for six weeks, followed by
one year's mercurial inunction--a piece of mercurial ointment the size
of a pea being inserted under the infant's binder. In older children the
dose is proportionately increased. The general health should be improved
in every possible direction; considerable benefit may be derived from
the use of cod-liver oil, and from preparations containing iron and
calcium. Surgical interference may be required in the destructive
gummatous lesions of the nose, throat, larynx, and bones, either with
the object of arresting the spread of the disease, or of removing or
alleviating the resulting deformities. In children suffering from
keratitis, the eyes should be protected from the light by smoked or
coloured glasses, and the pupils should be dilated with atropin from
time to time, especially in cases complicated with iritis.

#Acquired Syphilis in Infants and Young Children.#--When syphilis is met
with in infants and young children, it is apt to be taken for granted
that the disease has been inherited. It is possible, however, for them
to acquire the disease--as, for example, while passing through the
maternal passages during birth, through being nursed or kissed by
infected women, or through the rite of circumcision. The risk of
infection which formerly existed by the arm-to-arm method of
vaccination has been abolished by the use of calf lymph.

The clinical features of the acquired disease in infants and young
children are similar to those observed in the adult, with a tendency,
however, to be more severe, probably because the disease is often late
in being recognised and treated.



CHAPTER X

TUMOURS[2]


Definition--Etiology--General characters of innocent and malignant
    tumours. CLASSIFICATION OF TUMOURS: I. Connective-tissue tumours:
    (1) _Innocent_: _Lipoma_, _Xanthoma_, _Chondroma_, _Osteoma_,
    _Odontoma_, _Fibroma_, _Myxoma_, _Endothelioma_, etc.; (2)
    _Malignant_: _Sarcoma_--II. Epithelial tumours: (1) _Innocent_:
    _Papilloma_, _Adenoma_, _Cystic Adenoma_; (2) _Malignant_:
    _Epithelioma_, _Glandular Cancer_, _Rodent Cancer_, _Melanotic
    Cancer_--III. Dermoids--IV. Teratoma. Cysts: _Retention_,
    _Exudation_, _Implantation_, _Parasitic_, _Lymphatic or Serous_.
    Ganglion.

[2] For the histology of tumours the reader is referred to a text-book
of pathology.

A tumour or neoplasm is a localised swelling composed of newly formed
tissue which fulfils no physiological function. Tumours increase in size
quite independently of the growth of the body, and there is no natural
termination to their growth. They are to be distinguished from such
over-growths as are of the nature of simple hypertrophy or local
giantism, and also from inflammatory swellings, which usually develop
under the influence of a definite cause, have a natural termination, and
tend to disappear when the cause ceases to act.

The _etiology of tumours_ is imperfectly understood. Various factors,
acting either singly or in combination, may be concerned in their
development. Certain tumours, for example, are the result of some
congenital malformation of the particular tissue from which they take
origin. This would appear to be the case in many tumours of blood
vessels (angioma), of cartilage (chondroma), of bone (osteoma), and of
secreting gland tissue (adenoma). The theory that tumours originate from
fœtal residues or "rests," is associated with the name of Cohnheim.
These rests are supposed to be undifferentiated embryonic cells which
remain embedded amongst fully formed tissue elements, and lie dormant
until they are excited into active growth and give rise to a tumour.
This mode of origin is illustrated by the development of dermoids from
sequestrated portions of epidermis.

Among the local factors concerned in the development of tumours,
reference must be made to the influence of irritation. This is probably
an important agent in the causation of many of the tumours met with in
the skin and in mucous membranes--for example, cancer of the skin, of
the lip, and of the tongue. The part played by injury is doubtful. It
not infrequently happens that the development of a tumour is preceded by
an injury of the part in which it grows, but it does not necessarily
follow that the injury and the tumour are related as cause and effect.
It is possible that an injury may stimulate into active growth
undifferentiated tissue elements or "rests," and so determine the growth
of a tumour, or that it may alter the characters of a tumour which
already exists, causing it to grow more rapidly.

The popular belief that there is some constitutional peculiarity
concerned in the causation of tumours is largely based on the fact that
certain forms of new growth--for example, cancer--are known to occur
with undue frequency in certain families. The same influence is more
striking in the case of certain innocent tumours--particularly multiple
osteomas and lipomas--which are hereditary in the same sense as
supernumerary or webbed fingers, and appear in members of the same
family through several generations.


INNOCENT AND MALIGNANT TUMOURS

For clinical purposes, tumours are arbitrarily divided into two
classes--the innocent and the malignant. The outstanding difference
between them is, that while the evil effects of innocent tumours are
entirely local and depend for their severity on the environment of the
growth, malignant tumours wherever situated, in addition to producing
similar local effects, injure the general health and ultimately cause
death.

_Innocent_, benign, or simple tumours present a close structural
resemblance to the normal tissues of the body. They grow slowly, and are
usually definitely circumscribed by a fibrous capsule, from which they
are easily enucleated, and they do not tend to recur after removal. In
their growth they merely push aside and compress adjacent parts, and
they present no tendency to ulcerate and bleed unless the overlying skin
or mucous membrane is injured. Although usually solitary, some are
multiple from the outset--for example, fatty, fibrous, and bony tumours,
warts, and fibroid tumours of the uterus. They produce no constitutional
disturbance. They only threaten life when growing in the vicinity of
vital organs, and then only in virtue of their situation--for example,
death may result from an innocent tumour in the air-passage causing
suffocation, in the intestine causing obstruction of the bowels, or in
the vertebral canal causing pressure on the spinal medulla.

_Malignant tumours_ usually show a marked departure from the structure
and arrangement of the normal tissues of the body. Although the cells of
which they are composed are derived from normal tissue cells, they tend
to take on a lower, more vegetative form; they may be regarded as
parasites living at the expense of the organism, multiplying
indefinitely and destroying everything with which they come in contact.

Malignant tumours grow more rapidly than innocent tumours, and tend to
infiltrate their surroundings by sending out prolongations or offshoots;
they are therefore liable to recur after an operation which is
restricted to the removal of the main tumour. They are not encapsulated,
although they may appear to be circumscribed by condensation of the
surrounding tissues; they are rarely multiple at the outset, but show a
marked tendency to spread to other parts of the body. Fragments of the
parent tumour may become separated and be carried off in the lymph or
blood-stream and deposited in other parts of the body, where they give
rise to secondary growths. Malignant tumours tend to invade and destroy
the overlying skin or mucous membrane, and thus give rise to bleeding
ulcers; if the tumour tissue protrudes through the gap in the skin, it
is said to _fungate_. In course of time they give rise to a condition of
ill-health or _cachexia_, the patient becoming pale, sallow, feverish,
and emaciated, probably as a result of chronic poisoning from the
absorption of toxic products from the tumour. They ultimately destroy
life, it may be by their local effects, such as ulceration and
hæmorrhage, by favouring the entrance of septic infection, by
interfering with the function of organs which are essential to life, by
cachexia, or by a combination of these effects.

The situation of a malignant tumour exercises considerable influence on
the rapidity, as well as on the mode, in which it causes death. Some
cancers, such as that known as "rodent," show malignant features which
are entirely local, while others, such as melanotic cancer, exhibit a
malignancy characterised by rapid generalisation of growths throughout
the body. Tumours that are structurally alike may show variations in
malignancy, according to their situation and to the age of the patient,
as well as to other factors which are as yet unknown.

In attempting to arrive at a conclusion as to the innocence or
malignancy of any tumour, too much reliance must not be placed on its
histological features; its situation, rate of growth, and other clinical
features must also be taken into consideration. It cannot be too
emphatically stated that there is no hard-and-fast line between innocent
and malignant growths; there is an indefinite transition from one to the
other. The possibility of the transformation of a benign into a
malignant tumour must be admitted. Such a transformation implies a
change in the structure of the growth, and has been observed especially
in fibrous and cartilaginous tumours, in tumours of the thyreoid gland,
and in uterine fibroids. The alteration in character may take place
under the influence of injury, prolonged or repeated irritation,
incomplete removal of the benign tumour by operation, or the altered
physiological conditions of the tissues which attend upon advancing
years.

After a tumour has been removed by operation it should as a routine
measure be subjected to microscopical examination; the results are often
instructive and sometimes other than what was expected.

#Varieties of Tumours.#--In the following description, tumours are
classified on an anatomical basis, taking in order first the
connective-tissue group and subsequently those that originate in
epithelium.


INNOCENT CONNECTIVE-TISSUE TUMOURS

#Lipoma.#--A lipoma is composed of fat resembling that normally present
in the body. The commonest variety is the _subcutaneous lipoma_, which
grows from the subcutaneous fat, and forms a soft, irregularly lobulated
tumour (Fig. 45). The fat is arranged in lobules separated by
connective-tissue septa, which are continuous with the capsule
surrounding the tumour and with the overlying skin, which becomes
dimpled or puckered when an attempt is made to pinch it up. As the fat
is almost fluid at the body temperature, fluctuation can usually be
detected. These tumours vary greatly in size, occur at all ages, grow
slowly, and, while generally solitary, are sometimes multiple. They are
most commonly met with on the shoulder, buttock, or back. In certain
situations, such as the thigh and perineum, they tend to become
pedunculated (Fig. 46).

A fatty tumour is to be diagnosed from a cold abscess and from a cyst.
The distinguishing features of the lipoma are the tacking down and
dimpling of the overlying skin, the lobulation of the tumour, which is
recognised when it is pressed upon with the flat of the hand, and, more
reliable than either of these, the mobility, the tumour slipping away
when pressed upon at its margin.

[Illustration: FIG. 45.--Subcutaneous Lipoma showing lobulation.]

The prognosis is more favourable than in any other tumour as it never
changes its characters; the only reasons for its removal by operation
are its unsightliness and its probable increase in size in the course of
years. The operation consists in dividing the skin and capsule over the
tumour and shelling it out. Care must be taken that none of the outlying
lobules are left behind. If the overlying skin is damaged or closely
adherent, it should be removed along with the tumour.

[Illustration: FIG. 46.--Pedunculated Lipoma of Buttock of forty years'
duration in a woman æt. 68.]

_Multiple subcutaneous lipomas_ are frequently symmetrical, and in a
certain group of cases, met with chiefly in women, pain is a prominent
symptom, hence the term _adiposis dolorosa_ (Dercum). These multiple
tumours show little or no tendency to increase in size, and the pain
which attends their development does not persist.

In the neck, axilla, and pubes a diffuse overgrowth of the subcutaneous
fat is sometimes met with, forming symmetrical tumour-like masses, known
as _diffuse lipoma_. As this is not, strictly speaking, a tumour, the
term _diffuse lipomatosis_ is to be preferred. A similar condition was
described by Jonathan Hutchinson as being met with in the domestic
animals. If causing disfigurement, the mass of fat may be removed by
operation.

[Illustration: FIG. 47.--Diffuse Lipomatosis of Neck.]

_Lipoma in other Situations._--The _periosteal lipoma_ is usually
congenital, and is most often met with in the hand; it forms a
projecting lobulated tumour, which, when situated in the palm, resembles
an angioma or a lymphangioma. The _subserous lipoma_ arises from the
extra-peritoneal fat in the posterior abdominal wall, in which case it
tends to grow forwards between the layers of the mesentery and to give
rise to an abdominal tumour; or it may grow from the extra-peritoneal
fat in the anterior abdominal wall and protrude from one of the hernial
openings or through an abnormal opening in the parietes, constituting a
_fatty hernia_. A _subsynovial lipoma_ grows from the fat surrounding
the synovial membrane of a joint, and projects into its interior, giving
rise to the symptoms of loose body. Lipomas are also met with growing
from the adipose connective tissue _between or in the substance of
muscles_, and, when situated beneath the deep fascia, such as the fascia
lata of the thigh, the characteristic signs are obscured and a
differential diagnosis is difficult. It may be differentiated from a
cold abscess by puncture with an exploring needle.

[Illustration: FIG. 48.--Zanthoma of Hands in a girl æt. 14, showing
multiple subcutaneous tumours (cf. Fig. 49).

(Sir H. J. Stiles' case.)]

#Zanthoma# is a rare but interesting form of tumour, composed of a
fibrous and fatty tissue, containing a granular orange-yellow pigment,
resembling that of the corpus luteum. It originates in the corium and
presents two clinical varieties. In the first of these, it occurs in the
form of raised yellow patches, usually in the skin of the eyelids of
persons after middle life, and in many instances is associated with
chronic jaundice; the patches are often symmetrical, and as they
increase in size they tend to fuse with another.

The second form occurs in children and adolescents; it may affect
several generations of the same family, and is often multiple, there
being a combination of thickened yellow patches of skin and projecting
tumours, some of which may attain a considerable size (Figs. 48 and 49).
On section, the tumour tissue presents a brilliant orange or saffron
colour.

There is no indication for removing the tumours unless for the deformity
which they cause; exposure to the X-rays is to be preferred to
operation.

[Illustration: FIG. 49.--Zanthoma showing Subcutaneous Tumours on
Buttocks. From same patient as Fig. 48.]

#Chondroma.#--A chondroma is mainly composed of cartilage. Processes of
vascular connective tissue pass in between the nodules of cartilage
composing the tumour from the fibrous capsule which surrounds it. On
section it is of a greyish-blue colour and semi-translucent. The tumour
is firm and elastic in consistence, but certain portions may be densely
hard from calcification or ossification, while other portions may be
soft and fluctuating as a result of myxomatous degeneration and
liquefaction. These tumours grow slowly and painlessly, and may surround
nerves and arteries without injuring them. They may cause a deep hollow
in the bone from which they originate. All intermediate forms between
the innocent chondroma and the malignant chondro-sarcoma are met with.
Chondroma may occur in a multiple form, especially in relation to the
phalanges and metacarpal bones. When growing in the interior of a bone
it causes a spindle-shaped enlargement of the shaft, which in the case
of a phalanx or metacarpal bone may resemble the dactylitis resulting
from tubercle or syphilis. A chondroma appears as a clear area in a
skiagram.

A _skiagram_ of a bone in which there is a chondroma shows a clear
rounded area in the position of the tumour, which must be differentiated
from similar clear areas due to other kinds of tumour, especially the
myeloma; when it has undergone calcification or ossification, it gives a
shadow as dark as bone.

[Illustration: FIG. 50.--Chondroma growing from infraspinous fossa of
Scapula.]

[Illustration: FIG. 51.--Chondroma of Metacarpal Bone of Thumb.]

_Treatment._--In view of the unstable quality of the chondroma,
especially of its liability to become malignant, it should be removed as
soon as it is recognised. In those projecting from the surface of a
bone, both the tumour and its capsule should be removed. If in the
interior, a sufficient amount of the cortex should be removed to allow
of the tumour being scraped out, and care must be taken that no nodules
of cartilage are left behind. In multiple chondromas of the hand, when
the fingers are crippled and useless, exposure to the X-rays should be
given a trial, and in extreme cases the question of amputation may have
to be considered. When a cartilaginous tumour takes on active growth, it
must be treated as malignant.

The chondromas that are met with at the ends of the long bones in
children and young adults form a group by themselves. They are usually
related to the epiphysial cartilage, and it was suggested by Virchow
that they take origin from islands of cartilage which have not been used
up in the process of ossification. They are believed to occur more
frequently in those who have suffered from rickets. They have no
malignant tendencies and tend to undergo ossification concurrently with
the epiphysial cartilage from which they take origin, and constitute
what are known as _cartilaginous exostoses_. These are sometimes met
with in a multiple form, and may occur in several generations of the
same family. They are considered in greater detail in the chapter
dealing with tumours of bone.

Minute nodules of cartilage sometimes form in the synovial membrane of
joints and lining of tendon sheaths and bursæ: they tend to become
detached from the membrane and constitute loose bodies; they also
undergo a variable amount of calcification and ossification, so as to be
visible in skiagrams. They are further considered with loose bodies in
joints.

Cartilaginous tumours in the parotid, submaxillary gland, and testicle
belong to a class of "mixed tumours" that will be referred to later.

#Osteoma.#--The true osteoma is composed of bony tissue, and originates
from the skeleton. Two varieties are recognised--the spongy or
cancellous, and the ivory or compact. The _spongy_ or _cancellous
osteoma_ is really an ossified chondroma, and is met with at the ends of
the long bones (Fig. 52). From the fact that it projects from the
surface of the bone it is often spoken of as an _exostosis_. It grows
slowly, and rarely causes any discomfort unless it presses upon a
nerve-trunk or upon a bursa which has developed over it. The Röntgen
rays show a dark shadow corresponding to the ossified portion of the
tumour, and continuous with that of the bone from which it is growing
(Fig. 138). Operative interference is only indicated when the tumour is
giving rise to inconvenience. It is then removed, its base or neck being
divided by means of the chisel. The multiple variety of osteoma is
considered with the diseases of bone.

The bony outgrowth from the terminal phalanx of the great toe--known as
the _subungual exostosis_--is described and figured on p. 404. Bony
projections or "spurs" sometimes occur on the under surface of the
calcaneus, and, projecting downwards and forwards from the greater
process, cause pain on putting the heel to the ground.

[Illustration: FIG. 52.--Cancellous Osteoma of lower end of Femur.]

The _ivory_ or _compact osteoma_ is composed of dense bone, and usually
grows from the skull. It is generally sessile and solitary, and may grow
into the interior of the skull, into the frontal sinus, into the cavity
of the orbit or nose, or may fill up the external auditory meatus,
causing most unsightly deformity and interference with sight, breathing,
and hearing.

Bony formations occur in _muscles and tendons_, especially at their
points of attachment to the skeleton, and are known as false exostoses;
they are described with the diseases of muscles.

#Odontoma.#--An odontoma is composed of dental tissues in varying
proportions and different degrees of development, arising from
tooth-germs or from teeth still in process of growth (Bland Sutton).
Odontomas resemble teeth in so far that during their development they
remain hidden below the mucous membrane and give no evidence of their
existence. There then succeeds, usually between the twentieth and
twenty-fifth years, an eruptive stage, which is often attended with
suppuration, and this may be the means of drawing attention to the
tumour. Following Bland Sutton, several varieties of odontoma may be
distinguished according to the part of the tooth-germ concerned in their
formation.

The _epithelial odontoma_ is derived from persistent portions of the
epithelium of the enamel organ, and constitutes a multilocular cystic
tumour which is chiefly met with in the mandible. The cystic spaces of
the tumour contain a brownish glairy fluid. These tumours have been
described by Eve under the name of multilocular cystic epithelial
tumours of the jaw.

The _follicular odontoma_, also known as a _dentigerous cyst_, is
derived from the distension of a tooth follicle. It constitutes a cyst
containing a viscid fluid, and an imperfectly formed tooth is often
found embedded in its wall. The cyst usually forms in relation to one of
the permanent molars, and may attain considerable dimensions.

The _fibrous odontoma_ is the result of an overgrowth of fibrous tissue
surrounding the tooth sac, which encapsulates the tooth and prevents its
eruption. The thickened tooth sac is usually mistaken for a fibrous
tumour, until, after removal, the tooth is recognised in its interior.

_Composite Odontoma._--This is a convenient term to apply to certain
hard dental tumours which are met with in the jaws, and consist of
enamel, dentine, and cement. The tumour is to be regarded as being
derived from an abnormal growth of all the elements of a tooth germ, or
of two or more tooth germs, indiscriminately fused with one another. It
may appear in childhood, and form a smooth unyielding tumour, often of
considerable size, replacing the corresponding permanent tooth. It may
cause a purulent discharge, and in some cases it has been extruded after
sloughing of the overlying soft parts. Many examples of this variety of
odontoma, growing in the nasal cavity or in the maxillary sinus, have
been erroneously regarded as osteomas even after removal.

On section, the tumour is usually laminated, and is seen to consist
mainly of dentine with a partial covering of enamel and cement.

_Diagnosis._--Odontomas are often only diagnosed after removal. When
attended with suppuration, the condition has been mistaken for disease
of the jaw. Fibrous odontomas have been mistaken for sarcoma, and
portions of the maxilla removed unnecessarily. Any circumscribed tumour
of the jaw, particularly when met with in a young adult, should suggest
the possibility of an odontoma. Skiagrams often give useful information
both for diagnosis and for treatment.

_Treatment._--The solid varieties of odontoma can usually be shelled out
after dividing the overlying soft parts. In the follicular variety, it
is usually sufficient to excise a portion of the wall, scrape out the
interior, and remove any tooth that may be present. The cavity is then
packed and allowed to heal from the bottom.

#Fibroma.#--A fibroma is a tumour composed of fibrous connective tissue.
A distinction may be made between the _soft fibroma_, which is
comparatively rich in cells and blood vessels, and in which the fibres
are arranged loosely; and the _hard fibroma_, which is composed of
closely packed bundles of fibres often arranged in a concentric fashion
around the blood vessels. The cut surface of the soft fibroma presents a
pinkish-white, fleshy appearance, resembling the slowly growing forms of
sarcoma; that of a hard fibroma presents a dry, glistening appearance,
aptly compared to watered silk. The soft variety grows much more rapidly
than the hard. In certain fibromas--in those, for example, which grow
from the periosteum of the base of the skull and project into the
naso-pharynx--the blood vessels are dilated into sinuses and have no
proper sheaths; they therefore tend to remain open when divided, and to
bleed excessively. Transition forms between soft fibroma and sarcoma are
met with, so that in operating for their removal it is safer to take
away the capsule along with the tumour, and the patient should be kept
under observation in view of the risk of recurrence.

The skin--especially the skin of the buttock--is one of the favourite
seats of fibroma, and it may occur in a multiple form. It is met with
also in the subcutaneous and intermuscular cellular tissue, and in the
abdominal wall, where it sometimes attains considerable dimensions.
Various forms of fibroma are met with in the mamma and are described
with diseases of that organ. The fibrous overgrowths in the skin, known
as _keloid_ and _molluscum fibrosum_, and those met with in the _sheaths
of nerves_, are described elsewhere. Fibroid tumours of the uterus are
described with myoma.

_Diffuse fibroma_ or _Fibromatosis_, analogous to lipomatosis, is met
with in the connective tissue of the skin and sheaths of nerves, and
constitutes one form of neuro-fibromatosis; a similar change is also met
with in the stomach and colon.

#Myxoma.#--A myxoma is composed of tissue of a soft gelatinous,
semifluid consistence. The pure myxoma is extremely rare, and
clinically resembles the lipoma. Myxomatous tissue is, however,
frequently found in other connective-tissue tumours as a result of
degeneration, for example, in cartilaginous tumours and in sarcomas.
Myxomatous tissue is also a prominent constituent of the "innocent
parotid tumour." Mucous polypus of the nose, which is often described as
a myxoma, is merely a pendulous process of œdematous mucous membrane.

[Illustration: FIG. 53.--Myeloma of Shaft of Humerus, causing
pathological fracture. (Mr. J. W. Struthers' case.)

(The unusual site of the tumour is to be noted.)]

#Myeloma.#--A myeloma is composed of large multinuclear giant cells
surrounded by round and spindle cells. The cut surface of the tumour
presents a deep red or maroon colour. While occasionally met with in
tendon sheaths and bursæ, and is then of an orange-yellow colour, the
myeloma occurs most frequently in the cancellous tissue at the ends of
the long bones, its favourite site being the upper end of the tibia.
Although formerly classified as a sarcoma, it is the exception for it to
present malignant features, and it can usually be extirpated by local
measures without fear of recurrence. The diagnosis, X-ray appearances,
and the method of removal are considered with the diseases of bone.
Sometimes the myeloma is met with in multiple form in the skeleton, in
association with an unusual form of protein in the urine (Bence Jones).

#Myoma.#--A myoma is composed of non-striped muscle fibres. A pure myoma
is very rare, and is met with in organs possessed of non-striped muscle,
such as the stomach, intestine, urinary bladder, and prostate. In the
uterus, which is the most common situation, these tumours contain a
considerable admixture of fibrous tissue, and are known as _fibroids_ or
_fibro-myomas_. They present on section a fasciculated appearance, which
may resemble that of a section of balls of cotton (Fig. 54). They are
encapsulated and vascular, frequently attain a large size, and may be
single or multiple. While they may occasion neither inconvenience nor
suffering, they frequently give rise to profuse hæmorrhage from the
uterus, and may cause serious symptoms by pressing injuriously on the
ureters or the intestine, or by complicating pregnancy and parturition.

The #Rhabdomyoma# is an extremely rare form of tumour, met with in the
kidney, uterus, and testicle. It contains striped muscle fibres, and is
supposed to originate from a residue of muscular tissue which has become
sequestrated during development.

[Illustration: FIG. 54.--Fibro-myoma of Uterus.

(Anatomical Museum, University of Edinburgh.)]

#Glioma.#--A glioma is a tumour composed of neuroglia. It is met with
exclusively in the central nervous system, retina, and optic nerve. It
is a slowly growing, soft, ill-defined tumour, which displaces the
adjacent nerve centres and nerve tracts, and is liable to become the
seat of hæmorrhage and thus to give rise to pressure symptoms resembling
apoplexy. The glioma of the retina tends to grow into the vitreous
humour and to perforate the globe. It is usually of the nature of a
glio-sarcoma and is highly malignant.

#Endotheliomas# take origin from the endothelium of lymph vessels and
blood vessels, and serous cavities. They show great variation in type,
partly because of the number of different kinds of endothelium from
which they are derived, and partly because the new connective tissue
which is formed is liable to undergo transformation into other tissues.
They may be soft or hard, solid or cystic, diffuse or circumscribed;
they grow very slowly, and are almost always innocent, although
recurrence has been occasionally observed. Cases of multiple
endotheliomata of the skin have recently been described by Wise.

_Angioma_, _lymphangioma_, and _neuroma_ are described with the disease
of the individual tissues.


MALIGNANT CONNECTIVE-TISSUE TUMOURS--SARCOMA

The term sarcoma is applied to any connective-tissue tumour which
exhibits malignant characters. The essential structural feature is the
predominance of the cellular elements over the intercellular substance
or stroma, in which respect a sarcoma resembles the connective tissue of
the embryo. The typical sarcoma consists chiefly of immature or
embryonic connective tissue. It most frequently originates from fascia,
intermuscular connective tissue, periosteum, bone-marrow, and skin, and
forms a rounded or nodulated tumour which appears to be encapsulated,
but the capsule merely consists of the condensed surrounding tissues,
and usually contains sarcomatous elements. The consistence of the tumour
depends on the nature and amount of the stroma, and on the presence of
degenerative changes. The softer medullary forms are composed almost
exclusively of cells; while the harder forms--such as the fibro-,
chondro-, and osteo-sarcoma--are provided with an abundant stroma and
are relatively poor in cells. Degenerative changes may produce areas of
softening or liquefaction which result in the formation of cystic
cavities in the interior of the tumour. The colour depends on the amount
of blood in the tumour, and on the presence of the products of
degeneration.

The blood vessels are usually represented by mere chinks or spaces
between the cells. This peculiarity accounts for the facility with which
hæmorrhage takes place into the substance of the tumour, the persistence
of the bleeding when it is incised or ulcerates through the skin, and
the readiness with which the sarcomatous cells are carried off and
infect distant parts through the blood-stream. Sarcomas are devoid of
lymphatics, and unless originating in lymphatic structures--for example,
in the tonsil--they rarely infect the lymph glands. Minute portions of
the tumour grow into the small veins, and, becoming detached, are
transported by the blood-current to distant organs, where they are
arrested in the capillaries and give rise to secondary growths. These
are most frequently situated in the lungs, except when the primary
growth lies within the territory of the portal circulation, in which
case they occur in the liver. The secondary growths closely resemble the
parent tumour. Sarcoma may invade an adjacent vein on such a scale that
if the invading portion becomes detached it may constitute a dangerous
embolus. This may be observed in sarcoma of the kidney, the growth
taking place along the renal vein until it projects into the vena cava.

[Illustration: FIG. 55.--Recurrent Sarcoma of Sciatic Nerve in a woman
æt. 27. Recurrence twenty months after removal of primary growth.]

In its growth, a sarcoma compresses and destroys neighbouring parts,
surrounds vessels and nerves, and may lead to destruction of the skin,
either by invading it, or more commonly by causing sloughing from
pressure. Inflammatory and suppurative changes may take place as a
result of pyogenic infection following upon sloughing of the overlying
skin or upon an exploratory incision. Once the skin is broken the tumour
fungates through the opening. Sarcomas vary in malignancy, especially as
regards rapidity of growth and capacity for dissemination. Certain of
them, such as the so-called "recurrent fibroid of Paget," grow
comparatively slowly, and are only malignant in the sense that they tend
to recur locally after removal; others--especially the more cellular
ones--grow with extreme rapidity, and are early disseminated throughout
the body, resembling in these respects the most malignant forms of
cancer. They are usually solitary in the first instance, although
primary multiple growths are occasionally met with in the skin and in
the bones.

Many varieties of sarcoma are recognised, according to its structural
peculiarities. Thus, in virtue of the size and character of the cells,
we have the _small round-celled_ and the _large round-celled_ sarcoma,
the _small_ and the _large spindle-celled_, the _giant-celled_ and the
_mixed-celled_ sarcoma. The _lympho-sarcoma_ presents a structure
similar to that of lymph-follicular tissue, and the _alveolar sarcoma_
an arrangement of cells in alveoli resembling that seen in cancers. When
there is a considerable amount of intercellular fibrous tissue, the
tumour is called a _fibro-sarcoma_.

[Illustration: FIG. 56.--Fungating Sarcoma of Arm.

(Dr. J. M'Watt's case.)]

The term _lymphangio-sarcoma_ is applied when the cells of the tumour
are derived from the endothelium of lymph spaces and vessels. The
_angio-sarcomas_ are those in which blood vessels form a prominent
element in the structure of the tumour. They are sometimes derived from
innocent angiomas, and they may be so vascular as to pulsate and on
auscultation yield a blowing murmur like an aneurysm. The
_glio-sarcoma_, _myxo-sarcoma_, _chondro-sarcoma_, and _myo-sarcoma_ are
mixed forms which usually develop in pre-existing innocent tumours. The
_osteo-sarcoma_ is characterised by the formation in the tumour of bone,
the medullary spaces being occupied by sarcomatous cells in place of
marrow. The _osteoid sarcoma_ is characterised by the formation of a
tissue resembling bone but deficient in lime salts, and the _petrifying
sarcoma_ by the formation of calcified areas in the stroma. These
varieties, although met with chiefly in the bones, may occur in soft
tissues such as muscle, and in such organs as the mamma. The pigmented
varieties include the _chloroma_, which is of a light-green colour, and
the _melanotic sarcoma_, which is brown or black. The _psammoma_ is a
sarcoma containing a material resembling sand; it is chiefly met with in
the membranes of the brain. The _chordoma_ is a rare form of tumour
originating from the remains of the notochord in the region of the
spheno-occipital synchondrosis or in the sacro-coccygeal region.

_Diagnosis of Sarcoma._--A sarcoma is to be differentiated from an
inflammatory swelling such as results from tubercle, actinomycosis, or
syphilis, from an innocent tumour, and from a cancer. The points on
which the diagnosis is founded are discussed with the different tissues
and organs.

_Treatment._--The removal of the tumour by operation is the most
reliable method of treatment; in order to be successful it must be
undertaken before dissemination has taken place, and a considerable area
of healthy tissue beyond the apparent margin of the growth must be
removed, and in tumours near the surface of the body, the overlying skin
also.

In order to prevent recurrence, a tube of _radium_, to which a silk
thread is attached, is inserted into the space from which the tumour was
removed; the thread is brought out at the drain-opening, and at the end
of a week or ten days the tube of radium is removed by pulling on the
thread. Radium causes a reaction in the tissues attended with exudation
from the vessels, for the escape of which provision must be made. If
radium is not available, the affected area is repeatedly exposed to the
action of the _X-rays_ as soon as the wound has healed. The employment
of these measures has diminished to a remarkable degree the recurrence
of sarcoma after operation.

It will readily be understood that the less thoroughly or radically the
growth has been removed, the more do we depend upon radium or the X-rays
for bringing about a permanent cure, and that in advanced cases of
sarcoma and in cases in which, on account of their anatomical situation,
removal by operation is necessarily incomplete, the prospect of cure is
still more dependent on the use of radium or of the X-rays. Finally,
there are cases in which removal by operation is impossible, the
so-called _inoperable sarcoma_; a tube of radium, to which a silk thread
is attached, is inserted into the substance of the tumour, either
through an opening made by a large trocar, or, when necessary, by open
dissection. A second tube of radium is placed upon the skin over the
tumour and is secured there by a stitch or by a strip of plaster, thus
securing a cross-fire action of the radium rays, both from within and
without, as this is found to be much more efficacious in destroying or
inhibiting the cellular elements of the growth. The tubes of radium are
left _in situ_ for from eight to fourteen days, according to the power
of the radium employed, but are moved about every second day or so in
order that every part of the tumour may be efficiently radiated. If the
tumour shrinks in size after the use of radium and becomes operable, it
should be removed before time is given it to resume its growth. It will
depend upon the subsequent course of the disease, whether or not a
second, or it may be even a third, application of radium will be
required.

Where neither radium nor X-rays is available or applicable, recourse may
be had to the injection of Coley's fluid, a preparation containing the
mixed toxins of the streptococcus of erysipelas and the bacillus
prodigiosus; or of selenium.


EPITHELIAL TUMOURS

An excessive and erratic growth of epithelium is the essential and
distinguishing feature of these tumours. The innocent forms are the
papilloma and the adenoma; the malignant, the carcinoma or cancer.

#Papilloma.#--A papilloma is a tumour which projects from a cutaneous or
mucous surface, and consists of a central axis of vascular fibrous
tissue with a covering of epithelium resembling that of the surface from
which the tumour grows. In the papillomas of the skin--commonly known as
_warts_--the covering consists of epidermis; in those growing from
mucous surfaces it consists of the epithelium covering the mucous
membrane. When the surface epithelium projects as filiform processes,
the tumour is called a _villous papilloma_, the best-known example of
which is met with in the urinary bladder. Papillomatous growths are
also met with in the larynx, in the ducts of the breast, and in the
interior of certain cystic tumours of the breast and of the ovary.
Although papillomas are primarily innocent, they may become the
starting-point of cancer, especially in persons past middle life and if
the papilloma has been subjected to irritation and has ulcerated. The
clinical features and treatment of the various forms of papilloma are
considered with the individual tissues and organs.

#Adenoma.#--An adenoma is a tumour constructed on the type of, and
growing in connection with, a secreting gland. In the substance of such
glands as the mamma, parotid, thyreoid, and prostate, adenomas are met
with as encapsulated tumours. When they originate from the glands of the
skin or of a mucous membrane, they tend to project from the surface, and
form pedunculated tumours or polypi.

Adenomas may be single or multiple, and they vary greatly in size. The
tumour is seldom composed entirely of gland tissue; it usually contains
a considerable proportion of fibrous tissue, and is then called a
_fibro-adenoma_. When it contains myxomatous tissue it is called a
_myxo-adenoma_, and when the gland spaces of the tumour become distended
with accumulated secretion, a _cystic adenoma_, the best examples of
which are met with in the mamma and ovary. A characteristic feature of
the cystic variety is the tendency the tumour tissue exhibits to project
into the interior of the cysts, constituting what are known as
_intracystic growths_. They are essentially innocent, but intracystic
growths, especially in the mamma of women over fifty, should be regarded
with suspicion and therefore should be removed on radical lines.
Transition forms between adenoma and carcinoma are also met with in the
rectum and large intestine, and these should be treated on the same
lines as cancer.


CARCINOMA OR CANCER

A cancer is a malignant tumour which originates in epithelium. The
cancer cells are derived by proliferation from already existing
epithelium, and they invade the sub-epithelial connective tissue in the
form of simple or branching columns. These columns are enclosed in
spaces--termed alveoli--which are probably dilated lymph spaces, and
which communicate freely with the lymph vessels. The cells composing the
columns and filling the alveoli vary with the character of the
epithelium in which the cancer originates. The malignancy of cancer
depends on the tendency which the epithelium has of invading the tissues
in its neighbourhood, and on the capacity of the cells, when
transported elsewhere by the lymph or blood-stream, of giving rise to
secondary growths.

Cancer may arise on any surface covered by epithelium or in any of the
secreting glands of the body, but it is much more common in some
situations than in others. It is frequently met with, for example, in
the skin, in the stomach and large intestine, in the breast, the uterus,
and the external genitals; less frequently in the gall-bladder, larynx,
thyreoid, prostate, and urinary bladder.

Tissues appear to be most liable to cancer when, having attained
maturity, they enter upon the phase of decadence or involution, and this
phase is reached by different tissues at different periods. It is not so
much, therefore, the age of the person in whom it occurs, as the age of
the tissue in which it arises, that determines the maximum incidence of
cancer. Cancer of the stomach appears and attains a maximum frequency
earlier than cancer of the skin; cancer of the uterus and mamma is more
frequent towards the decline of reproductive activity than in the later
years of life; rectal cancer is not infrequently met with during the
second and third decades. There is evidence that the irritation caused
by alcohol and tobacco plays a part in the causation of cancer, in the
fact that a large proportion of those who become the subjects of cancer
of the mouth are excessive drinkers and smokers.

A cancer may appear as a papillary growth on a mucous or a skin surface,
as a nodule in the substance of an organ, or as a diffuse thickening of
a tubular organ such as the stomach or intestine. The absence of
definition in cancerous tumours explains the difficulty of completely
removing them by surgical measures, and has led to the practice of
complete extirpation of cancerous organs wherever this is possible. The
boundaries of the affected organ, moreover, are frequently transgressed
by the disease, and the epithelial infiltration implicates the
surrounding parts. In cancer of the breast, for example, the disease
often extends to the adjacent skin, fat, and muscle; in cancer of the
lip or tongue, to the mandible; in cancer of the uterus or intestine, to
the investing peritoneum.

In addition to its tendency to infiltrate adjacent tissues and organs,
cancer is also liable to give rise to _secondary growths_. These are
most often met with in the nearest lymph glands; those in the neck, for
example, becoming infected from cancer of the lip, tongue, or throat;
those in the axilla, from cancer of the breast; those along the
curvatures of the stomach, from cancer of the pylorus; and those in the
groin, from cancer of the external genitals. In lymph vessels the cancer
cells may merely accumulate so as to fill the lumen and form indurated
cords, or they may proliferate and give rise to secondary nodules along
the course of the vessels. When the lymphatic network in the skin is
diffusely infected, the appearance is either that of a multitude of
secondary nodules or of a diffuse thickening, so that the skin comes to
resemble coarse leather. On the wall of the chest this condition is
known as _cancer en cuirasse_. Although the cancer cells constantly
attack the walls of the adjacent veins and spread into their interior at
a comparatively early period, secondary growths due to dissemination by
the blood-stream rarely show themselves clinically until late in the
course of the disease. It is probable that many of the cancer cells
which are carried away in the blood or lymph stream undergo necrosis and
fail to give rise to secondary growths. Secondary growths present a
faithful reproduction of the structure of the primary tumour. Apart from
the lymph glands, the chief seats of secondary growths are the liver,
lungs, serous membranes, and bone marrow.

It is generally believed that the secondary growths in cancer that
develop at a distance from the primary tumour, those, for example, in
the medullary canal of the femur or in the diploë of the skull occurring
in advanced cases of cancer of the breast, are the result of
dissemination of cancer cells by way of the blood-stream and are to be
regarded as emboli. Sampson Handley disagrees with this view; he
believes that the dissemination is accomplished in a more subtle way,
namely, by the actual growth of cancer cells along the finer vessels of
the lymph plexuses that ramify in the deep fascia, a method of spread
which he calls _permeation_. It is maintained also that permeation
occurs as readily against the lymph stream as with it. He compares the
spread of cancer to that of an invisible annular ringworm. The growing
edge extends in a wider and wider circle, within which a healing process
may occur, so that the area of permeation is a ring, rather than a disc.
Healing occurs by a process of "peri-lymphatic fibrosis," but as the
natural process of healing may fail at isolated points, nodules of
cancer appear, which, although apparently separate from the primary
growth, have developed in continuity with it, peri-lymphatic fibrosis
having destroyed the cancer chain connecting the nodule with the primary
growth. This centrifugal spread of cancer is clearly seen in the
distribution of the subcutaneous secondary nodules so frequently met
with in the late stages of mammary cancer. The area within which the
secondary nodules occur is a circle of continually increasing diameter
with the primary growth in the centre.

In the rare cases in which the skin of the greater part of the body is
affected, the nodules rarely appear below the level of the deltoid or
the middle third of the thigh, the patient dying before the spread can
reach the distal portions of the limbs.

Handley argues against the embolic origin of the metastases in the bones
because of the rarity of these in the bones of the distal parts of the
limbs, because of the fact that secondary cancer of the femur nearly
always commences in the upper third of the shaft, which harmonises with
the intimate connection of the deep fascia with the periosteum over the
great trochanter, thus favouring invasion of the bone marrow when
permeation has spread thus far. He claims support for the permeation
theory from the fact that the humerus is rarely involved below the
insertion of the deltoid, and that spontaneous fracture of the femur is
three times more common on the side on which the breast cancer is
situated.

The tumour tissue may undergo necrosis, and when the overlying skin or
mucous membrane gives way an ulcer is formed. The margins of a
_cancerous ulcer_ (Fig. 57) are made up of tumour tissue which has not
broken down. Usually they are irregular, nodularly thickened or
indurated; sometimes they are raised and crater-like. The floor of the
ulcer is smooth and glazed, or occupied by necrosed tissue, and the
discharge is watery and blood-stained, and as a result of putrefactive
changes may become offensive. Hæmorrhage is rarely a prominent feature,
but discharge of blood may constitute a symptom of considerable
diagnostic importance in cancer of internal organs such as the rectum,
the bladder, or the uterus.

[Illustration: FIG. 57.--Carcinoma of Breast with Cancerous Ulcer.]

_The Contagiousness of Cancer._--A limited number of cases are on record
in which a cancer appears to have been transferred by contact, as from
the lower to the upper lip, from one labium majus to the other, from the
tongue to the cheek, and from one vocal cord to the other; these being
all examples of cancer involving surfaces which are constantly or
frequently in contact. The transference of cancer from one human being
to another, whether by accident, as in the case of a surgeon wounding
his finger while operating for cancer, or by the deliberate introduction
of a portion of cancerous tumour into the tissues, has never been known
to occur. It is by no means infrequent, however, that when recurrence
takes place after an operation for the removal of cancer, the recurrent
nodules make their appearance in the main scar or in the scars of
stitches in its neighbourhood. In the lower animals the grafting of
cancer only succeeds in animals of the same species; for example, a
cancer taken from a mouse will not grow in the tissues of a rat, but
only in a mouse of the same variety as that from which the graft was
taken.

While cancer cannot be regarded as either contagious or infectious, it
is important to bear in mind the possibility of infection of a wound
with cancer when operating for the disease. A cancer should not be cut
into unless this is essential for purposes of diagnosis, and the wound
made for exploration should be tightly closed by stitches before the
curative operation is proceeded with; the instruments used for the
exploration must not be used again until they have been boiled. The
greatest care should be taken that a cancer which has softened or broken
down is not opened into during the operation.

Investigations regarding the cause of cancer have been prosecuted with
great energy during recent years, but as yet without positive result. It
is recognised that there are a number of conditions which favour the
development of cancer, such as prolonged irritation, and a considerable
number of cases have been recorded in which cancer of the skin of the
hands has followed prolonged and repeated exposure to the Röntgen rays.

_The Alleged Increase of Cancer._--Regarding the alleged increase of
cancer, it may be pointed out that it is impossible to ascertain how
much of the apparent increase is due to more accurate diagnosis and
improved registration. It is probable also that some increase has taken
place in consequence of the increased average duration of life; a larger
proportion of persons now reach the age at which cancer is frequent.

_The prognosis_ largely depends on the variety of cancer and on its
situation. Certain varieties--such as the atrophic cancer of the breast
which occurs in old people, and some forms of cancer in the rectum--are
so indolent in their progress that they can scarcely be said to shorten
life; while others--such as the softer varieties of mammary cancer
occurring in young women--are among the most malignant of tumours. The
mode in which cancer causes death depends to a large extent upon its
situation. In the gullet, for example, it usually causes death by
starvation; in the larynx or thyreoid, by suffocation; in the intestine,
by obstruction of the bowels; in the uterus, prostate, and bladder, by
hæmorrhage or by implication of the ureters and kidneys. Independently
of their situation, however, cancers frequently cause death by giving
rise to a progressive impairment of health known as the _cancerous
cachexia_, a condition which is due to the continued absorption of
poisonous products from the tumour. The patient loses appetite, becomes
emaciated, pale, and feverish, and gradually loses strength until he
dies. In many cases, especially those in which ulceration has occurred,
the addition of pyogenic infection may also be concerned in the failure
of health.

_Treatment._--Removal by surgical means affords the best prospect of
cure. If carcinomatous disease is to be rooted out, its mode of spread
by means of the lymph vessels must be borne in mind, and as this occurs
at an early stage, and is not evident on examination, a wide area must
be included in the operation. The organ from which the original growth
springs should, if practicable, be altogether removed, because its lymph
vessels generally communicate freely with each other, and secondary
deposits have probably already taken place in various parts of it. In
addition, the nearest chain of lymph glands must also be removed, even
though they may not be noticeably enlarged, and in some cases--in cancer
of the breast, for example--the intervening lymph vessels should be
removed at the same time.

The treatment of cancer by other than operative methods has received a
great deal of attention within recent years, and many agents have been
put to the test, _e.g._ colloidal suspensions of selenium, but without
any positive results. Most benefit has resulted from the use of radium
and of the X-rays, and one or other should be employed as a routine
measure after every operation for cancer.

It has been demonstrated that cancer cells are more sensitive to radium
and to the Röntgen rays than the normal cells of the body, and are more
easily killed. The effect varies a good deal with the nature and seat of
the tumour. In rodent cancers of the skin, for example, both radium and
X-ray treatment are very successful, and are to be preferred to
operation because they yield a better cosmetic result. While small
epitheliomas of the skin may be cured by means of the rays, they are not
so amenable as rodent cancers.

Cancers of mucous membranes are less amenable to ray treatment because
they are less circumscribed and are difficult of access. In cancers
under the skin, the Röntgen rays are less efficient; if radium is
employed, the tube containing it should be inserted into the substance
of the tumour after the method described in connection with sarcoma--and
another tube should be placed on the overlying skin.

In the employment of X-rays and of radium in the treatment of cancer,
experience is required, not only to obtain the maximum effect of the
rays, but to avoid damage to the adjacent and overlying tissues.

Ray treatment is not to be looked upon as a rival but as a powerful
supplement to the operative treatment of cancer.


VARIETIES OF CANCER

The varieties of cancer are distinguished according to the character and
arrangement of the epithelial cells.

The _squamous epithelial cancer_ or _epithelioma_ originates from a
surface covered by squamous epithelium, such as the skin, or the mucous
membrane of the mouth, gullet, or larynx. The cancer cells retain the
characters of squamous epithelium, and, being confined within the lymph
spaces of the sub-epithelial connective tissue, become compressed and
undergo a horny change. This results in the formation of concentrically
laminated masses known as cell nests.

The clinical features are those of a slowly growing indurated tumour,
which nearly always ulcerates; there is a characteristic induration of
the edges and floor of the ulcer, and its surface is often covered with
warty or cauliflower-like outgrowths (Fig. 58). The infection of the
lymph glands is early and constant, and constitutes the most dangerous
feature of the disease; the secondary growths in the glands exhibit the
characteristic induration, and may themselves break down and lead to the
formation of ulcers.

[Illustration: FIG. 58.--Epithelioma of Lip.]

Epithelioma frequently originates in long-standing ulcers or sinuses,
and in scars, and probably results from the displacement and
sequestration of epithelial cells during the process of cicatrisation.

The _columnar epithelial cancer_ or _columnar epithelioma_ originates in
mucous membranes covered with columnar epithelium, and is chiefly met
with in the stomach and intestine. As it resembles an adenoma in
structure it is sometimes described as a _malignant adenoma_. Its
malignancy is shown by the proliferating epithelium invading the other
coats of the stomach or intestine, and by the development of secondary
growths.

_Glandular carcinoma_ originates in organs such as the breast, and in
the glands of mucous membranes and skin. The epithelial cells are not
arranged on any definite plan, but are closely packed in irregularly
shaped alveoli. If the alveoli are large and the intervening stroma is
scanty and delicate, the tumour is soft and brain-like, and is described
as a _medullary_ or _encephaloid cancer_. If the alveoli are small and
the intervening stroma is abundant and composed of dense fibrous tissue,
the tumour is hard, and is known as a _scirrhous cancer_--a form which
is most frequently met with in the breast. If the cells undergo
degeneration and absorption and the stroma contracts, the tumour becomes
still harder, and tends to shrink and to draw in the surrounding parts,
leading, in the breast, to retraction of the nipple and overlying skin,
and in the stomach and colon to narrowing of the lumen. When the cells
of the tumour undergo colloid degeneration, a _colloid cancer_ results;
if the degeneration is complete, as may occur in the breast, the
malignancy is thereby greatly diminished; if only partial, as is more
common in rectal cancer, the malignancy is not appreciably affected.
Melanin pigment is formed in relation to the cells and stroma of certain
epithelial tumours, giving rise to _melanotic cancer_, one of the most
malignant of all new growths. Cyst-like spaces may form in the tumour by
the accumulation of the secretion of the epithelial cells, or as a
result of their degeneration--_cystic carcinoma_. This is met with
chiefly in the breast and ovary, and the tumour resembles the cystic
adenoma, but it tends to infect its surroundings and gives rise to
secondary growths.

_Rodent cancer_ originates in the glands of the skin, and presents a
special tendency to break down and ulcerate on the surface (Figs. 102
and 103). It almost never infects the lymph glands.


DERMOIDS

A dermoid is a tumour containing skin or mucous membrane, occurring in a
situation where these tissues are not met under normal conditions.

The _skin dermoid_, or _derma-cyst_ as it has been called by Askanazy,
arises from a portion of epiblast, which has become sequestrated during
the process of coalescence of two cutaneous surfaces in development.
This form is therefore most frequently met with on the face and neck in
the situations which correspond to the various clefts and fissures of
the embryo. It occurs also on the trunk in situations where the lateral
halves of the body coalesce during development. Such a dermoid usually
takes the form of a globular cyst, the wall of which consists of skin,
and the contents of turbid fluid containing desquamated epithelium, fat
droplets, cholestrol crystals, and detached hairs. Delicate hairs may
also be found projecting from the epithelial lining of the cyst.

Faulty coalescence of the cutaneous covering of the back occurs most
frequently over the lower sacral vertebræ, giving rise to small
congenital recesses, known as post-anal dimples and coccygeal sinuses.
These recesses are lined with skin, which is furnished with hairs,
sebaceous and sweat glands. If the external orifice becomes occluded,
there results a dermoid cyst.

_Tubulo-dermoids_ arise from embryonic ducts and passages that are
normally obliterated at birth, for example, _lingual dermoids_ develop
in relation to the thyreo-glossal duct; _rectal and post-rectal_
dermoids to the post-anal gut; and _branchial dermoids_ in relation to
the branchial clefts. Tubulo-dermoids present the same structure as skin
dermoids, save that mucous membrane takes the place of skin in the wall
of the cyst, and the contents consist of the pent-up secretion of mucous
glands.

_Clinical Features._--Although dermoids are of congenital origin, they
are rarely evident at birth, and may not give rise to visible tumours
until puberty, when the skin and its appendages become more active, or
not till adult life. Superficial dermoids, such as those met with at the
outer angle of the orbit, form rounded, definitely limited tumours over
which the skin is freely movable. They are usually adherent to the
deeper parts, and when situated over the skull may be lodged in a
depression or actual gap in the bone. Sometimes the cyst becomes
infected and suppurates, and finally ruptures on the surface. This may
lead to a natural cure, or a persistent sinus may form. Dermoids more
deeply placed, such as those within the thorax, or those situated
between the rectum and sacrum, give rise to difficulty in diagnosis,
even with the help of the X-rays, and their nature is seldom recognised
until the escape of the contents--particularly hairs--supplies the clue.
The literature of dermoid cysts is full of accounts of puzzling tumours
met with in all sorts of situations.

The treatment is to remove the cyst. When it is impossible to remove the
whole of the lining membrane by dissection, the portion that is left
should be destroyed with the cautery.

_Ovarian Dermoids._--Dermoids are not uncommon in the ovary (Fig. 59).
They usually take the form of unilocular or multilocular cysts, the
wall of which contains skin, mucous membrane, hair follicles, sebaceous,
sweat, and mucous glands, nails, teeth, nipples, and mammary glands. The
cavity of the cyst usually contains a pultaceous mixture of shed
epithelium, fluid fat, and hair. If the cyst ruptures, the epithelial
elements are diffused over the peritoneum, and may give rise to
secondary dermoids.

[Illustration: FIG. 59.--Dermoid Cyst of Ovary showing Teeth in its
interior.]

The ovarian dermoid appears clinically as an abdominal or pelvic tumour
provided with a pedicle; if the pedicle becomes twisted, the tumour
undergoes strangulation, an event which is attended with urgent
symptoms, not unlike those of strangulated hernia.

The treatment consists in removing the tumour by laparotomy.

#Teratoma.#--A teratoma is believed to result from partial dichotomy or
cleavage of the trunk axis of the embryo, and is found exclusively in
connection with the skull and vertebral column. It may take the form of
a monstrosity such as conjoined twins or a parasitic fœtus, but more
commonly it is met with as an irregularly shaped tumour, usually growing
from the sacrum. On dissection, such a tumour is found to contain a
curious mixture of tissues--bones, skin, and portions of viscera, such
as the intestine or liver. The question of the removal of the tumour
requires to be considered in relation to the conditions present in each
individual case.


CYSTS[3]

[3] Cysts which form in relation to new-growths have been considered
with tumours.

Cysts are rounded sacs, the wall being composed of fibrous tissue lined
by epithelium or endothelium; the contents are fluid or semi-solid, and
vary in character according to the tissue in which the cyst has
originated.

_Retention and Exudation Cysts._--_Retention cysts_ develop when the
duct of a secreting gland is partly obstructed; the secretion
accumulates, and the gland and its duct become distended into a cyst.
They are met with in the mamma and in the salivary glands. Sebaceous
cysts or wens are described with diseases of the skin. _Exudation cysts_
arise from the distension of cavities which are not provided with
excretory ducts, such as those in the thyreoid.

_Implantation cysts_ are caused by the accidental transference of
portions of the epidermis into the underlying connective tissue, as may
occur in wounds by needles, awls, forks, or thorns. The implanted
epidermis proliferates and forms a small cyst. They are met with chiefly
on the palmar aspect of the fingers, and vary in size from a split pea
to a cherry. The treatment consists in removing them by dissection.

_Parasitic cysts_ are produced by the growth within the tissues of
cyst-forming parasites, the best known being the tænia echinococcus,
which gives rise to the _hydatid cyst_. The liver is by far the most
common site of hydatid cysts in the human subject.

With regard to the further life-history of hydatids, the living elements
of the cyst may die and degenerate, or the cyst may increase in size
until it ruptures. As a result of pyogenic infection the cyst may be
converted into an abscess.

The _clinical features_ of hydatids vary so much with their situation
and size, that they are best discussed with the individual organs. In
general it may be said that there is a slow formation of a globular,
elastic, fluctuating, painless swelling. Fluctuation is detected when
the cyst approaches the surface, and it is then also that percussion
may elicit the "hydatid thrill" or fremitus. This thrill is not often
obtainable, and in any case is not pathognomonic of hydatids, as it may
be elicited in ascites and in other abdominal cysts. Pressure of the
cyst upon adjacent structures, and the occurrence of suppuration, are
attended with characteristic clinical features.

The _diagnosis_ of hydatids will be considered with the individual
organs. The disease is more common in certain parts of Australia and in
Shetland and Iceland than in countries where the association of dogs in
the domestic life of the inhabitants is less intimate. Pfeiler, who has
worked at the _serum diagnosis of hydatid disease_, regards the
complement deviation method as the most reliable; he believes that a
positive reaction may almost be regarded as absolutely diagnostic of an
echinococcal lesion.

The _treatment_ is to excise the cyst completely, or to inject into it a
1 per cent. solution of formalin. In operating upon hydatids the utmost
care must be taken to avoid leakage of the contents of the cyst, as
these may readily disseminate the infection.

A _blood cyst_ or hæmatoma results from the encapsulation of
extravasated blood in the tissues, from hæmorrhage taking place into a
preformed cyst, or from the saccular pouching of a varicose vein.

A _lymph cyst_ usually results from a contusion in which the skin is
forcibly displaced from the subjacent tissues, and lymph vessels are
thereby torn across. The cyst is usually situated between the skin and
fascia, and contains clear or blood-stained serum. At first it is lax
and fluctuates readily, later it becomes larger and more tense. The
treatment consists in drawing off the contents through a hollow needle
and applying firm pressure. Apart from injury, lymph cysts are met with
as the result of the distension of lymph spaces and vessels
(_lymphangiectasis_); and in lymphangiomas, of which the best-known
example is the cystic hygroma or hydrocele of the neck.


GANGLION

This term is applied to a cyst filled with a clear colourless jelly or
colloid material, met with in the vicinity of a joint or tendon sheath.

The commonest variety--the _carpal ganglion_--popularly known as a
sprained sinew--is met with as a smooth, rounded, or oval swelling on
the dorsal aspect of the carpus, usually towards its radial side (Fig. 60).
It is situated over one of the intercarpal or other joints in this
region, and may be connected with one or other of the extensor tendons.
The skin and fascia are movable over the cyst. The cyst varies in size
from a pea to a pigeon's egg, and usually attains its maximum size
within a few months and then remains stationary. It becomes tense and
prominent when the hand is flexed towards the palm. Its appearance is
usually ascribed to some strain of the wrist--for example, in girls
learning gymnastics. It may cause no symptoms or it may interfere with
the use of the hand, especially in grasping movements and when the hand
is dorsiflexed. In girls it may give rise to pain which shoots up the
arm. Ganglia are also met with on the dorsum of the metacarpus and on
the palmar aspect of the wrist.

[Illustration: FIG. 60.--Carpal Ganglion in a woman æt. 25.]

The _tarsal ganglion_ is situated on the dorsum of the foot over one or
other of the intertarsal joints. It is usually smaller, flatter, and
more tense than that met with over the wrist, so that it is sometimes
mistaken for a bony tumour. It rarely causes symptoms, unless so
situated as to be pressed upon by the boot.

_Ganglia in the region of the knee_ are usually situated over the
interval between the femur and tibia, most often on the lateral aspect
of the joint in front of the tendon of the biceps (Fig. 61). The
swelling, which may attain the size of half a walnut, is tense and hard
when the knee is extended, and becomes softer and more prominent when it
is flexed. They are met with in young adults who follow laborious
occupations or who indulge in athletics, and they cause stiffness,
discomfort, and impairment of the use of the limb. A ganglion is
sometimes met with on the median aspect of the head of the metatarsal
bone of the great toe and may be the cause of considerable suffering; it
is indistinguishable from the thickened and enlarged bursa so commonly
present in this situation in the condition known as bunion.

[Illustration: FIG. 61.--Ganglion on lateral aspect of Knee in a young
woman.]

Ganglionic cysts are met with in other situations than those mentioned,
but they are so rare as not to require separate description.

Ganglia are to be diagnosed by their situation and physical characters;
enlarged bursæ, synovial cysts, and new-growths are the swellings most
likely to be mistaken for them. The diagnosis is sometimes only cleared
up by withdrawing the clear, jelly-like contents through a hollow
needle.

_Pathological Anatomy._--The wall of the cyst is composed of fibrous
tissue closely adherent to or fused with the surrounding tissues, so
that it cannot be shelled out. There is no endothelial lining, and the
fibrous tissue of the wall is in immediate contact with the colloid
material in the interior, which appears to be derived by a process of
degeneration from the surrounding connective tissue. In the region of
the knee the ganglion is usually multilocular, and consists of a
meshwork of fibrous tissue, the meshes of which are occupied by colloid
material.

It is often stated that a ganglion originates from a hernial protrusion
of the synovial membrane of a joint or tendon sheath. We have not been
able to demonstrate any communication between the cavity of the cyst
and that of an adjacent tendon sheath or joint. It is possible, however,
that the cyst may originate from a minute portion of synovial membrane
being protruded and strangulated so that it becomes disconnected from
that to which it originally belonged; it may then degenerate and give
rise to colloid material, which accumulates and forms a cyst. Ledderhose
and others regard ganglia as entirely new formations in the
peri-articular tissues, resulting from colloid degeneration of the
fibrous tissue of the capsular ligament, occurring at first in numerous
small areas which later coalesce. Ganglia are probably, therefore, of
the nature of degeneration cysts arising in the capsule of joints, in
tendons, and in their sheaths.

_Treatment._--A ganglion can usually be got rid of by a modification of
the old-fashioned seton. The skin and cyst wall are transfixed by a
stout needle carrying a double thread of silkworm gut; some of the
colourless jelly escapes from the punctures; the ends of the thread are
tied and cut short, and a dressing is applied. A week later the threads
are removed and the minute punctures are sealed with collodion. The
action of the threads is to convert the cyst wall into granulation
tissue, which undergoes the usual conversion into scar tissue. If the
cyst re-forms, it should be removed by open dissection under local
anæsthesia. Puncture with a tenotomy knife and scraping the interior,
and the injection of irritants, are alternative, but less satisfactory,
methods of treatment.

_Ganglia_ in the substance of _tendons_ are rare. The diagnosis rests on
the observation that the small tumour is cystic, and that it follows the
movements of the tendon. The cyst is at first multiple, but the
partitions disappear, and the spaces are thrown into one. The tendon is
so weakened that it readily ruptures. The best treatment is to resect
the affected segment of tendon.

The so-called "compound palmar ganglion" is a tuberculous disease of the
tendon sheaths, and is described with diseases of tendon sheaths.



CHAPTER XI

INJURIES


CONTUSIONS--WOUNDS: _Varieties_--WOUNDS BY FIREARMS AND
    EXPLOSIVES: _Pistol-shot wounds_; _Wounds by sporting guns_;
    _Wounds by rifle bullets_; _Wounds received in warfare_; _Shell
    wounds_. _Embedded foreign bodies_--BURNS AND
    SCALDS--INJURIES PRODUCED BY ELECTRICITY: _X-ray and
    radium_; _Electrical burns_; _Lightning stroke_.


CONTUSIONS

A contusion or bruise is a laceration of the subcutaneous soft tissues,
without solution of continuity of the skin. When the integument gives
way at the same time, a _contused-wound_ results. Bruising occurs when
force is applied to a part by means of a blunt object, whether as a
direct blow, a crush, or a grazing form of violence. If the force acts
at right angles to the part, it tends to produce localised lesions which
extend deeply; while, if it acts obliquely, it gives rise to lesions
which are more diffuse, but comparatively superficial. It is well to
remember that those who suffer from scurvy, or hæmophilia (bleeders),
and fat and anæmic females, are liable to be bruised by comparatively
trivial injuries.

_Clinical Features._--The less severe forms of contusion are associated
with _ecchymosis_, numerous minute and discrete punctate hæmorrhages
being scattered through the superficial layers of the skin, which is
slightly œdematous. The effused blood is soon reabsorbed.

The more severe forms are attended with _extravasation_, the
extravasated blood being widely diffused through the cellular tissue of
the part, especially where this is loose and lax, as in the region of
the orbit, the scrotum and perineum, and on the chest wall. A blue or
bluish-black discoloration occurs in patches, varying in size and depth
with the degree of force which produced the injury, and in shape with
the instrument employed. It is most intense in regions where the skin is
naturally thin and pigmented. In parts where the extravasated blood is
only separated from the oxygen of the air by a thin layer of epidermis
or by a mucous membrane, it retains its bright arterial colour. These
points are often well illustrated in cases of black eye, where the blood
effused under the conjunctiva is bright red, while that in the eyelids
is almost black. In severe contusions associated with great tension of
the skin--for example, over the front of the tibia or around the
ankle--blisters often form on the surface and constitute a possible
avenue of infection. When deeply situated, the blood tends to spread
along the lines of least resistance, partly under the influence of
gravity, passing under fasciæ, between muscles, along the sheaths of
vessels, or in connective-tissue spaces, so that it may only reach the
surface after some time, and at a considerable distance from the seat of
injury. This fact is sometimes of importance in diagnosis, as, for
example, in certain fractures of the base of the skull, where
discoloration appears under the conjunctiva or behind the mastoid
process some days after the accident.

Blood extravasated deeply in the tissues gives rise to a firm,
resistant, doughy swelling, in which there may be elicited on deep
palpation a peculiar sensation, not unlike the crepitus of fracture.

It frequently happens that, from the tearing of lymph vessels, serous
fluid is extravasated, and a _lymphatic_ or _serous cyst_ may form.

In all contusions accompanied by extravasation, there is marked swelling
of the area involved, as well as pain and tenderness. The temperature
may rise to 101° F., or, in the large extravasations that occur in
bleeders, even higher--a form of aseptic fever. The degree of shock is
variable, but sudden syncope frequently results from severe bruises of
the testicle, abdomen, or head, and occasionally marked nervous
depression follows these injuries.

Contusion of muscles or nerves may produce partial atrophy and paresis,
as is often seen after injuries in the region of the shoulder.

In alcoholic or other debilitated patients, suppuration is liable to
ensue in bruised parts, infection taking place from cocci circulating in
the blood, or through the overlying skin.

_Terminations of Contusions._--The usual termination is a complete
return to the normal, some of the extravasated blood being organised,
but most of it being reabsorbed. During the process characteristic
alterations in the colour of the effused blood take place as a result of
changes in the blood pigment. In from twenty-four to forty-eight hours
the margins of the blue area become of a violet hue, and as time goes on
the discoloured area increases in size, and becomes successively green,
yellow, and lemon-coloured at its margins, the central part being the
last to change. The rate at which this play of colours proceeds is so
variable, and depends on so many circumstances, that no time-limits can
be laid down. During the disintegration of the effused blood the
adjacent lymph glands may become enlarged, and on dissection may be
found to be pigmented. Sometimes the blood persists as a collection of
fluid with a newly formed connective-tissue capsule, constituting a
_hæmatoma_ or _blood cyst_, more often met with in the scalp than in
other parts.

The impairment of the blood supply of the skin may lead to the formation
of _blisters_, or to _necrosis_. Death of skin is more liable to occur
in bleeders, and when the slough separates the blood-clot is exposed and
the reparative changes go on extremely slowly. _Suppuration_ may occur
and lead to the formation of an abscess as a result of direct infection
from the skin or through the circulation.

_Treatment._--If the patient is seen immediately after the accident,
elevation of the part, and firm pressure applied by means of a thick pad
of cotton wool and an elastic bandage, are useful in preventing effusion
of blood. Ice-bags and evaporating lotions are to be used with caution,
as they are liable to lower the vitality of the damaged tissues and lead
to necrosis of the skin.

When extravasation has already taken place, massage is the most speedy
and efficacious means of dispersing the effused blood. The part should
be massaged several times a day, unless the presence of blebs or
abrasions of the skin prevents this being done. When this is the case,
the use of antiseptic dressings is called for to prevent infection and
to promote healing, after which massage is employed.

When the tension caused by the extravasated blood threatens the vitality
of the skin, incisions may be made, if asepsis can be assured. The blood
from a hæmatoma may be withdrawn by an exploring needle, and the
puncture sealed with collodion. Infective complications must be looked
for and dealt with on general principles.


WOUNDS

A wound is a solution in the continuity of the skin or mucous membrane
and of the underlying tissues, caused by violence.

Three varieties of wounds are described: incised, punctured, and
contused and lacerated.

#Incised Wounds.#--Typical examples of incised wounds are those made by
the surgeon in the course of an operation, wounds accidentally inflicted
by cutting instruments, and suicidal cut-throat wounds. It should be
borne in mind in connection with medico-legal inquiries, that wounds of
soft parts that closely overlie a bone, such as the skull, the tibia, or
the patella, although, inflicted by a blunt instrument, may have all the
appearances of incised wounds.

_Clinical Features._--One of the characteristic features of an incised
wound is its tendency to gape. This is evident in long skin wounds, and
especially when the cut runs across the part, or when it extends deeply
enough to divide muscular fibres at right angles to their long axis. The
gaping of a wound, further, is more marked when the underlying tissues
are in a state of tension--as, for example, in inflamed parts. Incised
wounds in the palm of the hand, the sole of the foot, or the scalp,
however, have little tendency to gape, because of the close attachment
of the skin to the underlying fascia.

Incised wounds, especially in inflamed tissues, tend to bleed profusely;
and when a vessel is only partly divided and is therefore unable to
contract, it continues to bleed longer than when completely cut across.

The _special risks_ of incised wounds are: (1) division of large blood
vessels, leading to profuse hæmorrhage; (2) division of nerve-trunks,
resulting in motor and sensory disturbances; and (3) division of tendons
or muscles, interfering with movement.

_Treatment._--If hæmorrhage is still going on, it must be arrested by
pressure, torsion, or ligature, as the accumulation of blood in a wound
interferes with union. If necessary, the wound should be purified by
washing with saline solution or eusol, and the surrounding skin painted
with iodine, after which the edges are approximated by sutures. The raw
surfaces must be brought into accurate apposition, care being taken that
no inversion of the cutaneous surface takes place. In extensive and deep
wounds, to ensure more complete closure and to prevent subsequent
stretching of the scar, it is advisable to unite the different
structures--muscles, fasciæ, and subcutaneous tissue--by separate series
of _buried sutures_ of catgut or other absorbable material. For the
approximation of the skin edges, stitches of horse-hair, fishing-gut, or
fine silk are the most appropriate. These _stitches of coaptation_ may
be interrupted or continuous. In small superficial wounds on exposed
parts, stitch marks may be avoided by approximating the edges with
strips of gauze fixed in position by collodion, or by subcutaneous
sutures of fine catgut. Where the skin is loose, as, for example, in the
neck, on the limbs, or in the scrotum, the use of Michel's clips is
advantageous in so far as these bring the deep surfaces of the skin into
accurate apposition, are introduced with comparatively little pain, and
leave only a slight mark if removed within forty-eight hours.

When there is any difficulty in bringing the edges of the wound into
apposition, a few interrupted _relaxation stitches_ may be introduced
wide of the margins, to take the strain off the coaptation stitches.
Stout silk, fishing-gut, or silver wire may be employed for this
purpose. When the tension is extreme, Lister's button suture may be
employed. The tension is relieved and death of skin prevented by scoring
it freely with a sharp knife. Relaxation stitches should be removed in
four or five days, and stitches of coaptation in from seven to ten days.
On the face and neck, wounds heal rapidly, and stitches may be removed
in two or three days, thus diminishing the marks they leave.

_Drainage._--In wounds in which no cavity has been left, and in which
there is no reason to suspect infection, drainage is unnecessary. When,
however, the deeper parts of an extensive wound cannot be brought into
accurate apposition, and especially when there is any prospect of oozing
of blood or serum--as in amputation stumps or after excision of the
breast--drainage is indicated. It is a wise precaution also to insert
drainage tubes into wounds in fat patients when there is the slightest
reason to suspect the presence of infection. Glass or rubber tubes are
the best drains; but where it is desirable to leave little mark, a few
strands of horse-hair, or a small roll of rubber, form a satisfactory
substitute. Except when infection occurs, the drain is removed in from
one to four days and the opening closed with a Michel's clip or a
suture.

#Punctured Wounds.#--Punctured wounds are produced by narrow, pointed
instruments, and the sharper and smoother the instrument the more does
the resulting injury resemble an incised wound; while from more rounded
and rougher instruments the edges of the wound are more or less contused
or lacerated. The depth of punctured wounds greatly exceeds their width,
and the damage to subcutaneous parts is usually greater than that to the
skin. When the instrument transfixes a part, the edges of the wound of
entrance may be inverted, and those of the exit wound everted. If the
instrument is a rough one, these conditions may be reversed by its
sudden withdrawal.

Punctured wounds neither gape nor bleed much. Even when a large vessel
is implicated, the bleeding usually takes place into the tissues rather
than externally.

The _risks_ incident to this class of wounds are: (1) the extreme
difficulty, especially when a dense fascia has been perforated, of
rendering them aseptic, on account of the uncertainty as to their depth,
and of the way in which the surface wound closes on the withdrawal of
the instrument; (2) different forms of aneurysm may result from the
puncture of a large vessel; (3) perforation of a joint, or of a serous
cavity, such as the abdomen, thorax, or skull, materially adds to the
danger.

_Treatment._--The first indication is to purify the whole extent of the
wound, and to remove any foreign body or blood-clot that may be in it.
It is usually necessary to enlarge the wound, freely dividing injured
fasciæ, paring away bruised tissues, and purifying the whole
wound-surface. Any blood vessel that is punctured should be cut across
and tied; and divided muscles, tendons, or nerves must be sutured. After
hæmorrhage has been arrested, iodoform and bismuth paste is rubbed into
the raw surface, and the wound closed. If there is any reason to doubt
the asepticity of the wound, it is better treated by the open method,
and a Bier's bandage should be applied.

#Contused and Lacerated Wounds.#--These may be considered together, as
they so occur in practice. They are produced by crushing, biting, or
tearing forms of violence--such as result from machinery accidents,
firearms, or the bites of animals. In addition to the irregular wound of
the integument, there is always more or less bruising of the parts
beneath and around, and the subcutaneous lesions are much wider than
appears on the surface.

Wounds of this variety usually gape considerably, especially when there
is much laceration of the skin. It is not uncommon to have considerable
portions of skin, muscle, or tendon completely torn away.

Hæmorrhage is seldom a prominent feature, as the crushing or tearing of
the vessel wall leads to the obliteration of the lumen.

The _special risks_ of these wounds are: (1) Sloughing of the bruised
tissues, especially when attempts to sterilise the wound have not been
successful. (2) Reactionary hæmorrhage after the initial shock has
passed off. (3) Secondary hæmorrhage as a result of infective processes
ensuing in the wound. (4) Loss of muscle or tendon, interfering with
motion. (5) Cicatricial contraction. (6) Gangrene, which may follow
occlusion of main vessels, or virulent infective processes. (7) It is
not uncommon to have particles of carbon embedded in the tissues after
lacerated wounds, leaving unsightly, pigmented scars. This is often seen
in coal-miners, and in those injured by firearms, and is to be prevented
by removing all gross dirt from the edges of the wound.

_Treatment._--In severe wounds of this class implicating the
extremities, the most important question that arises is whether or not
the limb can be saved. In examining the limb, attention should first be
directed to the state of the main blood vessels, in order to determine
if the vascular supply of the part beyond the lesion is sufficient to
maintain its vitality. Amputation is usually called for if there is
complete absence of pulsation in the distal arteries and if the part
beyond is cold. If at the same time important nerve-trunks are
lacerated, so that the function of the limb would be seriously impaired,
it is not worth running the risk of attempting to save it. If, in
addition, there is extensive destruction of large muscular masses or of
important tendons, or comminution of the bones, amputation is usually
imperative. Stripping of large areas of skin is not in itself a reason
for removing a limb, as much can be done by skin grafting, but when it
is associated with other lesions it favours amputation. In considering
these points, it must be borne in mind that the damage to the deeper
tissues is always more extensive than appears on the surface, and that
in many cases it is only possible to estimate the real extent of the
injury by administering an anæsthetic and exploring the wound. In
doubtful cases the possibility of rendering the parts aseptic will often
decide the question for or against amputation. If thorough purification
is accomplished, the success which attends conservative measures is
often remarkable. It is permissible to run an amount of risk to save an
upper extremity which would be unjustifiable in the case of a lower
limb. The age and occupation of the patient must also be taken into
account.

It having been decided to try and save the limb, the question is only
settled for the moment; it may have to be reconsidered from day to day,
or even from hour to hour, according to the progress of the case.

When it is decided to make the attempt to save the limb, the wound must
be thoroughly purified. All bruised tissue in which gross dirt has
become engrained should be cut away with knife or scissors. The raw
surface is then cleansed with eusol, washed with sterilised salt
solution followed by methylated spirit, and rubbed all over with "bipp"
paste. If the purification is considered satisfactory the wound may be
closed, otherwise it is left open, freely drained or packed with gauze,
and the limb is immobilised by suitable splints.


WOUNDS BY FIREARMS AND EXPLOSIVES

It is not necessary here to do more than indicate the general characters
of wounds produced by modern weapons. For further details the reader is
referred to works on military surgery. Experience has shown that the
nature and severity of the injuries sustained in warfare vary widely in
different campaigns, and even in different fields of the same campaign.
Slight variations in the size, shape, and weight of rifle bullets, for
example, may profoundly modify the lesions they produce: witness the
destructive effect of the pointed bullet compared with that of the
conical form previously used. The conditions under which the fighting is
carried on also influence the wounds. Those sustained in the open,
long-range fighting of the South African campaign of 1899–1902 were very
different from those met with in the entrenched warfare in France in
1914–1918. It has been found also that the infective complications are
greatly influenced by the terrain in which the fighting takes place. In
the dry, sandy, uncultivated veldt of South Africa, bullet wounds seldom
became infected, while those sustained in the highly manured fields of
Belgium were almost invariably contaminated with putrefactive organisms,
and gaseous gangrene and tetanus were common complications. It has been
found also that wounds inflicted in naval engagements present different
characters from those sustained on land. Many other factors, such as the
physical and mental condition of the men, the facilities for affording
first aid, and the transport arrangements, also play a part in
determining the nature and condition of the wounds that have to be dealt
with by military surgeons.

Whatever the nature of the weapon concerned, the wound is of the
_punctured, contused, and lacerated_ variety. Its severity depends on
the size, shape, and velocity of the missile, the range at which the
weapon is discharged, and the part of the body struck.

Shock is a prominent feature, but its degree, as well as the time of its
onset, varies with the extent and seat of the injury, and with the
mental state of the patient when wounded. We have observed pronounced
shock in children after being shot even when no serious injury was
sustained. At the moment of injury the patient experiences a sensation
which is variously described as being like the lash of a whip, a blow
with a stick, or an electric shock. There is not much pain at first, but
later it may become severe, and is usually associated with intense
thirst, especially when much blood has been lost.

In all forms of wounds sustained in warfare, septic infection
constitutes the main risk, particularly that resulting from
streptococci. The presence of anaërobic organisms introduces the
additional danger of gaseous forms of gangrene.

The earlier the wound is disinfected the greater is the possibility of
diminishing this risk. If cleansing is carried out within the first six
hours the chance of eliminating sepsis is good; with every succeeding
six hours it diminishes, until after twenty-four hours it is seldom
possible to do more than mitigate sepsis. (J. T. Morrison.)

The presence of a metallic foreign body having been determined and its
position localised by means of the X-rays, all devitalised and
contaminated tissue is excised, the foreign material, _e.g._, a missile,
fragments of clothing, gravel and blood-clot, removed, the wound
purified with antiseptics and closed or drained according to
circumstances.

#Pistol-shot Wounds.#--Wounds inflicted by pistols, revolvers, and small
air-guns are of frequent occurrence in civil practice, the weapon being
discharged usually by accident, but frequently with suicidal, and
sometimes with homicidal intent.

With all calibres and at all ranges, except actual contact, the wound of
entrance is smaller than the bullet. If the weapon is discharged within
a foot of the body, the skin surrounding the wound is usually stained
with powder and burned, and the hair singed. At ranges varying from six
inches to thirty feet, grains of powder may be found embedded in the
skin or lying loose on the surface, the greater the range the wider
being the area of spread. When black powder is used, the embedded grains
usually leave a permanent bluish-black tattooing of the skin. When the
weapon is placed in contact with the skin, the subcutaneous tissues are
lacerated over an area of two or three inches around the opening made by
the bullet and smoke and powder-staining and scorching are more marked
than at longer ranges.

When the bullet perforates, the exit wound is usually larger and more
extensively lacerated than the wound of entrance. Its margins are as a
rule everted, and it shows no marks of flame, smoke, or powder. These
features are common to all perforations caused by bullets.

Pistol wounds only produce dangerous effects when fired at close range,
and when the cavities of the skull, the thorax, or the abdomen are
implicated. In the abdomen a lethal injury may readily be caused even by
pistols of the "toy" order. These injuries will be described with
regional surgery.

Pistol-shot wounds of _joints_ and _soft parts_ are seldom of serious
import apart from the risk of hæmorrhage and of infection.

_Treatment._--The treatment of wounds of the soft parts consists in
purifying the wounds of entrance and exit and the surrounding skin, and
in providing for drainage if this is indicated.

There being no urgency for the removal of the bullet, time should be
taken to have it localised by the X-rays, preferably by stereoscopic
plates. In some cases it is not necessary to remove the bullet.

#Wounds by Sporting Guns.#--In the common sporting or scatter gun, with
which accidents so commonly occur during the shooting season, the charge
of small shot or pellets leave the muzzle of the gun as a solid mass
which makes a single ragged wound having much the appearance of that
caused by a single bullet. At a distance of from four to five feet from
the muzzle the pellets begin to disperse so that there are separate
punctures around the main central wound. As the range increases, these
outlying punctures make a wider and wider pattern, until at a distance
of from eighteen to twenty feet from the muzzle, the scattering is
complete, there is no longer any central wound, and each individual
pellet makes its own puncture. From these elementary data, it is usually
possible, from the features of the wound, to arrive at an approximately
accurate conclusion regarding the range at which the gun was discharged,
and this may have an important bearing on the question of accident,
suicide, or murder.

As regards the effects on the tissues at close range, that is, within a
few feet, there is widespread laceration and disruption; if a bone is
struck it is shattered, and portions of bone may be displaced or even
driven out through the exit wound.

When the charge impinges over one of the large cavities of the body, the
shot may scatter widely through the contained viscera, and there is
often no exit wound. In the thorax, for example, if a rib is struck, the
charge and possibly fragments of bone, will penetrate the pleura, and be
dispersed throughout the lung; in the head, the skull may be shattered
and the brain torn up; and in the abdomen, the hollow viscera may be
perforated in many places and the solid organs lacerated.

On covered parts the clothing, by deflecting the shot, influences the
size and shape of the wound; the entrance wound is increased in size and
more ragged, and portions of the clothes may be driven into the tissues.

[Illustration: FIG. 62.--Radiogram showing Pellets embedded in Arm.

(Mr. J. W. Dowden's case.)]

A charge of small shot is much more destructive to blood vessels,
tendons, and ligaments than a single bullet, which in many cases pushes
such structures aside without dividing them. In the abdomen and chest,
also, the damage done by a full charge of shot is much more extensive
than that inflicted by a single bullet, the deflection of the pellets
leading to a greater number of perforations of the intestine and more
widespread laceration of solid viscera.

When the charge impinges on one of the extremities at close range, we
often have the opportunity of observing that the exit wound is larger,
more ragged than that of entrance, and that its edges are everted; the
extensive tearing and bruising of all the tissues, including the bones,
and the marked tendency to early and progressive septic infection,
render amputation compulsory in the majority of such cases.

At a range of from twenty to thirty feet, although the scatter is
complete, the pellets are still close together, so that if they
encounter the shaft of a long bone, even the femur, they fracture the
bone across, often along with some longitudinal splintering.

Individual pellets striking the shafts of long bones become flattened or
distorted, and when cancellated bone is struck they become embedded in
it (Fig. 62).

The skin, when it is closely peppered with shot, is liable to lose its
vitality, and with the addition of a little sepsis, readily necroses and
comes away as a slough.

When the shot have diverged so as to strike singly, they seldom do much
harm, but fatal damage may be done to the brain or to the aorta, or the
eye may be seriously injured by a single pellet.

Small shot fired at longer ranges--over about a hundred and fifty
feet--usually go through the skin, but seldom pierce the fascia, and lie
embedded in the subcutaneous tissue, from which they can readily be
extracted.

The wad of the cartridge behaves erratically: so long as it remains flat
it goes off with the rest of the charge, and is often buried in the
wound; but if it curls up or turns on its side, it is usually deflected
and flies clear of the shot. It may make a separate wound.

Wounds from sporting guns are to be _treated_ on the usual lines, the
early efforts being directed to the alleviation of shock and the
prevention of septic infection. There is rarely any urgency in the
removal of pellets from the tissues.

#Wounds by Rifle Bullets.#--The vast majority of wounds inflicted by
rifle bullets are met with in the field during active warfare, and fall
to be treated by military surgeons. They occasionally occur
accidentally, however, during range practice for example, and may then
come under the notice of the civil surgeon.

It is only necessary here to consider the effects of modern small-bore
rifle or machine-gun bullets.

The trajectory is practically flat up to 675 yards. In destructive
effect there is not much difference between the various high velocity
bullets used in different armies; they will kill up to a distance of two
miles. The hard covering is employed to enable the bullet to take the
grooves in the rifle, and to prevent it stripping as it passes through
the barrel. It also increases the penetrating power of the missile, but
diminishes its "stopping" power, unless a vital part or a long bone is
struck. By removing the covering from the point of the bullet, as is
done in the Dum-Dum bullet, or by splitting the end, the bullet is made
to expand or "mushroom" when it strikes the body, and its stopping power
is thereby greatly increased, the resulting wound being much more
severe. These "soft-nosed" expanding bullets are to be distinguished
from "explosive" bullets which contain substances which detonate on
impact. High velocity bullets are unlikely to lodge in the body unless
spent, or pulled up by a sandbag, or metal buckle on a belt, or a book
in the pocket, or the core and the case separating--"stripping" of the
bullet. Spent shot may merely cause bruising of the surface, or they may
pass through the skin and lodge in the subcutaneous tissue, or may even
damage some deeper structure such as a nerve trunk.

A blank cartridge fired at close range may cause a severe wound, and, if
charged with black powder, may leave a permanent bluish-black
pigmentation of the skin.

The lesions of individual tissues--bones, nerves, blood vessels--are
considered with these.

#Treatment of Gunshot Wounds under War Conditions.#--It is only
necessary to indicate briefly the method of dealing with gunshot wounds
in warfare as practised in the European War.

1. _On the Field._--Hæmorrhage is arrested in the limbs by an improvised
tourniquet; in the head by a pad and bandage; in the thorax or abdomen
by packing if necessary, but this should be avoided if possible, as it
favours septic infection. If a limb is all but detached it should be
completely severed. A full dose of morphin is given hypodermically. The
ampoule of iodine carried by the wounded man is broken, and its contents
are poured over and around the wound, after which the field dressing is
applied. In extensive wounds, the "shell-dressing" carried by the
stretcher bearers is preferred. All bandages are applied loosely to
allow for subsequent swelling. The fragments of fractured bones are
immobilised by some form of emergency splint.

2. _At the Advanced Dressing Station_, after the patient has had a
liberal allowance of warm fluid nourishment, such as soup or tea, a full
dose of anti-tetanic serum is injected. The tourniquet is removed and
the wound inspected. Urgent amputations are performed. Moribund patients
are detained lest they die _en route_.

3. _In the Field Ambulance or Casualty Clearing Station_ further
measures are employed for the relief of shock, and urgent operations are
performed, such as amputation for gangrene, tracheotomy for dyspnœa, or
laparotomy for perforated or lacerated intestine. In the majority of
cases the main object is to guard against infection; the skin is
disinfected over a wide area and surrounded with towels; damaged tissue,
especially muscle, is removed with the knife or scissors, and foreign
bodies are extracted. Torn blood vessels, and, if possible, nerves and
tendons are repaired. The wound is then partly closed, provision being
made for free drainage, or some special method of irrigation, such as
that of Carrel, is adopted. Sometimes the wound is treated with bismuth,
iodoform, and paraffin paste (B.I.P.P.) and sutured.

4. _In the Base Hospital or Hospital Ship_ various measures may be
called for according to the progress of the wound and the condition of
the patient.

#Shell Wounds and Wounds produced by Explosions.#--It is convenient to
consider together the effects of the bursting of shells fired from heavy
ordnance and those resulting in the course of blasting operations from
the discharge of dynamite or other explosives, or from the bursting of
steam boilers or pipes, the breaking of machinery, and similar accidents
met with in civil practice.

Wounds inflicted by shell fragments and shrapnel bullets tend to be
extensive in area, and show great contusion, laceration, and destruction
of the tissues. The missiles frequently lodge and carry portions of the
clothing and, it may be, articles from the man's pocket, with them.
Shell wounds are attended with a considerable degree of shock. On
account of the wide area of contusion which surrounds the actual wound
produced by shell fragments, amputation, when called for, should be
performed some distance above the torn tissues, as there is considerable
risk of sloughing of the flaps.

Wounds produced by dynamite explosions and the bursting of boilers have
the same general characters as shell wounds. Fragments of stone, coal,
or metal may lodge in the tissues, and favour the occurrence of
infective complications.

All such injuries are to be treated on the general principles governing
contused and lacerated wounds.


EMBEDDED FOREIGN BODIES

In the course of many operations foreign substances are introduced into
the tissues and intentionally left there, for example, suture and
ligature materials, steel or aluminium plates, silver wire or ivory pegs
used to secure the fixation of bones, or solid paraffin employed to
correct deformities. Other substances, such as gauze, drainage tubes,
or metal instruments, may be unintentionally left in a wound.

Foreign bodies may also lodge in accidentally inflicted wounds, for
example, bullets, needles, splinters of wood, or fragments of clothing.
The needles of hypodermic syringes sometimes break and a portion remains
embedded in the tissues. As a result of explosions, particles of carbon,
in the form of coal-dust or gunpowder, or portions of shale, may lodge
in a wound.

The embedded foreign body at first acts as an irritant, and induces a
reaction in the tissues in which it lodges, in the form of hyperæmia,
local leucocytosis, proliferation of fibroblasts, and the formation of
granulation tissue. The subsequent changes depend upon whether or not
the wound is infected with pyogenic bacteria. If it is so infected,
suppuration ensues, a sinus forms, and persists until the foreign body
is either cast out or removed.

If the wound is aseptic, the fate of the foreign body varies with its
character. A substance that is absorbable, such as catgut or fine silk,
is surrounded and permeated by the phagocytes, which soften and
disintegrate it, the debris being gradually absorbed in much the same
manner as a fibrinous exudate. Minute bodies that are not capable of
being absorbed, such as particles of carbon, or of pigment used in
tattooing, are taken up by the phagocytes, and in course of time
removed. Larger bodies, such as needles or bullets, which are not
capable of being destroyed by the phagocytes, become encapsulated. In
the granulation tissue by which they are surrounded large multinuclear
giant-cells appear ("_foreign-body giant-cells_") and attach themselves
to the foreign body, the fibroblasts proliferate and a capsule of scar
tissue is eventually formed around the body. The tissues of the capsule
may show evidence of iron pigmentation. Sometimes fluid accumulates
around a foreign body within its capsule, constituting a cyst.

Substances like paraffin, strands of silk used to bridge a gap in a
tendon, or portions of calcined bone, instead of being encapsulated, are
gradually permeated and eventually replaced by new connective tissue.

Embedded bodies may remain in the tissues for an indefinite period
without giving rise to inconvenience. At any time, however, they may
cause trouble, either as a result of infective complications, or by
inducing the formation of a mass of inflammatory tissue around them,
which may simulate a gumma, a tuberculous focus, or a sarcoma. This
latter condition may give rise to difficulties in diagnosis,
particularly if there is no history forthcoming of the entrance of the
foreign body. The ignorance of patients regarding the possible lodgment
in the tissues of a foreign body--even of considerable size--is
remarkable. In such cases the X-rays will reveal the presence of the
foreign body if it is sufficiently opaque to cast a shadow. The heavy,
lead-containing varieties of glass throw very definite shadows little
inferior in sharpness and definition to those of metal; almost all the
ordinary forms of commercial glass also may be shown up by the X-rays.

Foreign bodies encapsulated in the peritoneal cavity are specially
dangerous, as the proximity of the intestine furnishes a constant
possibility of infection.

The question of removal of the foreign body must be decided according to
the conditions present in individual cases; in searching for a foreign
body in the tissues, unless it has been accurately located, a general
anæsthetic is to be preferred.


BURNS AND SCALDS

The distinction between a burn which results from the action of dry heat
on the tissues of the body and a scald which results from the action of
moist heat, has no clinical significance.

In young and debilitated subjects hot poultices may produce injuries of
the nature of burns. In old people with enfeebled circulation mere
exposure to a strong fire may cause severe degrees of burning, the
clothes covering the part being uninjured. This may also occur about the
feet, legs, or knees of persons while intoxicated who have fallen asleep
before the fire.

The damage done to the tissues by strong caustics, such as fuming nitric
acid, sulphuric acid, caustic potash, nitrate of silver, or arsenical
paste, presents pathological and clinical features almost identical with
those resulting from heat. Electricity and the Röntgen rays also produce
lesions of the nature of burns.

_Pathology of Burns._--Much discussion has taken place regarding the
explanation of the rapidly fatal issue in extensive superficial burns.
On post-mortem examination the lesions found in these cases are: (1)
general hyperæmia of all the organs of the abdominal, thoracic, and
cerebro-spinal cavities; (2) marked leucocytosis, with destruction of
red corpuscles, setting free hæmoglobin which lodges in the epithelial
cells of the tubules of the kidneys; (3) minute thrombi and
extravasations throughout the tissues of the body; (4) degeneration of
the ganglion cells of the solar plexus; (5) œdema and degeneration of
the lymphoid tissue throughout the body; (6) cloudy swelling of the
liver and kidneys, and softening and enlargement of the spleen. Bardeen
suggests that these morbid phenomena correspond so closely to those met
with where the presence of a toxin is known to produce them, that in all
probability death is similarly due to the action of some poison produced
by the action of heat on the skin and on the proteins of the blood.

#Clinical Features--Local Phenomena.#--The most generally accepted
classification of burns is that of Dupuytren, which is based upon the
depth of the lesion. Six degrees are thus, recognised: (1) hyperæmia or
erythema; (2) vesication; (3) partial destruction of the true skin; (4)
total destruction of the true skin; (5) charring of muscles; (6)
charring of bones.

It must be observed, however, that burns met with at the bedside always
illustrate more than one of these degrees, the deeper forms always being
associated with those less deep, and the clinical picture is made up of
the combined characters of all. A burn is classified in terms of its
most severe portion. It is also to be remarked that the extent and
severity of a burn usually prove to be greater than at first sight
appears.

_Burns of the first degree_ are associated with erythema of the skin,
due to hyperæmia of its blood vessels, and result from scorching by
flame, from contact with solids or fluids below 212° F., or from
exposure to the sun's rays. They are characterised clinically by acute
pain, redness, transitory swelling from œdema, and subsequent
desquamation of the surface layers of the epidermis. A special form of
pigmentation of the skin is seen on the front of the legs of women from
exposure to the heat of the fire.

_Burns of Second Degree--Vesication of the Skin._--These are
characterised by the occurrence of vesicles or blisters which are
scattered over the hyperæmic area, and contain a clear yellowish or
brownish fluid. On removing the raised epidermis, the congested and
highly sensitive papillæ of the skin are exposed. Unna has found that
pyogenic bacteria are invariably present in these blisters. Burns of the
second degree leave no scar but frequently a persistent discoloration.
In rare instances the burned area becomes the seat of a peculiar
overgrowth of fibrous tissue of the nature of keloid (p 401).

_Burns of Third Degree--Partial Destruction of the Skin._--The epidermis
and papillæ are destroyed in patches, leaving hard, dry, and insensitive
sloughs of a yellow or black colour. The pain in these burns is
intense, but passes off during the first or second day, to return again,
however, when, about the end of a week, the sloughs separate and expose
the nerve filaments of the underlying skin. Granulations spring up to
fill the gap, and are rapidly covered by epithelium, derived partly from
the margins and partly from the remains of skin glands which have not
been completely destroyed. These latter appear on the surface of the
granulations as small bluish islets which gradually increase in size,
become of a greyish-white colour, and ultimately blend with one another
and with the edges. The resulting cicatrix may be slightly depressed,
but otherwise exhibits little tendency to contract and cause deformity.

_Burns of Fourth Degree--Total Destruction of the Skin._--These follow
the more prolonged action of any form of intense heat. Large, black, dry
eschars are formed, surrounded by a zone of intense congestion. Pain is
less severe, and is referred to the parts that have been burned to a
less degree. Infection is liable to occur and to lead to wide
destruction of the surrounding skin. The amount of granulation tissue
necessary to fill the gap is therefore great; and as the epithelial
covering can only be derived from the margins--the skin glands being
completely destroyed--the healing process is slow. The resulting scars
are irregular, deep and puckered, and show a great tendency to contract.
Keloid frequently develops in such cicatrices. When situated in the
region of the face, neck, or flexures of joints, much deformity and
impairment of function may result (Fig. 63).

[Illustration: FIG. 63.--Cicatricial Contraction following Severe Burn.]

In _burns of the fifth degree_ the lesion extends through the
subcutaneous tissue and involves the muscles; while in those of the
_sixth degree_ it passes still more deeply and implicates the bones.
These burns are comparatively limited in area, as they are usually
produced by prolonged contact with hot metal or caustics. Burns of the
fifth and sixth degrees are met with in epileptics or intoxicated
persons who fall into the fire. Large blood vessels, nerve-trunks,
joints, or serous cavities may be implicated.

#General Phenomena.#--It is customary to divide the clinical history of
a severe burn into three periods; but it is to be observed that the
features characteristic of the periods have been greatly modified since
burns have been treated on the same lines as other wounds.

_The first period_ lasts for from thirty-six to forty-eight hours,
during which time the patient remains in a more or less profound state
of _shock_, and there is a remarkable absence of pain. When shock is
absent or little marked, however, the amount of suffering may be great.
When the injury proves fatal during this period, death is due to shock,
probably aggravated by the absorption of poisonous substances produced
in the burned tissues. In fatal cases there is often evidence of
cerebral congestion and œdema.

The _second period_ begins when the shock passes off, and lasts till the
sloughs separate. The outstanding feature of this period is _toxæmia_,
manifested by fever, the temperature rising to 102°, 103°, or 104° F.,
and congestive or inflammatory conditions of internal organs, giving
rise to such clinical complications as bronchitis, broncho-pneumonia, or
pleurisy--especially in burns of the thorax; or meningitis and
cerebritis, when the neck or head is the seat of the burn. Intestinal
catarrh associated with diarrhœa is not uncommon; and ulceration of the
duodenum leading to perforation has been met with in a few cases. These
phenomena are much more prominent when bacterial infection has taken
place, and it seems probable that they are to be attributed chiefly to
the infection, as they have become less frequent and less severe since
burns have been treated like other breaches of the surface. Albuminuria
is a fairly constant symptom in severe burns, and is associated with
congestion of the kidneys. In burns implicating the face, neck, mouth,
or pharynx, œdema of the glottis is a dangerous complication, entailing
as it does the risk of suffocation.

The _third period_ begins when the sloughs separate, usually between
the seventh and fourteenth days, and lasts till the wound heals, its
duration depending upon the size, depth, and asepticity of the raw area.
The chief causes of death during this period are toxin absorption in any
of its forms; waxy disease of the liver, kidneys, or intestine; less
commonly erysipelas, tetanus, or other diseases due to infection by
specific organisms. We have seen nothing to substantiate the belief that
duodenal ulcers are liable to perforate during the third period.

The _prognosis_ in burns depends on (1) the superficial extent, and, to
a much less degree, the depth of the injury. When more than one-third of
the entire surface of the body is involved, even in a mild degree, the
prognosis is grave. (2) The situation of the burn is important. Burns
over the serous cavities--abdomen, thorax, or skull--are, other things
being equal, much more dangerous than burns of the limbs. The risk of
œdema of the glottis in burns about the neck and mouth has already been
referred to. (3) Children are more liable to succumb to shock during the
early period, but withstand prolonged suppuration better than adults.
(4) When the patient survives the shock, the presence or absence of
infection is the all-important factor in prognosis.

#Treatment.#--The _general treatment_ consists in combating the shock.
When pain is severe, morphin must be injected.

_Local Treatment._--The local treatment must be carried out on
antiseptic lines, a general anæsthetic being administered, if necessary,
to enable the purification to be carried out thoroughly. After carefully
removing the clothing, the whole of the burned area is gently, but
thoroughly, cleansed with peroxide of hydrogen or warm boracic lotion,
followed by sterilised saline solution. As pyogenic bacteria are
invariably found in the blisters of burns, these must be opened and the
raised epithelium removed.

The dressings subsequently applied should meet the following
indications: the relief of pain; the prevention of sepsis; and the
promotion of cicatrisation.

An application which satisfactorily fulfils these requirements is
_picric acid_. Pads of lint or gauze are lightly wrung out of a solution
made up of picric acid, 1½ drams; absolute alcohol, 3 ounces;
distilled water, 40 ounces, and applied over the whole of the reddened
area. These are covered with antiseptic wool, _without_ any waterproof
covering, and retained in position by a many-tailed bandage. The
dressing should be changed once or twice a week, under the guidance of
the temperature chart, any portion of the original dressing which
remains perfectly dry being left undisturbed. The value of a general
anæsthetic in dressing extensive burns, especially in children, can
scarcely be overestimated.

Picric acid yields its best results in superficial burns, and it is
useful as _a primary dressing_ in all. As soon as the sloughs separate
and a granulating surface forms, the ordinary treatment for a healing
sore is instituted. Any slough under which pus has collected should be
cut away with scissors to permit of free drainage.

An occlusive dressing of melted _paraffin_ has also been employed. A
useful preparation consists of: Paraffin molle 25 per cent., paraffin
durum 67 per cent., olive oil 5 per cent., oil of eucalyptus 2 per
cent., and beta-naphthol ¼ per cent. It has a melting point of 48° C.
It is also known as _Ambrine_ and _Burnol_. After the burned area has
been cleansed and thoroughly dried, it is sponged or painted with the
melted paraffin, and before solidification takes place a layer of
sterilised gauze is applied and covered with a second coating of
paraffin. Further coats of paraffin are applied every other day to
prevent the gauze sticking to the skin.

An alternative method of treating extensive burns is by immersing the
part, or even the whole body when the trunk is affected, in a bath of
boracic lotion kept at the body temperature, the lotion being frequently
renewed.

If a burn is already infected when first seen, it is to be treated on
the same principles as govern the treatment of other infected wounds.

All moist or greasy applications, such as Carron oil, carbolic oil and
ointments, and all substances like collodion and dry powders, which
retain discharges, entirely fail to meet the indications for the
rational treatment of burns, and should be abandoned.

Skin-grafting is of great value in hastening healing after extensive
burns, and in preventing cicatricial contraction. The _deformities_
which are so liable to develop from contraction of the cicatrices are
treated on general principles. In the region of the face, neck, and
flexures of joints (Fig. 63), where they are most marked, the contracted
bands may be divided and the parts stretched, the raw surface left being
covered by Thiersch grafts or by flaps of skin raised from adjacent
surfaces or from other parts of the body (Fig. 1).


INJURIES PRODUCED BY ELECTRICITY

#Injuries produced by Exposure to X-Rays and Radium.#--In the routine
treatment of disease by radiations, injury is sometimes done to the
tissues, even when the greatest care is exercised as to dosage and
frequency of application. Robert Knox describes the following
ill-effects.

_Acute dermatitis_ varying in degree from a slight erythema to deep
ulceration or even necrosis of skin. When ulcers form they are extremely
painful and slow to heal. When hair-bearing areas are affected,
epilation may occur without destroying the hair follicles and the hairs
are reproduced, but if the reaction is excessive permanent alopecia may
result.

_Chronic dermatitis_, which results from persistence of the acute form,
is most intractable and may assume malignant characters. X-ray warts are
a late manifestation of chronic dermatitis and may become malignant.

Among the _late manifestations_ are neuritis, telangiectasis, and a
painful and intractable form of ulceration, any of which may come on
months or even years after the cessation of exposure. _Sterility_ may be
induced in X-ray workers who are imperfectly protected from the effects
of the rays.

#Electrical burns# usually occur in those who are engaged in industrial
undertakings where powerful electrical currents are employed.

The lesions--which vary from a slight superficial scorching to complete
charring of parts--are most evident at the points of entrance and exit
of the current, the intervening tissues apparently escaping injury.

The more superficial degrees of electrical burns differ from those
produced by heat in being almost painless, and in healing very slowly,
although as a rule they remain dry and aseptic.

The more severe forms are attended with a considerable degree of shock,
which is not only more profound, but also lasts much longer than the
shock in an ordinary burn of corresponding severity. The parts at the
point of entrance of the current are charred to a greater or lesser
depth. The eschar is at first dry and crisp, and is surrounded by a zone
of pallor. For the first thirty-six to forty-eight hours there is
comparatively little suffering, but at the end of that time the parts
become exceedingly painful. In a majority of cases, in spite of careful
purification, a slow form of moist gangrene sets in, and the slough
spreads both in area and in depth, until the muscles and often the
large blood vessels and nerves are exposed. A line of demarcation
eventually forms, but the sloughs are exceedingly slow to separate,
taking from three to five times as long as in an ordinary burn, and
during the process of separation there is considerable risk of secondary
hæmorrhage from erosion of large vessels.

_Treatment._--Electrical burns are treated on the same lines as ordinary
burns, by thorough purification and the application of dry dressings,
with a view to avoiding the onset of moist gangrene. After granulations
have formed, skin-grafting is of value in hastening healing.

#Lightning-stroke.#--In a large proportion of cases lightning-stroke
proves instantly fatal. In non-fatal cases the patient suffers from a
profound degree of shock, and there may or may not be any external
evidence of injury. In the mildest cases red spots or wheals--closely
resembling those of urticaria--may appear on the body, but they usually
fade again in the course of twenty-four hours. Sometimes large patches
of skin are scorched or stained, the discoloured area showing an
arborescent appearance. In other cases the injured skin becomes dry and
glazed, resembling parchment. Appearances are occasionally met with
corresponding to those of a superficial burn produced by heat. The chief
difference from ordinary burns is the extreme slowness with which
healing takes place. Localised paralysis of groups of muscles, or even
of a whole limb, may follow any degree of lightning-stroke. Treatment is
mainly directed towards combating the shock, the surface-lesions being
treated on the same lines as ordinary burns.



CHAPTER XII

METHODS OF WOUND TREATMENT


Varieties of wounds--Modes of infection--Lister's work--Means taken to
    prevent infection of wounds: _heat_; _chemical antiseptics_;
    _disinfection of hands_; _preparation of skin of patient_;
    _instruments_; _ligatures_; _dressings_--Means taken to combat
    infection: _purification_; _open-wound method_.

The surgeon is called upon to treat two distinct classes of wounds: (1)
those resulting from injury or disease in which _the skin is already
broken_, or in which a communication with a mucous surface exists; and
(2) those that he himself makes _through intact skin_, no infected
mucous surface being involved.

Infection by bacteria must be assumed to have taken place in all wounds
made in any other way than by the knife of the surgeon operating through
unbroken skin. On this assumption the modern system of wound treatment
is based. Pathogenic bacteria are so widely distributed, that in the
ordinary circumstances of everyday life, no matter how trivial a wound
may be, or how short a time it may remain exposed, the access of
organisms to it is almost certain unless preventive measures are
employed.

It cannot be emphasised too strongly that rigid precautions are to be
taken to exclude fresh infection, not only in dealing with wounds that
are free of organisms, but equally in the management of wounds and other
lesions that are already infected. Any laxity in our methods which
admits of fresh organisms reaching an infected wound adds materially to
the severity of the infective process and consequently to the patient's
risk.

There are many ways in which accidental infection may occur. Take, for
example, the case of a person who receives a cut on the face by being
knocked down in a carriage accident on the street. Organisms may be
introduced to such a wound from the shaft or wheel by which he was
struck, from the ground on which he lay, from any portion of his
clothing that may have come in contact with the wound, or from his own
skin. Or, again, the hands of those who render first aid, the water used
to bathe the wound, the handkerchief or other extemporised dressing
applied to it, may be the means of conveying bacterial infection. Should
the wound open on a mucous surface, such as the mouth or nasal cavity,
the organisms constantly present in such situations are liable to prove
agents of infection.

Even after the patient has come under professional care the risks of his
wound becoming infected are not past, because the hands of the doctor,
his instruments, dressings, or other appliances may all, unless
purified, become the sources of infection.

In the case of an operation carried out through unbroken skin, organisms
may be introduced into the wound from the patient's own skin, from the
hands of the surgeon or his assistants, through the medium of
contaminated instruments, swabs, ligature or suture materials, or other
things used in the course of the operation, or from the dressings
applied to the wound.

Further, bacteria may gain access to devitalised tissues by way of the
blood-stream, being carried hither from some infected area elsewhere in
the body.

_The Antiseptic System of Surgery._--Those who only know the surgical
conditions of to-day can scarcely realise the state of matters which
existed before the introduction of the antiseptic system by Joseph
Lister in 1867. In those days few wounds escaped the ravages of pyogenic
and other bacteria, with the result that suppuration ensued after most
operations, and such diseases as erysipelas, pyæmia, and "hospital
gangrene" were of everyday occurrence. The mortality after compound
fractures, amputations, and many other operations was appalling, and
death from blood-poisoning frequently followed even the most trivial
operations. An operation was looked upon as a last resource, and the
inherent risk from blood-poisoning seemed to have set an impassable
barrier to the further progress of surgery. To the genius of Lister we
owe it that this barrier was removed. Having satisfied himself that the
septic process was due to bacterial infection, he devised a means of
preventing the access of organisms to wounds or of counteracting their
effects. Carbolic acid was the first antiseptic agent he employed, and
by its use in compound fractures he soon obtained results such as had
never before been attained. The principle was applied to other
conditions with like success, and so profoundly has it affected the
whole aspect of surgical pathology, that many of the infective diseases
with which surgeons formerly had to deal are now all but unknown. The
broad principles upon which Lister founded his system remain unchanged,
although the methods employed to put them into practice have been
modified.

#Means taken to Prevent Infection of Wounds.#--The avenues by which
infective agents may gain access to surgical wounds are so numerous and
so wide, that it requires the greatest care and the most watchful
attention on the part of the surgeon to guard them all. It is only by
constant practice and patient attention to technical details in the
operating room and at the bedside, that the carrying out of surgical
manipulations in such a way as to avoid bacterial infection will become
an instinctive act and a second nature. It is only possible here to
indicate the chief directions in which danger lies, and to describe the
means most generally adopted to avoid it.

To prevent infection, it is essential that everything which comes into
contact with a wound should be sterilised or disinfected, and to ensure
the best results it is necessary that the efficiency of our methods of
sterilisation should be periodically tested. The two chief agencies at
our disposal are heat and chemical antiseptics.

#Sterilisation by Heat.#--The most reliable, and at the same time the
most convenient and generally applicable, means of sterilisation is by
heat. All bacteria and spores are completely destroyed by being
subjected for fifteen minutes to _saturated circulating steam_ at a
temperature of 130° to 145° C. (= 266° to 293° F.). The articles to be
sterilised are enclosed in a perforated tin casket, which is placed in a
specially constructed steriliser, such as that of Schimmelbusch. This
apparatus is so arranged that the steam circulates under a pressure of
from two to three atmospheres, and permeates everything contained in it.
Objects so sterilised are dry when removed from the steriliser. This
method is specially suitable for appliances which are not damaged by
steam, such, for example, as gauze swabs, towels, aprons, gloves, and
metal instruments; it is essential that the efficiency of the steriliser
be tested from time to time by a self-registering thermometer or other
means.

The best substitute for circulating steam is _boiling_. The articles are
placed in a "fish-kettle steriliser" and boiled for fifteen minutes in a
1 per cent. solution of washing soda.

To prevent contamination of objects that have been sterilised they must
on no account be touched by any one whose hands have not been
disinfected and protected by sterilised gloves.

#Sterilisation by Chemical Agents.#--For the purification of the skin of
the patient, the hands of the surgeon, and knives and other instruments
that are damaged by heat, recourse must be had to chemical agents.
These, however, are less reliable than heat, and are open to certain
other objections.

#Disinfection of the Hands.#--It is now generally recognised that one of
the most likely sources of wound infection is the hands of the surgeon
and his assistants. It is only by carefully studying to avoid all
contact with infective matter that the hands can be kept surgically
pure, and that this source of wound infection can be reduced to a
minimum. The risk of infection from this source has further been greatly
reduced by the systematic use of rubber gloves by house-surgeons,
dressers, and nurses. The habitual use of gloves has also been adopted
by the great majority of surgeons; the minority, who find they are
handicapped by wearing gloves as a routine measure, are obliged to do so
when operating in infective cases or dressing infected wounds, and in
making rectal and vaginal examinations.

The gloves may be sterilised by steam, and are then put on dry, or by
boiling, in which case they are put on wet. The gauntlet of the glove
should overlap and confine the end of the sleeve of the sterilised
overall, and the gloved hands are rinsed in lotion before and at
frequent intervals during the operation. The hands are sterilised before
putting on the gloves, preferably by a method which dehydrates the skin.
Cotton gloves may be worn by the surgeon when tying ligatures, or
between operations, and by the anæsthetist during operations on the
head, neck, and chest.

The first step in the disinfection of the hands is the mechanical
removal of gross surface dirt and loose epithelium by soap, a stream of
running water as hot as can be borne, and a loofah or nail-brush, that
has been previously sterilised by heat. The nails should be cut down
till there is no sulcus between the nail edge and the pulp of the finger
in which organisms may lodge. They are next washed for three minutes in
methylated spirit to dehydrate the skin, and then for two or three
minutes in 70 per cent. sublimate or biniodide alcohol (1 in 1000).
Finally, the hands are rubbed with dry sterilised gauze.

#Preparation of the Skin of the Patient.#--In the purification of the
skin of the patient before operation, reliance is to be placed chiefly
in the mechanical removal of dirt and grease by the same means as are
taken for the cleansing of the surgeon's hands. Hair-covered parts
should be shaved. The skin is then dehydrated by washing with methylated
spirit, followed by 70 per cent. sublimate or biniodide alcohol (1 in
1000). This is done some hours before the operation, and the part is
then covered with pads of dry sterilised gauze or a sterilised towel.
Immediately before the operation the skin is again purified in the same
way.

The _iodine method_ of disinfecting the skin introduced by Grossich is
simple, and equally efficient. The day before operation the skin, after
being washed with soap and water, is shaved, dehydrated by means of
methylated spirit, and then painted with a 5 per cent. solution of
iodine in rectified spirit. The painting with iodine is repeated just
before the operation commences, and again after it is completed. The
final application is omitted in the case of children. In emergency
operations the skin is shaved dry and dehydrated with spirit, after
which the iodine is applied as described above. The staining of the skin
is an advantage, as it enables the operator to recognise the area that
has been prepared.

If any acne pustules or infected sinuses are present, they should be
destroyed or purified by means of the thermo-cautery or pure carbolic
acid, after the patient is anæsthetised.

#Appliances used at Operation.#--_Instruments_ that are not damaged by
heat must be boiled in a fish-kettle or other suitable steriliser for
fifteen minutes in a 1 per cent. solution of cresol or washing soda.
Just before the operation begins they are removed in the tray of the
steriliser and placed on a sterilised towel within reach of the surgeon
or his assistant. Knives and instruments that are liable to be damaged
by heat should be purified by being soaked in pure cresol for a few
minutes, or in 1 in 20 carbolic for at least an hour.

_Pads of Gauze_ sterilised by compressed circulating steam have almost
entirely superseded marine sponges for operative purposes. To avoid the
risk of leaving swabs in the peritoneal cavity, large square pads of
gauze, to one corner of which a piece of strong tape about a foot long
is securely stitched, should be employed. They should be removed from
the caskets in which they are sterilised by means of sterilised forceps,
and handed direct to the surgeon. The assistant who attends to the swabs
should wear sterilised gloves.

_Ligatures and Sutures._--To avoid the risk of implanting infective
matter in a wound by means of the materials used for ligatures and
sutures, great care must be taken in their preparation.

_Catgut._--The following methods of preparing catgut have proved
satisfactory: (1) The gut is soaked in juniper oil for at least a month;
the juniper oil is then removed by ether and alcohol, and the gut
preserved in 1 in 1000 solution of corrosive sublimate in alcohol
(Kocher). (2) The gut is placed in a brass receiver and boiled for
three-quarters of an hour in a solution consisting of 85 per cent.
absolute alcohol, 10 per cent. water, and 5 per cent. carbolic acid, and
is then stored in 90 per cent. alcohol. (3) Cladius recommends that the
catgut, just as it is bought from the dealers, be loosely rolled on a
spool, and then immersed in a solution of--iodine, 1 part; iodide of
potassium, 1 part; distilled water, 100 parts. At the end of eight days
it is ready for use. Moschcowitz has found that the tensile strength of
catgut so prepared is increased if it is kept dry in a sterile vessel,
instead of being left indefinitely in the iodine solution. If
Salkindsohn's formula is used--tincture of iodine, 1 part; proof spirit,
15 parts--the gut can be kept permanently in the solution without
becoming brittle. To avoid contamination from the hands, catgut should
be removed from the bottle with aseptic forceps and passed direct to the
surgeon. Any portion unused should be thrown away.

_Silk_ is prepared by being soaked for twelve hours in ether, for other
twelve in alcohol, and then boiled for ten minutes in 1 in 1000
sublimate solution. It is then wound on spools with purified hands
protected by sterilised gloves, and kept in absolute alcohol. Before an
operation the silk is again boiled for ten minutes in the same solution,
and is used directly from this (Kocher). Linen thread is sterilised in
the same way as silk.

Fishing-gut and silver wire, as well as the needles, should be boiled
along with the instruments. Horse-hair and fishing-gut may be sterilised
by prolonged immersion in 1 in 20 carbolic, or in the iodine solutions
employed to sterilise catgut.

The field of operation is surrounded by sterilised towels, clipped to
the edges of the wound, and securely fixed in position so that no
contamination may take place from the surroundings.

The surgeon and his assistants, including the anæsthetist, wear
overalls sterilised by steam. To avoid the risk of infection from dust,
scurf, or drops of perspiration falling from the head, the surgeon and
his assistants may wear sterilised cotton caps. To obviate the risk of
infection taking place by drops of saliva projected from the mouth in
talking or coughing in the vicinity of a wound, a simple mask may be
worn.

The risk of infection from the _air_ is now known to be very small, so
long as there is no excess of floating dust. All sweeping, dusting, and
disturbing of curtains, blinds, or furniture must therefore be avoided
before or during an operation.

It has been shown that the presence of spectators increases the number
of organisms in the atmosphere. In teaching clinics, therefore, the risk
from air infection is greater than in private practice.

To facilitate primary union, all hæmorrhage should be arrested, and the
accumulation of fluid in the wound prevented. When much oozing is
anticipated, a glass or rubber drainage-tube is inserted through a small
opening specially made for the purpose. In aseptic wounds the tube may
be removed in from twenty-four to forty-eight hours, and where it is
important to avoid a scar, the opening should be closed with a Michel's
clip; in infected wounds the tube must remain as long as the discharge
continues.

The fascia and skin should be brought into accurate apposition by
sutures. If any cavity exists in the deeper part of the wound it should
be obliterated by buried sutures, or by so adjusting the dressing as to
bring its walls into apposition.

If these precautions have been successful, the wound will heal under the
original dressing, which need not be interfered with for from seven to
ten days, according to the nature of the case.

#Dressings.#--_Gauze_, sterilised by heat, is almost universally
employed for the dressing of wounds. _Double cyanide gauze_ may be used
in such regions as the neck, axilla, or groin, where complete
sterilisation of the skin is difficult to attain, and where it is
desirable to leave the dressing undisturbed for ten days or more.
_Iodoform_ or _bismuth gauze_ is of special value for the packing of
wounds treated by the open method.

One variety or another of _wool_, rendered absorbent by the extraction
of its fat, and sterilised by heat, forms a part of almost every
surgical dressing, and various antiseptic agents may be added to it. Of
these, corrosive sublimate is the most generally used. Wood-wool
dressings are more highly and more uniformly absorbent than cotton
wools. As evaporation takes place through wool dressings, the discharge
becomes dried, and so forms an unfavourable medium for bacterial growth.

Pads of _sphagnum moss_, sterilised by heat, are highly absorbent, and
being economical are used when there is much discharge, and in cases
where a leakage of urine has to be soaked up.

#Means adopted to combat Infection.#--As has already been indicated, the
same antiseptic precautions are to be taken in dealing with infected as
with aseptic wounds.

In _recent injuries_ such as result from railway or machinery accidents,
with bruising and crushing of the tissues and grinding of gross dirt
into the wounds, the scissors must be freely used to remove the tissues
that have been devitalised or impregnated with foreign material.
Hair-covered parts should be shaved and the surrounding skin painted
with iodine. Crushed and contaminated portions of bone should be
chiselled away. Opinions differ as to the benefit derived from washing
such wounds with chemical antiseptics, which are liable to devitalise
the tissues with which they come in contact, and so render them less
able to resist the action of any organisms that may remain in them. All
are agreed, however, that free washing with normal salt solution is
useful in mechanically cleansing the injured parts. Peroxide of hydrogen
sprayed over such wounds is also beneficial in virtue of its oxidising
properties. Efficient drainage must be provided, and stitches should be
used sparingly, if at all.

The best way in which to treat such wounds is by the _open method_. This
consists in packing the wound with iodoform or bismuth gauze, which is
left in position as long as it adheres to the raw surface. The packing
may be renewed at intervals until the wound is filled by granulations;
or, in the course of a few days when it becomes evident that the
infection has been overcome, _secondary_ sutures may be introduced and
the edges drawn together, provision being made at the ends for further
packing or for drainage-tubes.

If earth or street dirt has entered the wound, the surface may with
advantage be painted over with pure carbolic acid, as virulent
organisms, such as those of tetanus or spreading gangrene, are liable to
be present. Prophylactic injection of tetanus antitoxin may be
indicated.



CHAPTER XIII

CONSTITUTIONAL EFFECTS OF INJURIES


SYNCOPE--SHOCK--COLLAPSE--FAT EMBOLISM--TRAUMATIC ASPHYXIA--DELIRIUM
    IN SURGICAL PATIENTS: _Delirium in general_; _Delirium tremens_;
    _Traumatic delirium_.


SYNCOPE, SHOCK, AND COLLAPSE

Syncope, shock, and collapse are clinical conditions which, although
depending on different causes, bear a superficial resemblance to one
another.

#Syncope or Fainting.#--Syncope is the result of a suddenly produced
anæmia of the brain from temporary weakening or arrest of the heart's
action. In surgical practice, this condition is usually observed in
nervous persons who have been subjected to pain, as in the reduction of
a dislocation or the incision of a whitlow; or in those who have rapidly
lost a considerable quantity of blood. It may also follow the sudden
withdrawal of fluid from a large cavity, as in tapping an abdomen for
ascites, or withdrawing fluid from the pleural cavity. Syncope sometimes
occurs also during the administration of a general anæsthetic,
especially if there is a tendency to sickness and the patient is not
completely under. During an operation the onset of syncope is often
recognised by the cessation of oozing from the divided vessels before
the general symptoms become manifest.

_Clinical Features._--When a person is about to faint he feels giddy,
has surging sounds in his ears, and haziness of vision; he yawns,
becomes pale and sick, and a free flow of saliva takes place into the
mouth. The pupils dilate; the pulse becomes small and almost
imperceptible; the respirations shallow and hurried; consciousness
gradually fades away, and he falls in a heap on the floor.

Sometimes vomiting ensues before the patient completely loses
consciousness, and the muscular exertion entailed may ward off the
actual faint. This is frequently seen in threatened syncopal attacks
during chloroform administration.

Recovery begins in a few seconds, the patient sighing or gasping, or, it
may be, vomiting; the strength of the pulse gradually increases, and
consciousness slowly returns. In some cases, however, syncope is fatal.

_Treatment._--The head should at once be lowered--in imitation of
nature's method--to encourage the flow of blood to the brain, the
patient, if necessary, being held up by the heels. All tight clothing,
especially round the neck or chest, must be loosened. The heart may be
stimulated reflexly by dashing cold water over the face or chest, or by
rubbing the face vigorously with a rough towel. The application of
volatile substances, such as ammonia or smelling-salts, to the nose; the
administration by the mouth of sal-volatile, whisky or brandy, and the
intra-muscular injection of ether, are the most speedily efficacious
remedies. In severe cases the application of hot cloths over the heart,
or of the faradic current over the line of the phrenic nerve, just above
the clavicle, may be called for.

#Surgical Shock.#--The condition known as surgical shock may be looked
upon as a state of profound exhaustion of the mechanism that exists in
the body for the transformation of energy. This mechanism consists of
(1) the _brain_, which, through certain special centres, regulates all
vital activity; (2) the _adrenal glands_, the secretion of
which--adrenalin--acting as a stimulant of the sympathetic system, so
controls the tone of the blood vessels as to maintain efficient
oxidation of the tissues; and (3) _the liver_, which stores and delivers
glycogen as it is required by the muscles, and in addition, deals with
the by-products of metabolism.

Crile and his co-workers have shown that in surgical shock histological
changes occur in the cells of the brain, the adrenals, and the liver,
and that these are identical, whatever be the cause that leads to the
exhaustion of the energy-transforming mechanism. These changes vary in
degree, and range from slight alterations in the structure of the
protoplasm to complete disorganisation of the cell elements.

The influences which contribute to bring about this form of exhaustion
that we call shock are varied, and include such emotional states as
fear, anxiety, or worry, physical injury and toxic infection, and the
effects of these factors are augmented by anything that tends to lower
the vitality, such as loss of blood, exposure, insufficient food, loss
of sleep or antecedent illness.

Any one or any combination of these influences may cause shock, but the
most potent, and the one which most concerns the surgeon, is physical
injury, _e.g._, a severe accident or an operation (_traumatic shock_).
This is usually associated with some emotional disturbance, such as fear
or anxiety (_emotional shock_), or with hæmorrhage; and may be followed
by septic infection (_toxic shock_).

The exaggerated afferent impulses reaching the brain as a result of
trauma, inhibit the action of the nuclei in the region of the fourth
ventricle and cerebellum which maintain the muscular tone, with the
result that the muscular tone is diminished and there is a marked fall
in the arterial blood pressure. The capillaries dilate--the blood
stagnating in them and giving off its oxygen and transuding its fluid
elements into the tissues--with the result that an insufficient quantity
of oxygenated blood reaches the heart to enable it to maintain an
efficient circulation. As the sarco-lactic acid liberated in the muscles
is not oxygenated a condition of acidosis ensues.

The more highly the injured part is endowed with sensory nerves the more
marked is the shock; a crush of the hand, for example, is attended with
a more intense degree of shock than a correspondingly severe crush of
the foot; and injuries of such specially innervated parts as the testis,
the urethra, the face, or the spinal cord, are associated with severe
degrees, as are also those of parts innervated from the sympathetic
system, such as the abdominal or thoracic viscera. It is to be borne in
mind that a state of general anæsthesia does not prevent injurious
impulses reaching the brain and causing shock during an operation. If
the main nerves of the part are "blocked" by injection of a local
anæsthetic, however, the central nervous system is protected from these
impulses.

While the aged frequently manifest but few signs of shock, they have a
correspondingly feeble power of recovery; and while many young children
suffer little, even after severe operations, others with much less cause
succumb to shock.

When the injured person's mind is absorbed with other matters than his
own condition,--as, for example, during the heat of a battle or in the
excitement of a railway accident or a conflagration,--even severe
injuries may be unattended by pain or shock at the time, although when
the period of excitement is over, the severity of the shock is all the
greater. The same thing is observed in persons injured while under the
influence of alcohol.

_Clinical Features._--The patient is in a state of prostration. He is
roused from his condition of indifference with difficulty, but answers
questions intelligently, if only in a whisper. The face is pale, beads
of sweat stand out on the brow, the features are drawn, the eyes
sunken, and the cheeks hollow. The lips and ears are pallid; the skin of
the body of a greyish colour, cold, and clammy. The pulse is rapid,
fluttering, and often all but imperceptible at the wrist; the
respiration is irregular, shallow, and sighing; and the temperature may
fall to 96° F. or even lower. The mouth is parched, and the patient
complains of thirst. There is little sensibility to pain.

Except in very severe cases, shock tends towards recovery within a few
hours, the _reaction_, as it is called, being often ushered in by
vomiting. The colour improves; the pulse becomes full and bounding; the
respiration deeper and more regular; the temperature rises to 100° F. or
higher; and the patient begins to take notice of his surroundings. The
condition of neurasthenia which sometimes follows an operation may be
associated with the degenerative changes in nerve cells described by
Crile.

In certain cases the symptoms of traumatic shock blend with those
resulting from toxin absorption, and it is difficult to estimate the
relative importance of the two factors in the causation of the
condition. The conditions formerly known as "delayed shock" and
"prostration with excitement" are now generally recognised to be due to
toxæmia.

_Question of Operating during Shock._--Most authorities agree that
operations should only be undertaken during profound shock when they are
imperatively demanded for the arrest of hæmorrhage, the prevention of
infection of serous cavities, or for the relief of pain which is
producing or intensifying the condition.

_Prevention of Operation Shock._--In the preparation of a patient for
operation, drastic purgation and prolonged fasting must be avoided, and
about half an hour before a severe operation a pint of saline solution
should be slowly introduced into the rectum; this is repeated, if
necessary, during the operation, and at its conclusion. The
operating-room must be warm--not less than 70° F.--and the patient
should be wrapped in cotton wool and blankets, and surrounded by
hot-bottles. All lotions used must be warm (100° F.); and the operation
should be completed as speedily and as bloodlessly as possible. The
element of fear may to some extent be eliminated by the preliminary
administration of such drugs as scopolamin or morphin, and with a view
to preventing the passage of exciting afferent impulses, Crile advocates
"blocking" of the nerves by the injection of a 1 per cent. solution of
novocaine into their substance on the proximal side of the field of
operation. To prevent after-pain in abdominal wounds he recommends
injecting the edges with quinine and urea hydrochlorate before suturing,
the resulting anæsthesia lasting for twenty-four to forty-eight hours.
To these preventive measures the term _anoci-association_ has been
applied. In selecting an anæsthetic, it may be borne in mind that
chloroform lowers the blood pressure more than ether does, and that with
spinal anæsthesia there is no lowering of the blood pressure.

_Treatment._--A patient suffering from shock should be placed in the
recumbent position, with the foot of the bed raised to facilitate the
return circulation in the large veins, and so to increase the flow of
blood to the brain. His bed should be placed near a large fire, and the
patient himself surrounded by cotton wool and blankets and hot-bottles.
If he has lost much blood, the limbs should be wrapped in cotton wool
and firmly bandaged from below upwards, to conserve as much of the
circulating blood as possible in the trunk and head. If the shock is
moderate in degree, as soon as the patient has been put to bed, about a
pint of saline solution should be introduced into the rectum, and 10 to
15 minims of adrenalin chloride (1 in 1000) may with advantage be added
to the fluid. The injection should be repeated every two hours until the
circulation is sufficiently restored. In severe cases, especially when
associated with hæmorrhage, transfusion of whole blood from a compatible
donor, is the most efficient means (_Op. Surg._, p. 37). Cardiac
stimulants such as strychnin, digitalin, or strophanthin are
contra-indicated in shock, as they merely exhaust the already impaired
vaso-motor centre.

Artificial respiration may be useful in tiding a patient over the
critical period of shock, especially at the end of a severe operation.

Failing this, the introduction of saline solution at a temperature of
about 105° F. into a vein or into the subcutaneous tissue is useful
where much blood has been lost (p. 276). Two or three pints may be
injected into a vein, or smaller quantities under the skin.

Thirst is best met by giving small quantities of warm water by the
mouth, or by the introduction of saline solution into the rectum. Ice
only relieves thirst for a short time, and as it is liable to induce
flatulence should be avoided, especially in abdominal cases. Dryness of
the tongue may be relieved by swabbing the mouth with a mixture of
glycerine and lemon juice.

If severe pain calls for the use of morphin, 1/120th grain of atropin
should be added, or heroin alone may be given in doses of 1/24th to
1/12th grain.

#Collapse# is a clinical condition which comes on more insidiously than
shock, and which does not attain its maximum degree of severity for
several hours. It is met with in the course of severe illnesses,
especially such as are associated with the loss of large quantities of
fluid from the body--for example, by severe diarrhœa, notably in Asiatic
cholera; by persistent vomiting; or by profuse sweating, as in some
cases of heat-stroke. Severe degrees of collapse follow sudden and
profuse loss of blood.

Collapse often follows upon shock--for example, in intestinal
perforations, or after abdominal operations complicated by peritonitis,
especially if there is vomiting, as in cases of obstruction high up in
the intestine. The symptoms of collapse are aggravated if toxin
absorption is superadded to the loss of fluid.

The _clinical features_ of this condition are practically the same as
those of shock; and it is treated on the same lines.

FAT EMBOLISM.--After various injuries and operations, but
especially such as implicate the marrow of long bones--for example,
comminuted fractures, osteotomies, resections of joints, or the forcible
correction of deformities--fluid fat may enter the circulation in
variable quantity. In the vast majority of cases no ill effects follow,
but when the quantity is large or when the absorption is long continued
certain symptoms ensue, either immediately, or more frequently not for
two or three days. These are mostly referable to the lungs and brain.

In the lung the fat collects in the minute blood vessels and produces
venous congestion and œdema, and sometimes pneumonia. Dyspnœa, with
cyanosis, a persistent cough and frothy or blood-stained sputum, a
feeble pulse and low temperature, are the chief symptoms.

When the fat lodges in the capillaries of the brain, the pulse becomes
small, rapid, and irregular, delirium followed by coma ensues, and the
condition is usually rapidly fatal.

Fat is usually to be detected in the urine, even in mild cases.

The _treatment_ consists in tiding the patient over the acute stage of
his illness, until the fat is eliminated from the blood vessels.

TRAUMATIC ASPHYXIA OR TRAUMATIC CYANOSIS.--This term has been
applied to a condition which results when the thorax is so forcibly
compressed that respiration is mechanically arrested for several
minutes. It has occurred from being crushed in a struggling crowd, or
under a fall of masonry, and in machinery accidents. When the patient is
released, the face and the neck as low down as the level of the
clavicles present an intense coloration, varying from deep purple to
blue-black. The affected area is sharply defined, and on close
inspection the appearance is found to be due to the presence of
countless minute reddish-blue or black spots, with small areas or
streaks of normal skin between them. The punctate nature of the
coloration is best recognised towards the periphery of the affected
area--at the junction of the brow with the hairy scalp, and where the
dark patch meets the normal skin of the chest (Beach and Cobb). Pressure
over the skin does not cause the colour to disappear as in ordinary
cyanosis. It has been shown by Wright of Boston, that the coloration is
due to stasis from mechanical over-distension of the veins and
capillaries; actual extravasation into the tissues is exceptional. The
sharply defined distribution of the coloration is attributed to the
absence of functionating valves in the veins of the head and neck, so
that when the increased intra-thoracic pressure is transmitted to these
veins they become engorged. Under the conjunctivæ there are
extravasations of bright red blood; and sublingual hæmatoma has been
observed (Beatson).

The discoloration begins to fade within a few hours, and after the
second or third day it disappears, without showing any of the chromatic
changes which characterise a bruise. The sub-conjunctival ecchymosis,
however, persists for several weeks and disappears like other
extravasations. Apart from combating the shock, or dealing with
concomitant injuries, no treatment is called for.


DELIRIUM IN SURGICAL PATIENTS

Delirium is a temporary disturbance of mind which occurs in the course
of certain diseases, and sometimes after injuries or operations. It may
be associated with any of the acute pyogenic infections; with
erysipelas, especially when it affects the head or face; or with chronic
infective diseases of the urinary organs. In the various forms of
meningitis also, and in some cases of injury to the head, it is common;
and it is sometimes met with after severe hæmorrhage, and in cases of
poisoning by such drugs as iodoform, cocain, or alcohol. Delirium may
also, of course, be a symptom of insanity.

Often there is merely incoherent muttering regarding past incidents or
occupations, or about absent friends; or the condition may assume the
form of excitement, of dementia, or of melancholia; and the symptoms are
usually worst at night.

#Delirium Tremens# is seen in persons addicted to alcohol, who, as the
result of accident or operation, are suddenly compelled to lie in bed.
Although oftenest met with in habitual drunkards or chronic tipplers, it
is by no means uncommon in moderate drinkers, and has even been seen in
children.

_Clinical Features._--The delirium, which has been aptly described as
being of a "busy" character, usually manifests itself within a few days
of the patient being laid up. For two or three days he refuses food, is
depressed, suspicious, sleepless and restless, demanding to be allowed
up. Then he begins to mutter incoherently, to pull off the bedclothes,
and to attempt to get out of bed. There is general muscular tremor, most
marked in the tongue, the lips, and the hands. The patient imagines that
he sees all sorts of horrible beings around him, and is sometimes
greatly distressed because of rats, mice, beetles, or snakes, which he
fancies are crawling over him. The pulse is soft, rapid, and
compressible; the temperature is only moderately raised (100°–101° F.),
and as a rule there is profuse sweating. The digestion is markedly
impaired, and there is often vomiting. Patients in this condition are
peculiarly insensitive to pain, and may even walk about with a fractured
leg without apparent discomfort.

In most cases the symptoms begin to pass off in three or four days; the
patient sleeps, the hallucinations and tremors cease, and he gradually
recovers. In other cases the temperature rises, the pulse becomes rapid,
and death results from exhaustion.

The main indication in _treatment_ is to secure sleep, and this is done
by the administration of bromides, chloral, or paraldehyde, or of one or
other of the drugs of which sulphonal, trional, and veronal are
examples. Heroin in doses of from 1/24th to 1/12th grain is often of
service. Morphin must be used with great caution. In some cases hyoscin
(1/200 grain) injected hypodermically is found efficacious when all
other means have failed, but this drug must be used with great
discrimination. The patient must be encouraged to take plenty of easily
digested fluid food, supplemented, if necessary, by nutrient enemata and
saline infusions.

In the early stage a brisk mercurial purge is often of value. Alcohol
should be withheld, unless failing of the pulse strongly indicates its
use, and then it should be given along with the food.

A delirious patient must be constantly watched by a trained attendant or
other competent person, lest he get out of bed and do harm to himself or
others. Mechanical restraint is often necessary, but must be avoided if
possible, as it is apt to increase the excitement and exhaust the
patient. On account of the extreme restlessness, there is often great
difficulty in carrying out the proper treatment of the primary surgical
condition, and considerable modifications in splints and other
appliances are often rendered necessary.

A form of delirium, sometimes spoken of as #Traumatic Delirium#, may
follow on severe injuries or operations in persons of neurotic
temperament, or in those whose nervous system is exhausted by overwork.
It is met with apart from alcoholic intemperance. This form of delirium
seems to be specially prone to ensue on operations on the face, the
thyreoid gland, or the genito-urinary organs. The symptoms appear in
from two to five days after the operation, and take the form of
restlessness, sleeplessness, low incoherent muttering, and picking at
the bedclothes. It is not necessarily attended by fever or by muscular
tremors. The patient may show hysterical symptoms. This condition is
probably to be regarded as a form of insanity, as it is liable to merge
into mania or melancholia.

The _treatment_ is carried out on the same lines as that of delirium
tremens.



CHAPTER XIV

THE BLOOD VESSELS


Anatomy--INJURIES OF ARTERIES: _Varieties_--INJURIES OF
    VEINS: _Air Embolism_--Repair of blood vessels and natural
    arrest of hæmorrhage--HÆMORRHAGE: _Varieties_;
    _Prevention_; _Arrest_--Constitutional effects of
    hæmorrhage--Hæmophilia--DISEASES OF BLOOD VESSELS:
    Thrombosis; Embolism--Arteritis: _Varieties_;
    Arterio-sclerosis--Thrombo-phlebitis--Phlebitis:
    _Varieties_--VARIX--ANGIOMATA--Nævus: _Varieties_;
    _Electrolysis_--Cirsoid aneurysm--ANEURYSM: _Varieties_;
    _Methods of treatment_--ANEURYSMS OF INDIVIDUAL ARTERIES.

#Surgical Anatomy.#--An _artery_ has three coats: an internal coat--the
_tunica intima_--made up of a single layer of endothelial cells lining
the lumen; outside of this a layer of delicate connective tissue; and
still farther out a dense tissue composed of longitudinally arranged
elastic fibres--the internal elastic lamina. The tunica intima is easily
ruptured. The middle coat, or _tunica media_, consists of non-striped
muscular fibres, arranged for the most part concentrically round the
vessel. In this coat also there is a considerable proportion of elastic
tissue, especially in the larger vessels. The thickness of the vessel
wall depends chiefly on the development of the muscular coat. The
external coat, or _tunica externa_, is composed of fibrous tissue,
containing, especially in vessels of medium calibre, some yellow elastic
fibres in its deeper layers.

In most parts of the body the arteries lie in a sheath of connective
tissue, from which fine fibrous processes pass to the tunica externa.
The connection, however, is not a close one, and the artery when divided
transversely is capable of retracting for a considerable distance within
its sheath. In some of the larger arteries the sheath assumes the form
of a definite membrane.

The arteries are nourished by small vessels--the _vasa vasorum_--which
ramify chiefly in the outer coat. They are also well supplied with
nerves, which regulate the size of the lumen by inducing contraction or
relaxation of the muscular coat.

The _veins_ are constructed on the same general plan as the arteries,
the individual coats, however, being thinner. The inner coat is less
easily ruptured, and the middle coat contains a smaller proportion of
muscular tissue. In one important point veins differ structurally from
arteries--namely, in being provided with valves which prevent reflux of
the blood. These valves are composed of semilunar folds of the tunica
intima strengthened by an addition of connective tissue. Each valve
usually consists of two semilunar flaps attached to opposite sides of
the vessel wall, each flap having a small sinus on its cardiac side.
The distension of these sinuses with blood closes the valve and
prevents regurgitation. Valves are absent from the superior and inferior
venæ cavæ, the portal vein and its tributaries, the hepatic, renal,
uterine, and spermatic veins, and from the veins in the lower part of
the rectum. They are ill-developed or absent also in the iliac and
common femoral veins--a fact which has an important bearing on the
production of varix in the veins of the lower extremity.

The wall of _capillaries_ consists of a single layer of endothelial
cells.


HÆMORRHAGE

Various terms are employed in relation to hæmorrhage, according to its
seat, its origin, the time at which it occurs, and other circumstances.

The term _external hæmorrhage_ is employed when the blood escapes on the
surface; when the bleeding takes place into the tissues or into a cavity
it is spoken of as _internal_. The blood may infiltrate the connective
tissue, constituting an _extravasation_ of blood; or it may collect in a
space or cavity and form a _hæmatoma_.

The coughing up of blood from the lungs is known as _hæmoptysis_;
vomiting of blood from the stomach, as _hæmatemesis_; the passage of
black-coloured stools due to the presence of blood altered by digestion,
as _melæna_; and the passage of bloody urine, as _hæmaturia_.

Hæmorrhage is known as arterial, venous, or capillary, according to the
nature of the vessel from which it takes place.

In _arterial_ hæmorrhage the blood is bright red in colour, and escapes
from the cardiac end of the divided vessel in pulsating jets
synchronously with the systole of the heart. In vascular parts--for
example the face--both ends of a divided artery bleed freely. The blood
flowing from an artery may be dark in colour if the respiration is
impeded. When the heart's action is weak and the blood tension low the
flow may appear to be continuous and not in jets. The blood from a
divided artery at the bottom of a deep wound, escapes on the surface in
a steady flow.

_Venous_ bleeding is not pulsatile, but occurs in a continuous stream,
which, although both ends of the vessel may bleed, is more copious from
the distal end. The blood is dark red under ordinary conditions, but may
be purplish, or even black, if the respiration is interfered with. When
one of the large veins in the neck is wounded, the effects of
respiration produce a rise and fall in the stream which may resemble
arterial pulsation.

In _capillary_ hæmorrhage, red blood escapes from numerous points on the
surface of the wound in a steady ooze. This form of bleeding is serious
in those who are the subjects of hæmophilia.


INJURIES OF ARTERIES

The following description of the injuries of arteries refers to the
larger, named trunks. The injuries of smaller, unnamed vessels are
included in the consideration of wounds and contusions.

#Contusion.#--An artery may be contused by a blow or crush, or by the
oblique impact of a bullet. The bruising of the vessel wall, especially
if it is diseased, may result in the formation of a thrombus which
occludes the lumen temporarily or even permanently, and in rare cases
may lead to gangrene of the limb beyond.

#Subcutaneous Rupture.#--An artery may be ruptured subcutaneously by a
blow or crush, or by a displaced fragment of bone. This injury has been
produced also during attempts to reduce dislocations, especially those
of old standing at the shoulder. It is most liable to occur when the
vessels are diseased. The rupture may be incomplete or complete.

_Incomplete Subcutaneous Rupture._--In the majority of cases the rupture
is incomplete--the inner and middle coats being torn, while the outer
remains intact. The middle coat contracts and retracts, and the
internal, because of its elasticity, curls up in the interior of the
vessel, forming a valvular obstruction to the blood-flow. In most cases
this results in the formation of a thrombus which occludes the vessel.
In some cases the blood-pressure gradually distends the injured segment
of the vessel wall and leads to the formation of an aneurysm.

The pulsation in the vessels beyond the seat of rupture is arrested--for
a time at least--owing to the occlusion of the vessel, and the limb
becomes cold and powerless. The pulsation seldom returns within five or
six weeks of the injury, if indeed it is not permanently arrested, but,
as a rule, a collateral circulation is rapidly established, sufficient
to nourish the parts beyond. If the pulsation returns within a week of
the injury, the presumption is that the occlusion was due to pressure
from without--for example, by hæmorrhage into the sheath or the pressure
of a fragment of bone.

_Complete Subcutaneous Rupture._--When the rupture is complete, all the
coats of the vessel are torn and the blood escapes into the surrounding
tissues. If the original injury is attended with much shock, the
bleeding may not take place until the period of reaction. Rupture of the
popliteal artery in association with fracture of the femur, or of the
axillary or brachial artery with fracture of the humerus or dislocation
of the shoulder, are familiar examples of this injury.

Like incomplete rupture, this lesion is accompanied by loss of pulsation
and power, and by coldness of the limb beyond; a tense and excessively
painful swelling rapidly appears in the region of the injury, and, where
the cellular tissue is loose, may attain a considerable size. The
pressure of the effused blood occludes the veins and leads to congestion
and œdema of the limb beyond. The interference with the circulation, and
the damage to the tissues, may be so great that gangrene ensues.

_Treatment._--When an artery has been contused or ruptured, the limb
must be placed in the most favourable condition for restoration of the
circulation. The skin is disinfected and the limb wrapped in cotton wool
to conserve its heat, and elevated to such an extent as to promote the
venous return without at the same time interfering with the inflow of
blood. A careful watch must be kept on the state of nutrition of the
limb, lest gangrene occurs.

If no complications supervene, the swelling subsides, and recovery may
be complete in six or eight weeks. If the extravasation is great and the
skin threatens to give way, or if the vitality of the limb is seriously
endangered, it is advisable to expose the injured vessel, and, after
clearing away the clots, to attempt to suture the rent in the artery,
or, if torn across, to join the ends after paring the bruised edges. If
this is impracticable, a ligature is applied above and below the
rupture. If gangrene ensues, amputation must be performed.

These descriptions apply to the larger arteries of the extremities. A
good illustration of subcutaneous rupture of the arteries of the head is
afforded by the tearing of the middle meningeal artery caused by the
application of blunt violence to the skull; and of the arteries of the
trunk--caused by the tearing of the renal artery in rupture of the
kidney.

#Open Wounds of Arteries--Laceration.#--Laceration of large arteries is
a common complication of machinery and railway accidents. The violence
being usually of a tearing, twisting, or crushing nature, such injuries
are seldom associated with much hæmorrhage, as torn or crushed vessels
quickly become occluded by contraction and retraction of their coats and
by the formation of a clot. A whole limb even may be avulsed from the
body with comparatively little loss of blood. The risk in such cases is
secondary hæmorrhage resulting from pyogenic infection.

The _treatment_ is that applicable to all wounds, with, in addition, the
ligation of the lacerated vessels.

#Punctured wounds# of blood vessels may result from stabs, or they may
be accidentally inflicted in the course of an operation.

The division of the coats of the vessel being incomplete, the natural
hæmostasis that results from curling up of the intima and contraction of
the media, fails to take place, and bleeding goes on into the
surrounding tissues, and externally. If the sheath of the vessel is not
widely damaged, the gradually increasing tension of the extravasated
blood retained within it may ultimately arrest the hæmorrhage. A clot
then forms between the lips of the wound in the vessel wall and projects
for a short distance into the lumen, without, however, materially
interfering with the flow through the vessel. The organisation of this
clot results in the healing of the wound in the vessel wall.

In other cases the blood escapes beyond the sheath and collects in the
surrounding tissues, and a traumatic aneurysm results. Secondary
hæmorrhage may occur if the wound becomes infected.

The _treatment_ consists in enlarging the external wound to permit of
the damaged vessel being ligated above and below the puncture. In some
cases it may be possible to suture the opening in the vessel wall. When
circumstances prevent these measures being taken, the bleeding may be
arrested by making firm pressure over the wound with a pad; but this
procedure is liable to be followed by the formation of an aneurysm.

_Minute puncture of arteries_ such as frequently occur in the hypodermic
administration of drugs and in the use of exploring needles, are not
attended with any escape of blood, chiefly because of the elastic recoil
of the arterial wall; a tiny thrombus of platelets and thrombus forms at
the point where the intima is punctured.

#Incised Wounds.#--We here refer only to such incised wounds as partly
divide the vessel wall.

Longitudinal wounds show little tendency to gape, and are therefore not
attended with much bleeding. They usually heal rapidly, but, like
punctured wounds, are liable to be followed by the formation of an
aneurysm.

When, however, the incision in the vessel wall is oblique or transverse,
the retraction of the muscular coat causes the opening to gape, with the
result that there is hæmorrhage, which, even in comparatively small
arteries, may be so profuse as to prove dangerous. When the associated
wound in the soft parts is valvular the hæmorrhage is arrested and an
aneurysm may develop.

When a large arterial trunk, such as the external iliac, the femoral,
the common carotid, the brachial, or the popliteal, has been partly
divided, for example, in the course of an operation, the opening should
be closed with sutures--_arteriorrhaphy_. The circulation being
controlled by a tourniquet, or the artery itself occluded by a clamp,
fine silk or catgut stitches are passed through the outer and middle
coats after the method of Lembert, a fine, round needle being employed.
The sheath of the vessel or an adjacent fascia should be stitched
over the line of suture in the vessel wall. If infection be excluded,
there is little risk of thrombosis or secondary hæmorrhage; and even if
thrombosis should develop at the point of suture, the artery is
obstructed gradually, and the establishment of a collateral circulation
takes place better than after ligation. In the case of smaller trunks,
or when suture is impracticable, the artery should be tied above and
below the opening, and divided between the ligatures.

#Gunshot Wounds of Blood Vessels.#--In the majority of cases injuries of
large vessels are associated with an external wound; the profusion of
the bleeding indicates the size of the damaged vessel, and the colour of
the blood and the nature of the flow denote whether an artery or a vein
is implicated.

When an artery is wounded a firm _hæmatoma_ may form, with an expansile
pulsation and a palpable thrill--whether such a hæmatoma remains
circumscribed or becomes diffuse depends upon the density or laxity of
the tissues around it. In course of time a _traumatic arterial aneurysm_
may develop from such a hæmatoma.

When an artery and its companion vein are injured simultaneously an
_arterio-venous aneurysm_ (p. 310) may develop. This frequently takes
place without the formation of a hæmatoma as the arterial blood finds
its way into the vein and so does not escape into the tissues. Even if a
hæmatoma forms it seldom assumes a great size. In time a swelling is
recognised, with a palpable thrill and a systolic bruit, loudest at the
level of the communication and accompanied by a continuous venous hum.

If leakage occurs into the tissues, the extravasated blood may occlude
the vein by pressure, and the symptoms of arterial aneurysm replace
those of the arterio-venous form, the systolic bruit persisting, while
the venous hum disappears.

_Gangrene_ may ensue if the blood supply is seriously interfered with,
or the signs of _ischæmia_ may develop; the muscles lose their
elasticity, become hard and paralysed, and anæsthesia of the "glove" or
"stocking" type, with other alterations of sensation ensue. Apart from
ischæmia, _reflex paralysis_ of motion and sensation of a transient kind
may follow injury of a large vessel.

_Treatment_ is carried out on the same lines as for similar injuries due
to other causes.


INJURIES OF VEINS

Veins are subject to the same forms of injury as arteries, and the
results are alike in both, such variations as occur being dependent
partly on the difference in their anatomical structure, and partly on
the conditions of the circulation through them.

#Subcutaneous rupture# of veins occur most frequently in association
with fractures and in the reduction of dislocations. The veins most
commonly ruptured are the popliteal, the axillary, the femoral, and the
subclavian. On account of the smaller amount of elastic and muscular
tissue in the wall of a vein, the contraction and retraction of its
walls are less than in an artery, and so bleeding may continue for a
longer period. On the other hand, owing to the lower blood-pressure the
outflow goes on more slowly, and the gradually increasing pressure
produced by the extravasated blood is usually sufficient to arrest the
hæmorrhage before it becomes serious. As an aid in diagnosing the source
of the bleeding, it should be remembered that the rupture of a vein does
not affect the pulsation in the limb beyond. The risks are practically
the same as when an artery is ruptured, excepting that of aneurysm, and
the treatment is carried out on the same lines, but it is seldom
necessary to operate for the purpose of applying a ligature to the
injured vein.

#Wounds# of veins--punctured and incised--frequently occur in the course
of operations; for example, in the removal of tumours or diseased glands
from the neck, the axilla, or the groin. They are also met with as a
result of accidental stabs and of suicidal or homicidal injuries. The
hæmorrhage from a large vein so damaged is usually profuse, but it is
more readily controlled by external pressure than that from an artery.
When a vein is merely punctured, the bleeding may be arrested by
pressure with a pad of gauze, or by a lateral ligature--that is, picking
up the margins of the rent in the wall and securing them with a
ligature without occluding the lumen. In the large veins, such as the
internal jugular, the femoral, or the axillary, it is usually possible
to suture the opening in the wall. This does not necessarily result in
thrombosis in the vessel, or in obliteration of its lumen.

When an _artery and vein are simultaneously wounded_, the features
peculiar to each are present in greater or less degree. In the limbs
gangrene may ensue, especially if the wound is infected. Punctured and
gun-shot wounds implicating both artery and vein are liable to be
followed by the development of arterio-venous aneurysm.

#Entrance of Air into Veins--Air Embolism.#--This serious, though
fortunately rare, accident is apt to occur in the course of operations
in the region of the thorax, neck, or axilla, if a large vein is opened
and fails to collapse on account of the rigidity of its walls, its
incorporation in a dense fascia, or from traction being made upon it. If
the wound in a vein is thus held open, the negative pressure during
inspiration sucks air into the right side of the heart. This is
accompanied by a hissing or gurgling sound, and with the next expiration
some frothy blood escapes from the wound. The patient instantly becomes
pale, the pupils dilate, respiration becomes laboured, and although the
heart may continue to beat forcibly, the peripheral pulse is weak, and
may even be imperceptible. On auscultating the heart, a churning sound
may be heard. Death may result in a few minutes; or the heart may slowly
regain its power and recovery take place.

_Prevention._--In operations in the "dangerous area"--as the region of
the root of the neck is called in this connection--care must be taken
not to cut or divide any vein before it has been secured by forceps, and
to apply ligatures securely and at once. Deep wounds in this region
should be kept filled with normal salt solution. Immediately a cut is
recognised in a vein, a finger should be placed over the vessel on the
cardiac side of the wound, and kept there until the opening is secured.

_Treatment._--Little can be done after the air has actually entered the
vein beyond endeavouring to maintain the heart's action by hypodermic
injections of ether or strychnin and the application of mustard or hot
cloths over the chest. The head at the same time should be lowered to
prevent syncope. Attempts to withdraw the air by suction, and the
employment of artificial respiration, have proved futile, and are, by
some, considered dangerous. In a desperate case massage of the heart
might be tried.


THE NATURAL ARREST OF HÆMORRHAGE AND THE REPAIR OF BLOOD
VESSELS

#Primary Hæmorrhage.#--The term primary hæmorrhage is applied to the
bleeding which follows immediately on the wounding of a blood vessel.
The natural process by which such hæmorrhage is arrested varies with the
character of the wound in the vessel and may be modified by accidental
circumstances.

(a) _Repair of completely divided Artery._--When an artery is
_completely_ divided, the circular fibres of the muscular coat contract,
so that the lumen of the cut ends is diminished, and at the same time
each segment retracts within its sheath in virtue of the recoil of the
elastic elements in its walls, the tunica intima curls up in the
interior of the vessel, and the tunica externa collapses over the cut
ends. The blood that escapes from the injured vessel fills the
interstices of the tissues, and, coagulating, forms a clot which
temporarily arrests the bleeding. That part of the clot which lies
between the divided ends of the vessel and in the cellular tissue
outside, is known as the _external clot_, while the portion which
projects into the lumen of the vessel is known as the _internal clot_,
and it usually extends as far as the nearest collateral branch. These
processes constitute what is known as the _temporary arrest of
hæmorrhage_, which, it will be observed, is effected by the contraction
and retraction of the divided artery and by clotting.

The _permanent arrest_ takes place by the transformation of the clot
into scar tissue. The internal clot plays the most important part in the
process; it becomes invaded by leucocytes and proliferating endothelial
and connective-tissue cells, and new blood vessels permeate the mass,
which is thus converted into granulation tissue. This is ultimately
replaced by fibrous tissue, which permanently occludes the end of the
vessel. Concurrently and by the same process the external clot is
converted into scar tissue.

If a divided artery is _ligated at its cut end_, the tension of the
ligature is usually sufficient to rupture the inner and middle coats,
which curl up within the lumen, the outer coat alone being held in the
grasp of the ligature. An internal clot forms and, becoming organised,
permanently occludes the vessel as above described. The ligature and the
small portion of vessel beyond it are subsequently absorbed.

In course of time the collateral branches of the vessel above and below
the level of section enlarge and their inter-communication becomes more
free, so that even when large trunks have been divided the vascular
supply of the parts beyond may be completely restored. This is known as
the development of the _collateral circulation_.

_Imperfect Collateral Circulation._--While the development of the
collateral circulation after the ligation or obstruction from other
cause of a main arterial trunk may be sufficient to prevent gangrene of
the limb, it may be insufficient for its adequate nourishment; it may be
cold, bluish in colour, and there may be necrosis of the skin over bony
points; this is notably the case in the lower extremity after ligation
of the femoral or popliteal artery, when patches of skin may die over
the prominence of the heel, the balls of the toes, the projecting base
of the fifth metatarsal and the external malleolus.

If, during the period of reaction, the blood-pressure rises
considerably, the occluding clot at the divided end of the vessel may be
washed away or the ligature displaced, permitting of fresh bleeding
taking place--_reactionary_ or _intermediary hæmorrhage_ (p. 272).

In the event of the wound becoming infected with pyogenic organisms, the
occluding blood-clot or the young fibrous tissue may become
disintegrated in the suppurative process, and the bleeding start
afresh--_secondary hæmorrhage_ (p. 273).

(b) If an artery is only _partly cut across_, the divided fibres of
the tunica muscularis contract and those of the tunica externa retract,
with the result that a more or less circular hole is formed in the wall
of the vessel, from which free bleeding takes place, as the conditions
are unfavourable for the formation of an occluding clot. Even if a clot
does form, when the blood-pressure rises it is readily displaced,
leading to reactionary hæmorrhage. Should the wound become infected,
secondary hæmorrhage is specially liable to occur. A further risk
attends this form of injury, in that the intra-vascular tension may in
time lead to gradual stretching of the scar tissue which closes the gap
in the vessel wall, with the result that a localised dilatation or
diverticulum forms, constituting a _traumatic aneurysm_.

(c) When the injury merely takes the form of a _puncture_ or _small
incision_ a blood-clot forms between the edges, becomes organised, and
is converted into cicatricial tissue which seals the aperture. Such
wounds may also be followed by reactionary or secondary hæmorrhage, or
later by the formation of a traumatic aneurysm.

_Conditions which influence the Natural Arrest of Hæmorrhage._--The
natural arrest of bleeding is favoured by tearing or crushing of the
vessel walls, owing to the contraction and retraction of the coats and
the tendency of blood to coagulate when in contact with damaged tissue.
Hence the primary hæmorrhage following lacerated wounds is seldom
copious. The occurrence of syncope or of profound shock also helps to
stop bleeding by reducing the force of the heart's action.

On the other hand, there are conditions which retard the natural arrest.
When, for example, a vessel is only partly divided, the contraction and
retraction of the muscular coat, instead of diminishing the calibre of
the artery, causes the wound in the vessel to gape; by completing the
division of the vessel under these circumstances the bleeding can often
be arrested. In certain situations, also, the arteries are so intimately
connected with their sheaths, that when cut across they were unable to
retract and contract--for example, in the scalp, in the penis, and in
bones--and copious bleeding may take place from comparatively small
vessels. This inability of the vessels to contract and retract is met
with also in inflamed and œdematous parts and in scar tissue. Arteries
divided in the substance of a muscle also sometimes bleed unduly. Any
increase in the force of the heart's action, such as may result from
exertion, excitement, or over-stimulation, also interferes with the
natural arrest. Lastly, in bleeders, there are conditions which
interfere with the natural arrest of hæmorrhage.

#Repair of a Vessel ligated in its Continuity.#--When a ligature is
applied to an artery it should be pulled sufficiently tight to occlude
the lumen without causing rupture of its coats. It often happens,
however, that the compression causes rupture of the inner and middle
coats, so that only the outer coat remains in the grasp of the ligature.
While this weakens the wall of the vessel, it has the advantage of
hastening coagulation, by bringing the blood into contact with damaged
tissue. Whether the inner and middle coats are ruptured or not, blood
coagulates both above and below the ligature, the proximal clot being
longer and broader than that on the distal side. In small arteries these
clots extend as far as the nearest collateral branch, but in the larger
trunks their length varies. The permanent occlusion of those portions of
the vessel occupied by clot is brought about by the formation of
granulation tissue, and its replacement by cicatricial tissue, so that
the occluded segment of the vessel is represented by a fibrous cord. In
this process the coagulum only plays a passive rôle by forming a
scaffolding on which the granulation tissue is built up. The ligature
surrounding the vessel, and the elements of the clot, are ultimately
absorbed.

#Repair of Veins.#--The process of repair in veins is the same as that
in arteries, but the thrombosed area may become canalised and the
circulation through the vessel be re-established.


HÆMORRHAGE IN SURGICAL OPERATIONS

The management of the hæmorrhage which accompanies an operation includes
(a) preventive measures, and (b) the arrest of the bleeding.

#Prevention of Hæmorrhage.#--Whenever possible, hæmorrhage should be
controlled by _digital compression_ of the main artery supplying the
limb rather than by a tourniquet. If efficiently applied compression
reduces the immediate loss of blood to a minimum, and the bleeding from
small vessels that follows the removal of the tourniquet is avoided.
Further, the pressure of a tourniquet has been shown to be a material
factor in producing shock.

In selecting a point at which to apply digital compression, it is
essential that the vessel should be lying over a bone which will furnish
the necessary resistance. The common carotid, for example, is pressed
backward and medially against the transverse process (carotid tubercle)
of the sixth cervical vertebra; the temporal against the temporal
process (zygoma) in front of the ear; and the facial against the
mandible at the anterior edge of the masseter.

In the upper extremity, the subclavian is pressed against the first rib
by making pressure downwards and backwards in the hollow above the
clavicle; the axillary and brachial by pressing against the shaft of the
humerus.

In the lower extremity, the femoral is controlled by pressing in a
direction backward and slightly upward against the brim of the pelvis,
midway between the symphysis pubis and the anterior superior iliac
spine.

The abdominal aorta may be compressed against the bodies of the lumbar
vertebræ opposite the umbilicus, if the spine is arched well forwards
over a pillow or sand-bag, or by the method suggested by Macewen, in
which the patient's spine is arched forwards by allowing the lower
extremities and pelvis to hang over the end of the table, while the
assistant, standing on a stool, applies his closed fist over the
abdominal aorta and compresses it against the vertebral column.
Momburg recommends an elastic cord wound round the body between the
iliac crest and the lower border of the ribs, but this procedure has
caused serious damage to the intestine.

When digital compression is not available, the most convenient and
certain means of preventing hæmorrhage--say in an amputation--is by the
use of some form of _tourniquet_, such as the elastic tube of Esmarch or
of Foulis, or an elastic bandage, or the screw tourniquet of Petit.
Before applying any of these it is advisable to empty the limb of blood.
This is best done after the manner suggested by Lister: the limb is held
vertical for three or four minutes; the veins are thus emptied by
gravitation, and they collapse, and as a physiological result of this
the arteries reflexly contract, so that the quantity of blood entering
the limb is reduced to a minimum. With the limb still elevated the
tourniquet is firmly applied, a part being selected where the vessel can
be pressed directly against a bone, and where there is no risk of
exerting injurious pressure on the nerve-trunks. The tourniquet should
be applied over several layers of gauze or lint to protect the skin, and
the first turn of the tourniquet must be rapidly and tightly applied to
arrest completely the arterial flow, otherwise the veins only are
obstructed and the limb becomes congested. In the lower extremity the
best place to apply a tourniquet is the middle third of the thigh; in
the upper extremity, in the middle of the arm. A tourniquet should never
be applied tighter or left on longer than is absolutely necessary.

The screw tourniquet of Petit is to be preferred when it is desired to
intermit the flow through the main artery as in operations for aneurysm.

When a tourniquet cannot conveniently be applied, or when its presence
interferes with the carrying out of the operation--as, for example, in
amputations at the hip or shoulder--the hæmorrhage may be controlled by
preliminary ligation of the main artery above the seat of operation--for
instance, the external iliac or the subclavian. For such contingencies
also the steel skewers used by Spence and Wyeth, or a special clamp or
forceps, such as that suggested by Lynn Thomas, may be employed. In the
case of vessels which it is undesirable to occlude permanently, such as
the common carotid, the temporary application of a ligature or clamp is
useful.

#Arrest of Hæmorrhage.#--_Ligature._--This is the best means of securing
the larger vessels. The divided vessel having been caught with forceps
as near to its cut end as possible, a ligature of catgut or silk is tied
round it. When there is difficulty in applying a ligature securely, for
example in a dense tissue like the scalp or periosteum, or in a friable
tissue like the thyreoid gland or the mesentery, a stitch should be
passed so as to surround the bleeding vessel a short distance from its
end, in this way ensuring a better hold and preventing the ligature from
slipping.

If the hæmorrhage is from a partly divided vessel, this should be
completely cut across to enable its walls to contract and retract, and
to facilitate the application of forceps and ligatures.

_Torsion._--This method is seldom employed except for comparatively
small vessels, but it is applicable to even the largest arteries. In
employing torsion, the end of the vessel is caught with forceps, and the
terminal portion twisted round several times. The object is to tear the
inner and middle coats so that they curl up inside the lumen, while the
outer fibrous coat is twisted into a cord which occludes the end of the
vessel.

_Forci-pressure._--Bleeding from the smallest arteries and from
arterioles can usually be arrested by firmly squeezing them for a few
minutes with artery forceps. It is usually found that on the removal of
the forceps at the end of an operation no further hæmorrhage takes
place. By the use of specially strong clamps, such as the angiotribes of
Doyen, large trunks may be occluded by pressure.

_Cautery._--The actual cautery or Paquelin's thermo-cautery is seldom
employed to arrest hæmorrhage, but is frequently useful in preventing
it, as, for example, in the removal of piles, or in opening the bowel in
colostomy. It is used at a dull-red heat, which sears the divided ends
of the vessel and so occludes the lumen. A bright-red or a white heat
cuts the vessel across without occluding it. The separation of the
slough produced by the charring of the tissues is sometimes attended
with secondary bleeding.

_Hæmostatics_ or _Styptics_.--The local application of hæmostatics is
seldom to be recommended. In the treatment of epistaxis or bleeding from
the nose, of hæmorrhage from the socket of a tooth, and sometimes from
ulcerating or granulating surfaces, however, they may be useful. All
clots must be removed and the drug applied directly to the bleeding
surface. Adrenalin and turpentine are the most useful drugs for this
purpose.

Hæmorrhage from bone, for example the skull, may be arrested by means of
Horsley's aseptic plastic wax. To stop persistent oozing from soft
tissues, Horsley successfully applied a portion of living vascular
tissue, such as a fragment of muscle, which readily adheres to the
oozing surface and yields elements that cause coagulation of the blood
by thrombo-kinetic processes. When examined after two or three days the
muscle has been found to be closely adherent and undergoing
organisation.

#Arrest of Accidental Hæmorrhage.#--The most efficient means of
temporarily controlling hæmorrhage is by pressure applied with the
finger, or with a pad of gauze, directly over the bleeding point. While
this is maintained an assistant makes digital pressure, or applies a
tourniquet, over the main vessel of the limb on the proximal side of the
bleeding point. A useful _emergency tourniquet_ may be improvised by
folding a large handkerchief _en cravatte_, with a cork or piece of wood
in the fold to act as a pad. The handkerchief is applied round the
limb, with the pad over the main artery, and the ends knotted on the
lateral aspect of the limb. With a strong piece of wood the handkerchief
is wound up like a Spanish windlass, until sufficient pressure is
exerted to arrest the bleeding.

When hæmorrhage is taking place from a number of small vessels, its
arrest may be effected by elevation of the bleeding part, particularly
if it is a limb. By this means the force of the circulation is
diminished and the formation of coagula favoured. Similarly, in wounds
of the hand or forearm, or of the foot or leg, bleeding may be arrested
by placing a pad in the flexure and acutely flexing the limb at the
elbow or knee respectively.

#Reactionary Hæmorrhage.#--Reactionary or intermediary hæmorrhage
is really a recurrence of primary bleeding. As the name indicates, it
occurs during the period of reaction--that is, within the first twelve
hours after an operation or injury. It may be due to the increase in the
blood-pressure that accompanies reaction displacing clots which have
formed in the vessels, or causing vessels to bleed which did not bleed
during the operation; to the slipping of a ligature; or to the giving
way of a grossly damaged portion of the vessel wall. In the scrotum, the
relaxation of the dartos during the first few hours after operation
occasionally leads to reactionary hæmorrhage.

As a rule, reactionary hæmorrhage takes place from small vessels as a
result of the displacement of occluding clots, and in many cases the
hæmorrhage stops when the bandages and soaked dressings are removed. If
not, it is usually sufficient to remove the clots and apply firm
pressure, and in the case of a limb to elevate it. Should the hæmorrhage
recur, the wound must be reopened, and ligatures applied to the bleeding
vessels. Douching the wound with hot sterilised water (about 110° F.),
and plugging it tightly with gauze, are often successful in arresting
capillary oozing. When the bleeding is more copious, it is usually due
to a ligature having slipped from a large vessel such as the external
jugular vein after operations in the neck, and the wound must be opened
up and the vessel again secured. The internal administration of heroin
or morphin, by keeping the patient quiet, may prove useful in preventing
the recurrence of hæmorrhage.

#Secondary Hæmorrhage.#--The term secondary hæmorrhage refers to
bleeding that is delayed in its onset and is due to pyogenic infection
of the tissues around an artery. The septic process causes softening and
erosion of the wall of the artery so that it gives way under the
pressure of the contained blood. The leakage may occur in drops, or as a
rush of blood, according to the extent of the erosion, the size of the
artery concerned, and the relations of the erosion to the surrounding
tissues. When met with as a complication of a wound there is an
interval--usually a week to ten days--between the receipt of the wound
and the first hæmorrhage, this time being required for the extension of
the septic process to the wall of the artery and the consequent erosion
of its coats. When secondary hæmorrhage occurs apart from a wound, there
is a similar septic process attacking the wall of the artery from the
outside; for example in sloughing sore-throat, the separation of a
slough may implicate the wall of an artery and be followed by serious
and it may be fatal hæmorrhage. The mechanical pressure of a fragment of
bone or of a rubber drainage tube upon the vessel may aid the septic
process in causing erosion of the artery. In pre-Listerian days, the
silk ligature around the artery likewise favoured the changes that lead
to secondary hæmorrhage, and the interesting observation was often made,
that when the collateral circulation was well established, the leakage
occurred on the _distal_ side of the ligature. While it may happen that
the initial hæmorrhage is rapidly fatal, as for example when the
external carotid or one of its branches suddenly gives way, it is quite
common to have one, two or more _warning hæmorrhages_ before the leakage
on a large scale, which is rapidly fatal.

The _appearances of the wound_ in cases complicated by secondary
hæmorrhage are only characteristic in so far that while obviously
infected, there is an absence of all reaction; instead of frankly
suppurating, there is little or no discharge and the surrounding
cellular tissue and the limb beyond are œdematous and pit on pressure.

The _general symptoms_ of septic poisoning in cases of secondary
hæmorrhage vary widely in severity: they may be so slight that the
general health is scarcely affected and the convalescence from an
operation, for example, may be apparently normal except that the wound
does not heal satisfactorily. For example, a patient may be recovering
from an operation such as the removal of an epithelioma of the mouth,
pharynx or larynx and the associated lymph glands in the neck, and be
able to be up and going about his room, when, suddenly, without warning
and without obvious cause, a rush of blood occurs from the mouth or the
incompletely healed wound in the neck, causing death within a few
minutes.

On the other hand, the toxæmia may be of a profound type associated with
marked pallor and progressive failure of strength, which, of itself,
even when the danger from hæmorrhage has been overcome, may have a fatal
termination. The _prognosis_ therefore in cases of secondary hæmorrhage
can never be other than uncertain and unfavourable; the danger from loss
of blood _per se_ is less when the artery concerned is amenable to
control by surgical measures.

_Treatment._--The treatment of secondary hæmorrhage includes the use of
local measures to arrest the bleeding, the employment of general
measures to counteract the accompanying toxæmia, and when the loss of
blood has been considerable, the treatment of the bloodless state.

_Local Measures to arrest the Hæmorrhage._--The occurrence of even
slight hæmorrhages from a septic wound in the vicinity of a large blood
vessel is to be taken seriously; it is usually necessary to _open up the
wound_, clear out the clots and infected tissues with a sharp spoon,
disinfect the walls of the cavity with eusol or hydrogen peroxide, and
_pack_ it carefully but not too tightly with gauze impregnated with some
antiseptic, such as "bipp," so that, if the bleeding does not recur, it
may be left undisturbed for several days. The packing should if possible
be brought into actual contact with the leaking point in the vessel, and
so arranged as to make pressure on the artery above the erosion. The
dressings and bandage are then applied, with the limb in the attitude
that will diminish the force of the stream through the main artery, for
example, flexion at the elbow in hæmorrhage from the deep palmar arch.
Other measures for combating the local sepsis, such as the irrigation
method of Carrel, may be considered.

If the wound involves one of the extremities, it may be useful; and it
imparts confidence to the nurse, and, it may be, to the patient, if a
Petit's tourniquet is loosely applied above the wound, which the nurse
is instructed to tighten up in the event of bleeding taking place.

_Ligation of the Artery._--If the hæmorrhage recurs in spite of packing
the wound, or if it is serious from the outset and likely to be critical
if repeated, ligation of the artery itself or of the trunk from which it
springs, at a selected spot higher up, should be considered. This is
most often indicated in wounds of the extremities.

As examples of proximal ligation for secondary hæmorrhage may be cited
ligation of the hypogastric artery for hæmorrhage in the buttock, of the
common iliac for hæmorrhage in the thigh, of the brachial in the upper
arm for hæmorrhage from the deep palmar arch, and of the posterior
tibial behind the medial malleolus for hæmorrhage from the sole of the
foot.

_Amputation_ is the last resource, and should be decided upon if the
hæmorrhage recurs after proximal ligation, or if this has been followed
by gangrene of the limb; it should also be considered if the nature of
the wound and the virulence of the sepsis would of themselves justify
removal of the limb. Every surgeon can recall cases in which a timely
amputation has been the means of saving life.

The _counteraction of the toxæmia_ and the _treatment of the bloodless
state_, are carried out on the usual lines.

#Hæmorrhage of Toxic Origin.#--Mention must also be made of hæmorrhages
which depend upon infective or toxic conditions and in which no gross
lesion of the vessels can be discovered. The bleeding occurs as an
oozing, which may be comparatively slight and unimportant, or by its
persistence may become serious. It takes place into the superficial
layers of the skin, from mucous membranes, and into the substance of
such organs as the pancreas. Hæmorrhage from the stomach and intestine,
attended with a brown or black discoloration of the vomit and of the
stools, is one of the best known examples: it is not uncommonly met with
in infective conditions originating in the appendix, intestine,
gall-bladder, and other abdominal organs. Hæmorrhage from the mucous
membrane of the stomach after abdominal operations--apparently also due
to toxic causes and not to the operation--gives rise to the so-called
_post-operative hæmatemesis_.

#Constitutional Effects of Hæmorrhage.#--The severity of the symptoms
resulting from hæmorrhage depends as much on the rapidity with which the
bleeding takes place as on the amount of blood lost. The sudden loss of
a large quantity, whether from an open wound or into a serous
cavity--for example, after rupture of the liver or spleen--is attended
with marked pallor of the surface of the body and coldness of the skin,
especially of the face, feet, and hands. The skin is moist with a cold,
clammy sweat, and beads of perspiration stand out on the forehead. The
pulse becomes feeble, soft, and rapid, and the patient is dull and
listless, and complains of extreme thirst. The temperature is usually
sub-normal; and the respiration rapid, shallow, and sighing in
character. Abnormal visual sensations, in the form of flashes of light
or spots before the eyes; and rushing, buzzing, or ringing sounds in the
ears, are often complained of.

In extreme cases, phenomena which have been aptly described as those of
"air-hunger" ensue. On account of the small quantity of blood
circulating through the body, and the diminished hæmoglobin content of
the blood, the tissues are imperfectly oxygenated, and the patient
becomes extremely restless, gasping for breath, constantly throwing
about his arms and baring his chest in the vain attempt to breath more
freely. Faintness and giddiness are marked features. The diminished
supply of oxygen to the brain and to the muscles produces muscular
twitchings, and sometimes convulsions. Finally the pupils dilate, the
sphincters relax, and death ensues.

Young children stand the loss of blood badly, but they quickly recover,
as the regeneration of blood takes place rapidly. In old people also,
and especially when they are fat, the loss of blood is badly borne, and
the ill effects last longer. Women, on the whole, stand loss of blood
better than men, and in them the blood is more rapidly re-formed. A few
hours after a severe hæmorrhage there is usually a leucocytosis of from
15,000 to 30,000.

#Treatment of the Bloodless State.#--The patient should be placed in a
warm, well-ventilated room, and the foot of the bed elevated. Cardiac
stimulants, such as strychnin or alcohol, must be judiciously
administered, over-stimulation being avoided. The inhalation of oxygen
has been found useful in relieving the urgent symptoms of dyspnœa.

The blood may be emptied from the limbs into the vessels of the trunk,
where it is more needed, by holding them vertically in the air for a few
minutes, and then applying a firm elastic bandage over a layer of cotton
wool, from the periphery towards the trunk.

_Introduction of Fluids into the Circulation._--The most valuable
measure for maintaining the circulation, however, is by transfusion of
blood (_Op. Surg._, p. 37). If this is not immediately available the
introduction of from one to three pints of physiological salt
solution (a teaspoonful of common salt to a pint of water) into a vein,
or a 6 per cent. solution of gum acacia, is a useful expedient. The
solution is sterilised by boiling, and cooled to a temperature of about
105° F. The addition of 5 to 10 minims of adrenalin solution (1 in 1000)
is advantageous in raising the blood-pressure (_Op. Surg._, p. 565).

When the intra-venous method is not available, one or two pints of
saline solution with adrenalin should be slowly introduced into the
rectum, by means of a long rubber tube and a filler. Satisfactory,
although less rapidly obtained results follow the introduction of saline
solution into the cellular tissue--for example, under the mamma, into
the axilla, or under the skin of the back.

If the patient can retain fluids taken by the mouth--such as hot coffee,
barley water, or soda water--these should be freely given, unless the
injury necessitates operative treatment under a general anæsthetic.

Transfusion of blood is most valuable as _a preliminary to operation_ in
patients who are bloodless as a result of hæmorrhage from gastric and
duodenal ulcers, and in bleeders.


HÆMOPHILIA

The term hæmophilia is applied to an inherited disease which renders the
patient liable to serious hæmorrhage from even the most trivial
injuries; and the subjects of it are popularly known as "bleeders."

The cause of the disease and its true nature are as yet unknown. There
is no proof of any structural defect in the blood vessels, and beyond
the fact that there is a diminution in the number of blood-plates, it
has not been demonstrated that there is any alteration in the
composition of the blood.

The affection is in a marked degree hereditary, all the branches of an
affected family being liable to suffer. Its mode of transmission to
individuals, moreover, is characteristic: the male members of the stock
alone suffer from the affection in its typical form, while the tendency
is transmitted through the female line. Thus the daughters of a father
who is a bleeder, whilst they do not themselves suffer from the disease,
transmit the tendency to their male offspring. The sons, on the other
hand, neither suffer themselves nor transmit the disease to their
children (Fig. 64). The female members of a hæmophilic stock are often
very prolific, and there is usually a predominance of daughters in their
families.


FIG 64.--Genealogical Tree of a Hæmophilic Family.

Great-Great-Grandmother                Great-Great-Grandfather
Mrs D. (Lancashire) F                  M (History not known
                   .|                  |  as to bleeding)
                   .|                  |
                   .+----------+-------+
                   ............|
                              .|
                           ....|
                           .+---------+--------+
         Great-Grandmother .|         |        |
           (Married three  .F        MB       MB
                times)     .|
                           .|
                           .|
      By First Husband     .|                  By Second           By Third
              ..............|                  Husband             Husband
   +-----------+------------+----------+-------+-------+-----------+------+
   |          .|            |          |       +-------+-----------+------+
   M          .F            F          F       |       |           +------+
   |          .|            |          |       MB      F Died in      No
Died       Grandmother      |          |               | Childbed    Family
 æt.          .|            |     +-----------+   +----+---
 70           .|        +------+  |had family |   |
              .|        |      |  |but history|   |
              .|        MB    MB  |not known  |   MB
              .|
              .|
              .|.............................
+-----+----------+------------+------------+------------+-------------+
|     |          |            |            |.           |             |
|     |          |            |            |.           |             |
M     M          M            MB           F.           F             F
      |                                    |.           |             |
      |                                  Mother   +--+--+---+--+--+   |
    +----+                                 |.     |  |  |   |  |  |   |
    |    |                                 |.     M  M  MB  F  F  F   |
    M    F                                 |.                         |
     Not Married                           |.             +---+---+---+---+
                                           |.             |   |   |   |   |
                                           |.             MB  M   MB  M   M
                              .............|.
                         +-----+-----+-----+-----+-----+
                         |    .|    .|     |     |     |
                         |    .|*   .|*    |     |     |
                         M    MB    MB     F     F     F


F = Females.  M = Males (not bleeders).  MB = Males (bleeders)

 ** the patients observed by the authors. The dotted line shows the
    transmission of the disease to our patients through four
    generations.


The disease is met with in boys who are otherwise healthy, and usually
manifests itself during the first few years of life. In rare instances
profuse hæmorrhage takes place when the umbilical cord separates. As a
rule the first evidence is the occurrence of long-continued and
uncontrollable bleeding from a comparatively slight injury, such as the
scratch of a pin, the extraction of a tooth, or after the operation of
circumcision. The blood oozes slowly from the capillaries; at first it
appears normal, but after flowing for some days, or it may be weeks, it
becomes pale, thin, and watery, and shows less and less tendency to
coagulate.

Female members of hæmophilia families sometimes show a tendency to
excessive hæmorrhage, but they seldom manifest the characteristic
features met with in the male members.

Sometimes the hæmorrhage takes place apparently spontaneously from the
gums, the nasal or the intestinal mucous membrane. In other cases the
bleeding occurs into the cellular tissue under the skin or mucous
membrane, producing large areas of ecchymosis and discoloration. One of
the commonest manifestations of the disease is the occurrence of
hæmorrhage into the cavities of the large joints, especially the knee,
elbow, or hip. The patient suffers repeatedly from such hæmorrhages, the
determining injury being often so slight as to have passed unobserved.

There is evidence that the tendency to bleed is greater at certain times
than at others--in some cases showing almost a cyclical
character--although nothing is known as to the cause of the variation.

After a severe hæmorrhage into the cellular tissue or into a joint, the
patient becomes pale and anæmic, the temperature may rise to 102° or
103° F., the pulse become small and rapid, and hæmic murmurs are
sometimes developed over the heart and large arteries. The swelling is
tense, fluctuating, and hot, and there is considerable pain and
tenderness.

In exceptional cases, blisters form over the seat of the effusion, or
the skin may even slough, and the clinical features may therefore come
to simulate closely those of an acute suppurative condition. When the
skin sloughs, an ulcer is formed with altered blood-clot in its floor
like that seen in scurvy, and there is a remarkable absence of any
attempt at healing.

The acute symptoms gradually subside, and the blood is slowly absorbed,
the discoloration of the skin passing through the same series of changes
as occur after an ordinary bruise. The patients seldom manifest the
symptoms of the bloodless state, and the blood is rapidly regenerated.

The _diagnosis_ is easy if the patient or his friends are aware of the
family tendency to hæmorrhage and inform the doctor of it, but they are
often sensitive and reticent regarding the fact, and it may only be
elicited after close investigation. From the history it is usually easy
to exclude scurvy and purpura. Repeated hæmorrhages into a joint may
result in appearances which closely simulate those of tuberculous
disease. Recent hæmorrhages into the cellular tissue often present
clinical features closely resembling those of acute cellulitis or
osteomyelitis. A careful examination, however, may reveal ecchymoses on
other parts of the body which give a clue to the nature of the
condition, and may prevent the disastrous consequences that may follow
incision.

These patients usually succumb sooner or later to hæmorrhage, although
they often survive several severe attacks. After middle life the
tendency to bleed appears to diminish.

_Treatment._--As a rule the ordinary means of arresting hæmorrhage are
of little avail. From among the numerous means suggested, the following
may be mentioned: The application to the bleeding point of gauze soaked
in a 1 in 1000 solution of adrenalin; prolonged inhalation of oxygen;
freezing the part with a spray of ethyl-chloride; one or more
subcutaneous injections of gelatin--5 ounces of a 2½ per cent.
solution of white gelatin in normal salt solution being injected at a
temperature of about 100° F.; the injection of pituitary extract. The
application of a pad of gauze soaked in the blood of a normal person
sometimes arrests the bleeding.

To prevent bleeding in hæmophilics, intra-venous or subcutaneous
injections of fresh blood serum, taken from the human subject, the
sheep, the dog, or the horse, have proved useful. If fresh serum is not
available, anti-diphtheritic or anti-tetanic serum or trade
preparations, such as hemoplastin, may be employed. We have removed the
appendix and amputated through the thigh in hæmophilic subjects without
excessive loss of blood after a course of fresh sheep's serum given by
the mouth over a period of several weeks.

The chloride and lactate of calcium, and extract of thymus gland have
been employed to increase the coagulability of the blood. The patient
should drink large quantities of milk, which also increases the
coagulability of the blood. Monro has observed remarkable results from
the hypodermic injection of emetin hydrochloride in ½-grain doses.


THROMBOSIS AND EMBOLISM

The processes known as thrombosis and embolism are so intimately
associated with the diseases of blood vessels that it is convenient to
define these terms in the first instance.

#Thrombosis.#--The term _thrombus_ is applied to a clot of blood formed
in the interior of the heart or of a blood vessel, and the process by
which such a clot forms is known as _thrombosis_. It would appear that
slowing or stagnation of the blood-stream, and interference with the
integrity of the lining membrane of the vessel wall, are the most
important factors determining the formation of the clot. Alterations in
the blood itself, such as occur, for example, in certain toxæmias, also
favour coagulation. When the thrombus is formed slowly, it consists of
white blood cells with a small proportion of fibrin, and, being
deposited in successive layers, has a distinctly laminated appearance on
section. It is known as a _white thrombus_ or laminated clot, and is
often met with in the sac of an aneurysm (Fig. 72). When rapidly formed
in a vessel in which the blood is almost stagnant--as, for example, in a
pouched varicose vein--the blood coagulates _en masse_, and the clot
consists of all the elements of the blood, constituting a _red thrombus_
(Fig. 66). Sometimes the thrombus is _mixed_--a red thrombus being
deposited on a white one, it may be in alternate layers.

When aseptic, a thrombus may become detached and be carried off in the
blood-stream as an embolus; it may become organised; or it may
degenerate and undergo calcification. Occasionally a small thrombus
situated behind a valve in a varicose vein or in the terminal end of a
dilated vein--for example in a pile--undergoes calcification, and is
then spoken of as a _phlebolith_; it gives a shadow with the X-rays.

When infected with pyogenic bacteria, the thrombus becomes converted
into pus and a localised abscess forms; or portions of the thrombus may
be carried as emboli in the circulation to distant parts, where they
give rise to secondary foci of suppuration--pyæmic abscesses.

#Embolism.#--The term _embolus_ is applied to any body carried along in
the circulation and ultimately becoming impacted in a blood vessel. This
occurrence is known as _embolism_. The commonest forms of embolus are
portions of thrombi or of fibrinous formations on the valves of the
heart, the latter being usually infected with micro-organisms.

Embolism plays an important part in determining one form of gangrene, as
has already been described. Infective emboli are the direct cause of the
secondary abscesses that occur in pyæmia; and they are sometimes
responsible for the formation of aneurysm.

Portions of malignant tumours also may form emboli, and their impaction
in the vessels may lead to the development of secondary growths in
distant parts of the body.

Fat and air embolism have already been referred to.


ARTERITIS

_Pyogenic._--Non-suppurative inflammation of the coats of an artery may
so soften the wall of the vessel as to lead to aneurysmal dilatation. It
is not uncommon in children, and explains the occurrence of aneurysm in
young subjects.

When suppuration occurs, the vessel wall becomes disintegrated and gives
way, leading to secondary hæmorrhage. If the vessel ruptures into an
abscess cavity, dangerous bleeding may occur when the abscess bursts or
is opened.

_Syphilitic._--The inflammation associated with syphilis results in
thickening of the tunica intima, whereby the lumen of the vessel becomes
narrowed, or even obliterated--_endarteritis obliterans_. The middle
coat usually escapes, but the tunica externa is generally thickened.
These changes cause serious interference with the nutrition of the parts
supplied by the affected arteries. In large trunks, by diminishing the
elasticity of the vessel wall, they are liable to lead to the formation
of aneurysm.

Changes in the arterial walls closely resembling those of syphilitic
arteritis are sometimes met with in _tuberculous_ lesions.

#Arterio-sclerosis# or #Chronic Arteritis#.--These terms are applied to
certain changes which result in narrowing of the lumen and loss of
elasticity in the arteries. The condition may affect the whole vascular
system or may be confined to particular areas. In the smaller arteries
there is more or less uniform thickening of the tunica intima from
proliferation of the endothelium and increase in the connective tissue
in the elastic lamina--a form of obliterative endarteritis. The
narrowing of the vessels may be sufficient to determine gangrene in the
extremities. In course of time, particularly in the larger arteries,
this new tissue undergoes degeneration, at first of a fatty nature, but
progressing in the direction of calcification, and this is followed by
the deposit of lime salts in the young connective tissue and the
formation of calcareous plates or rings over a considerable area of the
vessel wall. To this stage in the process the term _atheroma_ is
applied. The endothelium over these plates often disappears, leaving
them exposed to the blood-stream.

Changes of a similar kind sometimes occur in the middle coat, the lime
salts being deposited among the muscle fibres in concentric rings.

The primary cause of arterio-sclerosis is not definitely known, but its
almost constant occurrence, to a greater or less degree, in the aged
suggests that it is of the nature of a senile degeneration. It is
favoured by anything which throws excessive strain on the vessel walls,
such as heavy muscular work; by chronic alcoholism and syphilis; or by
such general diseases as tend to raise the blood-pressure--for example,
chronic Bright's disease or gout. It occurs with greater frequency and
with greater severity in men than in women.

Atheromatous degeneration is most common in the large arterial trunks,
and the changes are most marked at the arch of the aorta, opposite the
flexures of joints, at the mouths of large branches, and at parts where
the vessel lies in contact with bone. The presence of diseased patches
in the wall of an artery diminishes its elasticity and favours
aneurysmal dilatation. Such a vessel also is liable to be ruptured by
external violence and so give rise to traumatic aneurysm. Thrombosis is
liable to occur when calcareous plates are exposed in the lumen of the
vessel by destruction of the endothelium, and this predisposes to
embolism. Arterio-sclerosis also interferes with the natural arrest of
hæmorrhage, and by rendering the vessels brittle, makes it difficult to
secure them by ligature. In advanced cases the accessible arteries--such
as the radial, the temporal or the femoral--may be felt as firm,
tortuous cords, which are sometimes so hard that they have been aptly
compared to "pipe-stems." The pulse is smaller and less compressible
than normal, and the vessel moves bodily with each pulsation. It must be
borne in mind, however, that the condition of the radial artery may fail
to afford a clue to that of the larger arteries. Calcified arteries are
readily identified in skiagrams (Fig. 65).

[Illustration: FIG. 65.--Radiogram showing Calcareous Degeneration
(Atheroma) of Arteries.]

We have met with a chronic form of arterial degeneration in elderly
women, affecting especially the great vessels at the root of the neck,
in which the artery is remarkably attenuated and dilated, and so friable
that the wall readily tears when seized with an artery-forceps,
rendering ligation of the vessel in the ordinary way well-nigh
impossible. Matas suggests infolding the wall of the vessel with
interrupted sutures that do not pierce the intima, and wrapping it
round with a strip of peritoneum or omentum.

The most serious form of arterial _thrombosis_ is that met with _in the
abdominal aorta_, which is attended with violent pains in the lower
limbs, rapidly followed by paralysis and arrest of the circulation.


THROMBO-PHLEBITIS AND THROMBOSIS IN VEINS

#Thrombosis# is more common in veins than in arteries, because slowing
of the blood-stream and irritation of the endothelium of the vessel wall
are, owing to the conditions of the venous circulation, more readily
induced in veins.

Venous thrombosis may occur from purely mechanical causes--as, for
example, when the wall of a vein is incised, or the vessel included in a
ligature, or when it is bruised or crushed by a fragment of a broken
bone or by a bandage too tightly applied. Under these conditions
thrombosis is essentially a reparative process, and has already been
considered in relation to the repair of blood vessels.

In other cases thrombosis is associated with certain constitutional
diseases--gout, for example; the endothelium of the veins undergoing
changes--possibly the result of irritation by abnormal constituents in
the blood--which favour the formation of thrombi.

Under these various conditions the formation of a thrombus is not
necessarily associated with the action of bacteria, although in any
of them this additional factor may be present.

The most common cause of venous thrombosis, however, is inflammation of
the wall of the vein--phlebitis.

#Phlebitis.#--Various forms of phlebitis are met with, but for practical
purposes they may be divided into two groups--one in which there is a
tendency to the formation of a thrombus; the other in which the
infective element predominates.

In surgical patients, the _thrombotic form_ is almost invariably met
with in the lower extremity, and usually occurs in those who are
debilitated and anæmic, and who are confined to bed for prolonged
periods--for example, during the treatment of fractures of the leg or
pelvis, or after such operations as herniotomy, prostatectomy, or
appendectomy.

_Clinical Features._--The most typical example of this form of phlebitis
is that so frequently met with in the great saphena vein, especially
when it is varicose. The onset of the attack is indicated by a sudden
pain in the lower limb--sometimes below, sometimes above the knee. This
initial pain may be associated with shivering or even with a rigor, and
the temperature usually rises one or two degrees. There is swelling and
tenderness along the line of the affected vein, and the skin over it is
a dull-red or purple colour. The swollen vein may be felt as a firm
cord, with bead-like enlargements in the position of the valves. The
patient experiences a feeling of stiffness and tightness throughout the
limb. There is often œdema of the leg and foot, especially when the limb
is in the dependent position. The acute symptoms pass off in a few days,
but the swelling and tenderness of the vein and the œdema of the limb
may last for many weeks.

When the deep veins--iliac, femoral, popliteal--are involved, there is
great swelling of the whole limb, which is of a firm almost "wooden"
consistence, and of a pale-white colour; the œdema may be so great that
it is impossible to feel the affected vein until the swelling has
subsided. This is most often seen in puerperal women, and is known as
_phlegmasia alba dolens_.

_Treatment._--The patient must be placed at absolute rest, with the foot
of the bed raised on blocks 10 or 12 inches high, and the limb
immobilised by sand-bags or splints. It is necessary to avoid handling
the parts, lest the clot be displaced and embolism occur. To avoid
frequent movement of the limb, the necessary dressings should be kept in
position by means of a many-tailed rather than a roller bandage.

To relieve the pain, warm fomentations or lead and opium lotion should
be applied. Later, ichthyol-glycerin, or glycerin and belladonna, may be
substituted.

When, at the end of three weeks, the danger of embolism is past,
douching and gentle massage may be employed to disperse the œdema; and
when the patient gets up he should wear a supporting elastic bandage.

The _infective_ form usually begins as a peri-phlebitis arising in
connection with some focus of infection in the adjacent tissues. The
elements of the vessel wall are destroyed by suppuration, and the
thrombus in its lumen becomes infected with pyogenic bacteria and
undergoes softening.

_Occlusion of the inferior vena cava_ as a result of infective
thrombosis is a well-known condition, the thrombosis extending into the
main trunk from some of its tributaries, either from the femoral or
iliac veins below or from the hepatic veins above.

Portions of the softened thrombus are liable to become detached and to
enter the circulating blood, in which they are carried as emboli. These
may lodge in distant parts, and give rise to secondary foci of
suppuration--pyæmic abscesses.

_Clinical Features._--Infective phlebitis is most frequently met with in
the transverse sinus as a sequel to chronic suppuration in the mastoid
antrum and middle ear. It also occurs in relation to the peripheral
veins, but in these it can seldom be recognised as a separate entity,
being merged in the general infective process from which it takes
origin. Its occurrence may be inferred, if in the course of a
suppurative lesion there is a sudden rise of temperature, with pain,
redness, and swelling along the line of a venous trunk, and a rapidly
developed œdema of the limb, with pitting of the skin on pressure. In
rare cases a localised abscess forms in the vein and points towards the
surface.

_Treatment._--Attention must be directed towards the condition with
which the phlebitis is associated. Ligation of the vein on the cardiac
side of the thrombus with a view to preventing embolism is seldom
feasible in the peripheral veins, although, as will be pointed out
later, the jugular vein is ligated with this object in cases of
phlebitis of the transverse sinus.


VARIX--VARICOSE VEINS

The term varix is applied to a condition in which veins are so altered
in structure that they remain permanently dilated, and are at the same
time lengthened and tortuous. Two types are met with: one in which
dilatation of a large superficial vein and its tributaries is the most
obvious feature; the other, in which bunches of distended and tortuous
vessels develop at one or more points in the course of a vein, a
condition to which Virchow applied the term _angioma racemosum venosum_.
The two types may occur in combination.

Any vein in the body may become varicose, but the condition is rare
except in the veins of the lower extremity, in the veins of the
spermatic cord (varicocele), and in the veins of the anal canal
(hæmorrhoids).

We are here concerned with varix as it occurs in the veins of the lower
extremity.

_Etiology._--Considerable difference of opinion exists as to the
essential cause of varix. The weight of evidence is in favour of the
view that, when dilatation is the predominant element, it results from a
congenital deficiency in the number, size, and strength of the valves of
the affected veins, and in an inherent weakness in the vessel walls.
The _angioma racemosum venosum_ is probably also due to a congenital
alteration in the structure of the vessels, and is allied to tumours of
blood vessels. The view that varix is congenital in origin, as was first
suggested by Virchow, is supported by the fact that in a large
proportion of cases the condition is hereditary; not only may several
members of the same family in succeeding generations suffer from varix,
but it is often found that the same vein, or segment of a vein, is
involved in all of them. The frequent occurrence of varix in youth is
also an indication of its congenital origin.

In the majority of cases it is only when some exciting factor comes into
operation that the clinical phenomena associated with varix appear. The
most common exciting cause is increased pressure within the veins, and
this may be produced in a variety of ways. In certain diseases of the
heart, lungs, and liver, for example, the venous pressure may be so
raised as to cause a localised dilatation of such veins as are
congenitally weak. The direct pressure of a tumour, or of the gravid
uterus on the large venous trunks in the pelvis, may so obstruct the
flow as to distend the veins of the lower extremity. It is a common
experience in women that the signs of varix date from an antecedent
pregnancy. The importance of the wearing of tight garters as a factor in
the production of varicose veins has been exaggerated, although it must
be admitted that this practice is calculated to aggravate the condition
when it is once established. It has been proved experimentally that the
backward pressure in the veins may be greatly increased by straining, a
fact which helps to explain the frequency with which varicosity occurs
in the lower limbs of athletes and of those whose occupation involves
repeated and violent muscular efforts. There is reason to believe,
moreover, that a sudden strain may, by rupturing the valves and so
rendering them incompetent, induce varicosity independently of any
congenital defect. Prolonged standing or walking, by allowing gravity to
act on the column of blood in the veins of the lower limbs, is also an
important determining factor in the production of varix.

Thrombosis of the deep veins--in the leg, for example--may induce marked
dilatation of the superficial veins, by throwing an increased amount of
work upon them. This is to be looked upon rather as a compensatory
hypertrophy of the superficial vessels than as a true varix.

_Morbid Anatomy._--In the lower extremity the varicosity most commonly
affects the vessels of the great saphena system; less frequently those
of the small saphena system. Sometimes both systems are involved, and
large communicating branches may develop between the two.

The essential lesion is the absence or deficiency of valves, so that
they are incompetent and fail to support the column of blood which bears
back upon them. Normally the valves in the femoral and iliac veins and
in the inferior vena cava are imperfectly developed, so that in the
erect posture the great saphena receives a large share of the backward
pressure of the column of venous blood.

The whole length of the vein may be affected, but as a rule the disease
is confined to one or more segments, which are not only dilated, but are
also increased in length, so that they become convoluted. The adjacent
loops of the convoluted vein are often bound together by fibrous tissue.
All the coats are thickened, chiefly by an increased development of
connective tissue, and in some cases changes similar to those of
arterio-sclerosis occur. The walls of varicose veins are often
exceedingly brittle. In some cases the thickening is uniform, and in
others it is irregular, so that here and there thin-walled sacs or
pouches project from the side of the vein. These pouches vary in size
from a bean to a hen's egg, the larger forms being called _venous
cysts_, and being most commonly met with in the region of the saphenous
opening and of the opening in the popliteal fascia. Such pouches, being
exposed to injury, are frequently the seat of thrombosis (Fig. 66).

[Illustration: FIG. 66.--Thrombosis in Tortuous and Pouched Great
Saphena Vein, in longitudinal section.]

_Clinical Features._--Varix is most frequently met with between puberty
and the age of thirty, and the sexes appear to suffer about equally.

The amount of discomfort bears no direct proportion to the extent of
the varicosity. It depends rather upon the degree of pressure in the
veins, as is shown by the fact that it is relieved by elevation of the
limb. When the whole length of the main trunk of the great saphena is
implicated, the pressure in the vein is high and the patient suffers a
good deal of pain and discomfort. When, on the contrary, the upper part
of the saphena and its valves are intact, and only the more distal veins
are involved, the pressure is not so high and there is comparatively
little suffering. The usual complaint is of a sense of weight and
fulness in the limb after standing or walking, sometimes accompanied by
actual pain, from which relief is at once obtained by raising the limb.
Cramp-like pains in the muscles are often associated with varix of the
deep veins.

The dilated and tortuous vein can be readily seen and felt when the
patient is examined in the upright posture. In advanced cases, bead-like
swellings are sometimes to be detected over the position of the valves,
and, on running the fingers along the course of the vessel, a firm
ridge, due to periphlebitis, may be detected on each side of the vein.
When the limb is œdematous, the outline of the veins is obscured, but
they can be identified on palpation as gutter-like tracks. When large
veins are implicated, a distinct impulse on coughing may be seen to pass
down as far as the knee; and if the vessel is sharply percussed a fluid
wave may be detected passing both up and down the vein.

If the patient is placed on a couch and the limb elevated, the veins are
emptied, and if pressure is then made over the region of the saphenous
opening and the patient allowed to stand up, so long as the great
saphena system alone is involved, the veins fill again very slowly from
below. If the small saphena system also is involved, and if
communicating branches are dilated, the veins fill up from below more
rapidly. When the pressure over the saphenous opening is removed, the
blood rapidly rushes into the varicose vessels from above; this is known
as Trendelenburg's test.

The most marked dilatation usually occurs on the medial side of the
limb, between the middle of the thigh and the middle of the calf, the
arrangement of the veins showing great variety (Fig. 67).

There are usually one or more bunches of enlarged and tortuous veins in
the region of the knee. Frequently a large branch establishes a
communication between the systems of the great and small saphenous veins
in the region of the popliteal space, or across the front of the upper
part of the tibia. The superficial position of this last branch and its
proximity to the bone render it liable to injury.

[Illustration: FIG. 67.--Extensive Varix of Internal Saphena System on
Left Leg, of many years' standing.]

The small veins of the skin of the ankle and foot often show as fine
blue streaks arranged in a stellate or arborescent manner, especially in
women who have borne children.

_Complications._--When the varix is of long standing, the skin in the
lower part of the leg sometimes assumes a mahogany-brown or bluish hue,
as a result of the _deposit of blood pigment_ in the tissues, and this
is frequently a precursor of ulceration.

_Chronic dermatitis_ (_varicose eczema_) is often met with in the lower
part of the leg, and is due to interference with the nutrition of the
skin. The incompetence of the valves allows the pressure in the varicose
veins to equal that in the arterioles, so that the capillary circulation
is impeded. From the same cause the blood in the deep veins is enabled
to enter the superficial veins, where the backward pressure is so great
that the blood flows down again, and so a vicious circle is established.
The blood therefore loses more and more of its oxygen, and so fails to
nourish the tissues.

The _ulcer_ of the leg associated with varicose veins has already been
described.

_Hæmorrhage_ may take place from a varicose vein as a result of a wound
or of ulceration of its wall. Increased intra-venous pressure produced
by severe muscular strain may determine rupture of a vein exposed in the
floor of an ulcer. If the limb is dependent, the incompetency of the
valves permits of rapid and copious bleeding, which may prove fatal,
particularly if the patient is intoxicated when the rupture takes place
and no means are taken to arrest the hæmorrhage. The bleeding may be
arrested at once by elevating the limb, or by applying pressure directly
over the bleeding point.

_Phlebitis and thrombosis_ are common sequelæ of varix, and may prove
dangerous, either by spreading into the large venous trunks or by giving
rise to emboli. The larger the varix the greater is the tendency for a
thrombus to spread upwards and to involve the deep veins. Thrombi
usually originate in venous cysts or pouches, and at acute bends on the
vessel, especially when these are situated in the vicinity of the knee,
and are subjected to repeated injuries--for example in riding.
Phleboliths sometimes form in such pouches, and may be recognised in a
radiogram. In a certain proportion of cases, especially in elderly
people, the occurrence of thrombosis leads to cure of the condition by
the thrombus becoming organised and obliterating the vein.

_Treatment._--At best the treatment of varicose veins is only
palliative, as it is obviously impossible to restore to the vessels
their normal structure. The patient must avoid wearing anything, such as
a garter, which constricts the limb, and any obvious cause of direct
pressure on the pelvic veins, such as a tumour, persistent
constipation, or an ill-fitting truss, should be removed. Cardiac,
renal, or pulmonary causes of venous congestion must also be treated,
and the functions of the liver regulated. Severe forms of muscular
exertion and prolonged standing or walking are to be avoided, and the
patient may with benefit rest the limb in an elevated position for a few
hours each day. To support the distended vessels, a closely woven silk
or worsted stocking, or a light and porous form of elastic bandage,
applied as a puttee, should be worn. These appliances should be put on
before the patient leaves his bed in the morning, and should only be
removed after he lies down at night. In this way the vessels are never
allowed to become dilated. Elastic stockings, and bandages made entirely
of india-rubber, are to be avoided. In early and mild cases these
measures are usually sufficient to relieve the patient's discomfort.

_Operative Treatment._--In aggravated cases, when the patient is
suffering pain, when his occupation is interfered with by repeated
attacks of phlebitis, or when there are large pouches on the veins,
operative treatment is called for. The younger the patient the clearer
is the indication to operate. It may be necessary to operate to enable a
patient to enter one of the public services, even although no symptoms
are present. The presence of an ulcer does not contra-indicate
operation; the ulcer should be excised, and the raw surface covered with
skin grafts, before dealing with the veins.

The _operation of Trendelenburg_ is especially appropriate to cases in
which the trunk of the great saphena vein in the thigh is alone
involved. It consists in exposing three or four inches of the vein in
its upper part, applying a ligature at the upper and lower ends of the
exposed portion, and, after tying all tributary branches, resecting this
portion of the vein.

The procedure of C. H. Mayo is adapted to cases in which it is desirable
to remove longer segments of the veins. It consists in the employment of
special instruments known as "ring-enucleators" or "vein-strippers," by
means of which long portions of the vein are removed through
comparatively small incisions.

An alternative procedure consists in avulsing segments of the vein by
means of Babcock's stylet, which consists of a flexible steel rod, 30
inches in length, with acorn-shaped terminals. The instrument is passed
along the lumen of the segment to be dealt with, and a ligature applied
around the vein above the bulbous end of the stylet enables nearly the
whole length of the great saphena vein to be dragged out in one piece.
These methods are not suitable when the veins are brittle, when there
are pouches or calcareous deposits in their walls, or where there has
been periphlebitis binding the coils together.

Mitchell of Belfast advises exposing the varices at numerous points by
half-inch incisions, and, after clamping the vein between two pairs of
forceps, cutting it across and twisting out the segments of the vein
between adjacent incisions. The edges of the incisions are sutured; and
the limb is firmly bandaged from below upwards, and kept in an elevated
position. We have employed this method with satisfactory results.

The treatment of the complications of varix has already been considered.


ANGIOMA[4]

[4] In the description of angiomas we have followed the teaching of the
late John Duncan.

Tumours of blood vessels may be divided, according to the nature of the
vessels of which they are composed, into the capillary, the venous, and
the arterial angiomas.


CAPILLARY ANGIOMA

The most common form of capillary angioma is the nævus or congenital
telangiectasis.

#Nævus.#--A nævus is a collection of dilated capillaries, the afferent
arterioles and the efferent venules of which often share in the
dilatation. Little is known regarding the _etiology_ of nævi beyond the
fact that they are of congenital origin. They often escape notice until
the child is some days old, but attention is usually drawn to them
within a fortnight of birth. For practical purposes the most useful
classification of nævi is into the cutaneous, the subcutaneous, and the
mixed forms.

_The cutaneous nævus_, "mother's mark," or "port-wine stain," consists
of an aggregation of dilated capillaries in the substance of the skin.
On stretching the skin the vessels can be seen to form a fine network,
or to run in leashes parallel to one another. A dilated arteriole or a
vein winding about among the capillaries may sometimes be detected.
These nævi occur on any part of the body, but they are most frequently
met with on the face. They may be multiple, and vary greatly in size,
some being no bigger than a pin-head, while others cover large areas of
the body. In colour they present every tint from purple to brilliant
red; in the majority there is a considerable dash of blue, especially in
cold weather.

Unlike the other forms of nævi, the cutaneous variety shows little
tendency to disappear, and it is especially persistent when associated
with overgrowth of the epidermis and of the hairs--_nævoid mole_.

The _treatment_ of the cutaneous nævus is unsatisfactory, owing to the
difficulty of removing the nævus without leaving a scar which is even
more disfiguring. Very small nævi may be destroyed by a fine pointed
Paquelin thermo-cautery, or by escharotics, such as nitric acid. For
larger nævi, radium and solidified carbon dioxide ("CO₂ snow") may be
used. The extensive port-wine stains so often met with on the face are
best left alone.

The _subcutaneous nævus_ is comparatively rare. It constitutes a
well-defined, localised tumour, which may possess a distinct capsule,
especially when it has ceased to grow or is retrogressing. On section,
it presents the appearance of a finely reticulated sponge.

Although it may be noticed at, or within a few days of, birth, a
subcutaneous nævus is often overlooked, especially when on a covered
part of the body, and may not be discovered till the patient is some
years old. It forms a rounded, lobulated swelling, seldom of large size
and yielding a sensation like that of a sponge; the skin over it is
normal, or may exhibit a bluish tinge, especially in cold weather. In
some cases the tumour is diminished by pressing the blood out of it, but
slowly fills again when the pressure is relaxed, and it swells up when
the child struggles or cries. From a cold abscess it is diagnosed by the
history and progress of the swelling and by the absence of fluctuation.
When situated over one of the hernial openings, it closely simulates a
hernia; and when it occurs in the middle line of the face, head, or
back, it may be mistaken for such other congenital conditions as
meningocele or spina bifida. When other means fail, the use of an
exploring needle clears up the diagnosis.

_Mixed Nævus._--As its name indicates, the mixed nævus partakes of the
characters of the other two varieties; that is, it is a subcutaneous
nævus with involvement of the skin.

It is frequently met with on the face and head, but may occur on any
part of the body. It also affects parts covered by mucous membrane, such
as the cheek, tongue, and soft palate. The swelling is rounded or
lobulated, and projects beyond the level of its surroundings. Sometimes
the skin is invaded by the nævoid tissue over the whole extent of the
tumour, sometimes only over a limited area. Frequently the margin only
is of a bright-red colour, while the skin in the centre resembles a
cicatrix. The swelling is reduced by steady pressure, and increases in
size and becomes tense when the child cries.

[Illustration: FIG. 68.--Mixed Nævus of Nose which was subsequently
cured by Electrolysis.]

_Prognosis._--The rate of growth of the subcutaneous and mixed forms of
nævi varies greatly. They sometimes increase rapidly, especially during
the first few months of life; after this they usually grow at the same
rate as the child, or more slowly. There is a decided tendency to
disappearance of these varieties, fully 50 per cent. undergoing natural
cure by a process of obliteration, similar to the obliteration of
vessels in cicatricial tissue. This usually begins about the period of
the first dentition, sometimes at the second dentition, and sometimes at
puberty. On the other hand, an increased activity of growth may be shown
at these periods. The onset of natural cure is recognised by the tumour
becoming firmer and less compressible, and, in the mixed variety, by the
colour becoming less bright. Injury, infection, or ulceration of the
overlying skin may initiate the curative process.

Towards adult life the spaces in a subcutaneous nævus may become greatly
enlarged, leading to the formation of a cavernous angioma.

_Treatment._--In view of the frequency with which subcutaneous and mixed
nævi disappear spontaneously, interference is only called for when the
growth of the tumour is out of proportion to that of the child, or when,
from its situation--for example in the vicinity of the eye--any marked
increase in its size would render it less amenable to treatment.

The methods of treatment most generally applicable are the use of radium
and carbon dioxide snow, igni-puncture, electrolysis, and excision.

For nævi situated on exposed parts, where it is desirable to avoid a
scar, the use of _radium_ is to be preferred. The tube of radium is
applied at intervals to different parts of the nævus, the duration and
frequency of the applications varying with the strength of the
emanations and the reaction produced. The object aimed at is to induce
obliteration of the nævoid tissue by cicatricial contraction without
destroying the overlying skin. _Carbon-dioxide snow_ may be employed in
the same manner, but the results are inferior to those obtained by
radium.

_Igni-puncture_ consists in making a number of punctures at different
parts of the nævus with a fine-pointed thermo-cautery, with the object
of starting at each point a process of cicatrisation which extends
throughout the nævoid tissue and so obliterates the vessels.

_Electrolysis_ acts by decomposing the blood and tissues into their
constituent elements--oxygen and acids appearing at the positive,
hydrogen and bases at the negative electrode. These substances and gases
being given off in a nascent condition, at once enter into new
combinations with anything in the vicinity with which they have a
chemical affinity. In the nævus the practical result of this reaction is
that at the positive pole nitric acid, and at the negative pole caustic
potash, both in a state of minute subdivision, make their appearance.
The effect on the tissues around the positive pole, therefore, is
equivalent to that of an acid cauterisation, and on those round the
negative pole, to an alkaline cauterisation.

As the process is painful, a general anæsthetic is necessary. The
current used should be from 20 to 80 milliampères, gradually increasing
from zero, without shock; three to six large Bunsen cells give a
sufficient current, and no galvanometer is required. Steel needles,
insulated with vulcanite to within an eighth of an inch of their points,
are the best. Both poles are introduced into the nævus, the positive
being kept fixed at one spot, while the negative is moved about so as to
produce a number of different tracks of cauterisation. On no account
must either pole be allowed to come in contact with the skin, lest a
slough be formed. The duration of the sitting is determined by the
effect produced, as indicated by the hardening of the tumour, the
average duration being from fifteen to twenty minutes. If pallor of the
skin appears, it indicates that the needles are too near the surface, or
that the blood supply to the integument is being cut off, and is an
indication to stop. To cauterise the track and so prevent bleeding, the
needles should be slowly withdrawn while the current is flowing. When
the skin is reached the current is turned off. The punctures are covered
with collodion. Six or eight weeks should be allowed to elapse before
repeating the procedure. From two to eight or ten sittings may be
necessary, according to the size and character of the nævus.

_Excision_ is to be preferred for nævi of moderate size situated on
covered parts of the body, where a scar is of no importance. Its chief
advantages over electrolysis are that a single operation is sufficient,
and that the cure is speedy and certain. The operation is attended with
much less hæmorrhage than might be expected.

#Cavernous Angioma.#--This form of angioma consists of a series of large
blood spaces which are usually derived from the dilatation of the
capillaries of a subcutaneous nævus. The spaces come to communicate
freely with one another by the disappearance of adjacent capillary
walls. While the most common situation is in the subcutaneous tissue, a
cavernous angioma is sometimes met with in internal organs. It may
appear at any age from early youth to middle life, and is of slow growth
and may become stationary. The swelling is rounded or oval, there is no
pulsation or bruit, and the tumour is but slightly compressible. The
treatment consists in dissecting it out.

#Aneurysm by Anastomosis# is the name applied to a vascular tumour in
which the arteries, veins, and capillaries are all involved. It is met
with chiefly on the upper part of the trunk, the neck, and the scalp. It
tends gradually to increase in size, and may, after many years, attain
an enormous size. The tumour is ill-defined, and varies in consistence.
It is pulsatile, and a systolic bruit or a "thrilling" murmur may be
heard over it. The chief risk is hæmorrhage from injury or ulceration.

[Illustration: FIG. 69.--Cirsoid Aneurysm of Forehead in a boy æt. 10.

(Mr. J. W. Dowden's case.)]

The _treatment_ is conducted on the same lines as for nævus. When
electrolysis is employed, it should be directed towards the afferent
vessels; and if it fails to arrest the flow through these, it is useless
to persist with it. In some cases ligation of the afferent vessels has
been successful.

#Arterial Angioma# or #Cirsoid Aneurysm#.--This is composed of the
enlarged branches of an arterial trunk. It originates in the smaller
branches of an artery--usually the temporal--and may spread to the main
trunk, and may even involve branches of other trunks with which the
affected artery anastomoses.

The condition is probably congenital in origin, though its appearance is
frequently preceded by an injury. It almost invariably occurs in the
scalp, and is usually met with in adolescent young adults.

The affected vessels slowly increase in size, and become tortuous, with
narrowings and dilatations here and there. Grooves and gutters are
frequently found in the bone underlying the dilated vessels.

There is a constant loud bruit in the tumour, which greatly troubles the
patient and may interfere with sleep. There is no tendency either to
natural cure or to rupture, but severe and even fatal hæmorrhage may
follow a wound of the dilated vessels.

[Illustration: FIG. 70.--Cirsoid Aneurysm of Orbit and Face, which
developed after a blow on the Orbit with a cricket ball.

(From a photograph lent by Sir Montagu Cotterill.)]

The condition may be treated by excision or by electrolysis. In excision
the hæmorrhage is controlled by an elastic tourniquet applied
horizontally round the head, or by ligation of the feeding trunks. In
large tumours the bleeding is formidable. In many cases electrolysis is
to be preferred, and is performed in the same way as for nævus. The
positive pole is placed in the centre of the tumour, while the negative
is introduced into the main affluents one after another.


ANEURYSM

An aneurysm is a sac communicating with an artery, and containing fluid
or coagulated blood.

Two types are met with--the pathological and the traumatic. It is
convenient to describe in this section also certain conditions in which
there is an abnormal communication between an artery and a
vein--arterio-venous aneurysm.


PATHOLOGICAL ANEURYSM

In this class are included such dilatations as result from weakening of
the arterial coats, combined, in most cases, with a loss of elasticity
in the walls and increase in the arterial tension due to
arterio-sclerosis. In some cases the vessel wall is softened by
arteritis--especially the embolic form--so that it yields before the
pressure of the blood.

Repeated and sudden raising of the arterial tension, as a result, for
example, of violent muscular efforts or of excessive indulgence in
alcohol, plays an important part in the causation of aneurysm. These
factors probably explain the comparative frequency of aneurysm in those
who follow such arduous occupations as soldiers, sailors,
dock-labourers, and navvies. In these classes the condition usually
manifests itself between the ages of thirty and fifty--that is, when the
vessels are beginning to degenerate, although the heart is still
vigorous and the men are hard at work. The comparative immunity of women
may also be explained by the less severe muscular strain involved by
their occupations and recreations.

Syphilis plays an important part in the production of aneurysm, probably
by predisposing the patient to arterio-sclerosis and atheroma, and
inducing an increase in the vascular tension in the peripheral vessels,
from loss of elasticity of the vessel wall and narrowing of the lumen as
a result of syphilitic arteritis. It is a striking fact that aneurysm is
seldom met with in women who have not suffered from syphilis.

#Varieties--Fusiform Aneurysm.#--When the _whole circumference_ of an
artery has been weakened, the tension of the blood causes the walls to
dilate uniformly, so that a fusiform or tubular aneurysm results. All
the coats of the vessel are stretched and form the sac of the aneurysm,
and the affected portion is not only dilated but is also increased in
length. This form is chiefly met with in the arch of the aorta, but may
occur in any of the main arterial trunks. As the sac of the aneurysm
includes all three coats, and as the inner and outer coats are usually
thickened by the deposit in them of connective tissue, this variety
increases in size slowly and seldom gives rise to urgent symptoms.

As a rule a fusiform aneurysm contains fluid blood, but when the intima
is roughened by disease, especially in the form of calcareous plates,
shreds of clot may adhere to it.

It has little tendency to natural cure, although this is occasionally
effected by the emerging artery becoming occluded by a clot; it has also
little tendency to rupture.

#Sacculated Aneurysm.#--When a _limited area_ of the vessel wall is
weakened--for example by atheroma or by other form of arteritis--this
portion yields before the pressure of the blood, and a sacculated
aneurysm results. The internal and middle coats being already damaged,
or, it may be, destroyed, by the primary disease, the stress falls on
the external coat, which in the majority of cases constitutes the sac.
To withstand the pressure the external coat becomes thickened, and as
the aneurysm increases in size it forms adhesions to surrounding
tissues, so that fasciæ, tendons, nerves, and other structures may be
found matted together in its wall. The wall is further strengthened by
the deposit on its inner aspect of blood-clot, which may eventually
become organised.

The contents of the sac consist of fluid blood and a varying amount of
clot which is deposited in concentric layers on the inner aspect of the
sac, where it forms a pale, striated, firm mass, which constitutes a
laminated clot. Near the blood-current the clot is soft, red, and
friable (Fig. 72). The laminated clot not only strengthens the sac,
enabling it to resist the blood-pressure and so prevent rupture, but, if
it increases sufficiently to fill the cavity, may bring about cure. The
principle upon which all methods of treatment are based is to imitate
nature in producing such a clot.

Sacculated aneurysm, as compared with the fusiform variety, tends to
rupture and also to cure by the formation of laminated clot; natural
cure is sometimes all but complete when extension and rupture occur and
cause death.

An aneurysm is said to be _diffused_ when the sac ruptures and the blood
escapes into the cellular tissue.

#Clinical Features of Aneurysm.#--Surgically, the sacculated is by far
the most important variety. The outstanding feature is the existence in
the line of an artery of a globular swelling, which pulsates. The
pulsation is of an expansile character, which is detected by observing
that when both hands are placed over the swelling they are separated
with each beat of the heart. If the main artery be compressed on the
cardiac side of the swelling, the pulsation is arrested and the tumour
becomes smaller and less tense, and it may be still further reduced in
size by gentle pressure being made over it so as to empty it of fluid
blood. On allowing the blood again to flow through the artery, the
pulsation returns at once, but several beats are required before the sac
regains its former size. In most cases a distinct thrill is felt on
placing the hand over the swelling, and a blowing, systolic murmur may
be heard with the stethoscope. It is to be borne in mind that
occasionally, when the interchange of blood between an aneurysm and the
artery from which it arises is small, pulsation and bruit may be slight
or even absent. This is also the case when the sac contains a
considerable quantity of clot. When it becomes filled with
clot--_consolidated aneurysm_--these signs disappear, and the clinical
features are those of a solid tumour lying in contact with an artery,
and transmitting its pulsation.

A comparison of the pulse in the artery beyond the seat of the aneurysm
with that in the corresponding artery on the healthy side, shows that on
the affected side the wave is smaller in volume, and delayed in time. A
pulse tracing shows that the normal impulse and dicrotic waves are lost,
and that the force and rapidity of the tidal wave are diminished.

[Illustration: FIG. 71.--Radiogram of Aneurysm of Aorta, showing
laminated clot and erosion of bodies of vertebræ. The intervertebral
discs are intact.]

An aneurysm exerts pressure on the surrounding structures, which are
usually thickened and adherent to it and to one another. Adjacent veins
may be so compressed that congestion and œdema of the parts beyond are
produced. Pain, disturbances of sensation, and muscular paralyses may
result from pressure on nerves. Such bones as the sternum and vertebræ
undergo erosion and are absorbed by the gradually increasing pressure of
the aneurysm. Cartilage, on the other hand, being elastic, yields before
the pressure, so that the intervertebral discs or the costal cartilages
may escape while the adjacent bones are destroyed (Fig. 71). The skin
over the tumour becomes thinned and stretched, until finally a slough
forms, and when it separates hæmorrhage takes place.

[Illustration: FIG. 72.--Sacculated Aneurysm of Abdominal Aorta nearly
filled with laminated clot. Note greater density of clot towards
periphery.]

In the progress of an aneurysm towards rupture, timely clotting may
avert death for the moment, but while extension in one direction has
been arrested there is apt to be extension in another, with imminence of
rupture, or it may be again postponed.

#Differential Diagnosis.#--The diagnosis is to be made from other
pulsatile swellings. Pulsation is sometimes transmitted from a large
artery to a tumour, a mass of enlarged lymph glands, or an inflammatory
swelling which lies in its vicinity, but the pulsation is not
expansile--a most important point in differential diagnosis. Such
swellings may, by appropriate manipulation, be moved from the artery and
the pulsation ceases, and compression of the artery on the cardiac side
of the swelling, although it arrests the pulsation, does not produce any
diminution in the size or tension of the swelling, and when the pressure
is removed the pulsation is restored immediately.

Fluid swellings overlying an artery, such as cysts, abscesses, or
enlarged bursæ, may closely simulate aneurysm. An apparent expansion may
accompany the pulsation, but careful examination usually enables this to
be distinguished from the true expansion of an aneurysm. Compression of
the artery makes no difference in the size or tension of the swelling.

Vascular tumours, such as sarcoma and goitre, may yield an expansile
pulsation and a soft, whifling bruit, but they differ from an aneurysm
in that they are not diminished in size by compression of the main
artery, nor can they be emptied by pressure.

The exaggerated pulsation sometimes observed in the abdominal aorta, the
"pulsating aorta" seen in women, should not be mistaken for aneurysm.

#Prognosis.#--When _natural cure_ occurs it is usually brought about by
the formation of laminated clot, which gradually increases in amount
till it fills the sac. Sometimes a portion of the clot in the sac is
separated and becomes impacted as an embolus in the artery beyond,
leading to thrombosis which first occludes the artery and then extends
into the sac.

The progress of natural cure is indicated by the aneurysm becoming
smaller, firmer, less expansile, and less compressible; the murmur and
thrill diminish and the pressure effects become less marked. When the
cure is complete the expansile pulsation is lost, and there remains a
firm swelling attached to the vessel (_consolidated aneurysm_). While
these changes are taking place the collateral arteries become enlarged,
and an anastomotic circulation is established.

An aneurysm may prove _fatal_ by exerting pressure on important
structures, by causing syncope, by rupture, or from the occurrence of
suppuration. _Pressure_ symptoms are usually most serious from aneurysms
situated in the neck, thorax, or skull. Sudden fatal _syncope_ is not
infrequent in cases of aneurysm of the thoracic aorta.

_Rupture_ may take place through the skin, on a mucous or serous
surface, or into the cellular tissue. The first hæmorrhage is often
slight and stops naturally, but it soon recurs, and is so profuse,
especially when the blood escapes externally, that it rapidly proves
fatal. When the bleeding takes place into the cellular tissue, the
aneurysm is said to become _diffused_, and the extravasated blood
spreads widely through the tissues, exerting great pressure on the
surrounding structures.

The _clinical features_ associated with rupture are sudden and severe
pain in the part, and the patient becomes pale, cold, and faint. If a
comparatively small escape of blood takes place into the tissues, the
sudden alteration in the size, shape, and tension of the aneurysm,
together with loss of pulsation, may be the only local signs. When the
bleeding is profuse, however, the parts beyond the aneurysm become
greatly swollen, livid, and cold, and the pulse beyond is completely
lost. The arrest of the blood supply may result in gangrene. Sometimes
the pressure of the extravasated blood causes the skin to slough and,
later, give way, and fatal hæmorrhage results.

The _treatment_ is carried out on the same lines as for a ruptured
artery (p. 261), it being remembered, however, that the artery is
diseased and does not lend itself to reconstructive procedures.

_Suppuration_ may occur in the vicinity of an aneurysm, and the aneurysm
may burst into the abscess which forms, so that when the latter points
the pus is mixed with broken-down blood-clot, and finally free
hæmorrhage takes place. It has more than once happened that a surgeon
has incised such an abscess without having recognised its association
with aneurysm, with tragic results.

#Treatment.#--In treating an aneurysm, the indications are to imitate
Nature's method of cure by means of laminated clot.

_Constitutional treatment_ consists in taking measures to reduce the
arterial tension and to diminish the force of the heart's action. The
patient must be kept in bed. A dry and non-stimulating diet is
indicated, the quantity being gradually reduced till it is just
sufficient to maintain nutrition. Saline purges are employed to reduce
the vascular tension. The benefit derived from potassium iodide
administered in full doses, as first recommended by George W. Balfour,
probably depends on its depressing action on the heart and its
therapeutic benefit in syphilis. Pain or restlessness may call for the
use of opiates, of which heroin is the most efficient.

_Local Treatment._--When constitutional treatment fails, local measures
must be adopted, and many methods are available.

#Endo-aneurysmorrhaphy.#--The operation devised by Rudolf Matas in 1888
aims at closing the opening between the sac and its feeding artery, and
in addition, folding the wall of the sac in such a way as to leave no
vacant space. If there is marked disease of the vessel, Matas' operation
is not possible and recourse is then had to ligation of the artery just
above the sac.

_Extirpation of the Sac--The Old Operation._--The procedure which goes
by this name consists in exposing the aneurysm, incising the sac,
clearing out the clots, and ligating the artery above and below the sac.
This method is suitable to sacculated aneurysm of the limbs, so long as
they are circumscribed and free from complications. It has been
successfully practised also in aneurysm of the subclavian, carotid, and
external iliac arteries. It is not applicable to cases in which there is
such a degree of atheroma as would interfere with the successful
ligation of the artery. The continuity of the artery may be restored by
grafting into the gap left after excision of the sac a segment of the
great saphena vein.

_Ligation of the Artery._--The object of tying the artery is to diminish
or to arrest the flow of blood through the aneurysm so that the blood
coagulates both in the sac and in the feeding artery. The ligature may
be applied on the cardiac side of the aneurysm--proximal ligation, or to
the artery beyond--distal ligation.

_Proximal Ligation._--The ligature may be applied immediately above the
sac (Anel, 1710) or at a distance above (John Hunter, 1785). The
_Hunterian operation_ ensures that the ligature is applied to a part of
the artery that is presumably healthy and where relations are
undisturbed by the proximity of the sac; the best example is the
ligation of the superficial femoral artery in Scarpa's triangle or in
Hunter's canal for popliteal aneurysm; it is on record that Syme
performed this operation with cure of the aneurysm on thirty-nine
occasions.

It is to be noted that the Hunterian ligature does not aim at
_arresting_ the flow of blood through the sac, but is designed so to
diminish its volume and force as to favour the deposition within the sac
of laminated clot. The development of the collateral circulation which
follows upon ligation of the artery at a distance above the sac may be
attended with just that amount of return stream which favours the
deposit of laminated clot, and consequently the cure of the aneurysm;
the return stream may, however, be so forcible as to prevent coagulation
of the blood in the sac, or only to allow of the formation of a red
thrombus which may in its turn be dispersed so that pulsation in the sac
recurs. This does not necessarily imply failure to cure, as the
recurrent pulsation may only be temporary; the formation of laminated
clot may ultimately take place and lead to consolidation of the
aneurysm.

The least desirable result of the Hunterian ligature is met with in
cases where, owing to widespread arterial disease, the collateral
circulation does not develop and gangrene of the limb supervenes.

_Anel's ligature_ is only practised as part of the operation which deals
with the sac directly.

_Distal Ligation._--The tying of the artery beyond the sac, or of its
two branches where it bifurcates (Brasdor, 1760, and Wardrop, 1825), may
arrest or only diminish the flow of blood through the sac. It is less
successful than the proximal ligature, and is therefore restricted to
aneurysms so situated as not to be amenable to other methods; for
example, in aneurysm of the common carotid near its origin, the artery
may be ligated near its bifurcation, or in aneurysm of the innominate
artery, the carotid and subclavian arteries are tied at the seat of
election.

_Compression._--Digital compression of the feeding artery has been given
up except as a preparation for operations on the sac with a view to
favouring the development of a collateral circulation.

_Macewen's acupuncture or "needling"_ consists in passing one or more
fine, highly tempered steel needles through the tissues overlying the
aneurysm, and through its outer wall. The needles are made to touch the
opposite wall of the sac, and the pulsation of the aneurysm imparts a
movement to them which causes them to scarify the inner surface of the
sac. White thrombus forms on the rough surface produced, and leads to
further coagulation. The needles may be left in position for some hours,
being shifted from time to time, the projecting ends being surrounded
with sterile gauze.

The _Moore-Corradi method_ consists in introducing through the wall of
the aneurysm a hollow insulated needle, through the lumen of which from
10 to 20 feet of highly drawn silver or other wire is passed into the
sac, where it coils up into an open meshwork (Fig. 73). The positive
pole of a galvanic battery is attached to the wire, and the negative
pole placed over the patient's back. A current, varying in strength from
20 to 70 milliampères, is allowed to flow for about an hour. The hollow
needle is then withdrawn, but the wire is left _in situ_. The results
are somewhat similar to those obtained by needling, but the clot formed
on the large coil of wire is more extensive.

[Illustration: FIG. 73.--Radiogram of Innominate Aneurysm after
treatment by the Moore-Corradi method. Two feet of finely drawn silver
wire were introduced. The patient, a woman, æt. 47, lived for ten months
after operation, free from pain (cf. Fig. 75).]

Colt's method of wiring has been mainly used in the treatment of
abdominal aneurysm; gilt wire in the form of a wisp is introduced
through the cannula and expands into an umbrella shape.

_Subcutaneous Injections of Gelatin._--Three or four ounces of a 2 per
cent. solution of white gelatin in sterilised water, at a temperature of
about 100° F., are injected into the subcutaneous tissue of the abdomen
every two, three, or four days. In the course of a fortnight or three
weeks improvement may begin. The clot which forms is liable to soften
and be absorbed, but a repetition of the injection has in several cases
established a permanent cure.

_Amputation of the limb_ is indicated in cases complicated by
suppuration, by secondary hæmorrhage after excision or ligation, or by
gangrene. Amputation at the shoulder was performed by Fergusson in a
case of subclavian aneurysm, as a means of arresting the blood-flow
through the sac.


TRAUMATIC ANEURYSM

The essential feature of a traumatic aneurysm is that it is produced by
some form of injury which divides all the coats of the artery. The walls
of the injured vessel are presumably healthy, but they form no part of
the sac of the aneurysm. The sac consists of the condensed and thickened
tissues around the artery.

The injury to the artery may be a subcutaneous one such as a tear by a
fragment of bone: much more commonly it is a punctured wound from a stab
or from a bullet.

The aneurysm usually forms soon after the injury is inflicted; the blood
slowly escapes into the surrounding tissues, gradually displacing and
condensing them, until they form a sac enclosing the effused blood.

Less frequently a traumatic aneurysm forms some considerable time after
the injury, from gradual stretching of the fibrous cicatrix by which the
wound in the wall of the artery has been closed. The gradual stretching
of this cicatrix results in condensation of the surrounding structures
which form the sac, on the inner aspect of which laminated clot is
deposited.

A traumatic aneurysm is almost always sacculated, and, so long as it
remains circumscribed, has the same characters as a pathological
sacculated aneurysm, with the addition that there is a scar in the
overlying skin. A traumatic aneurysm is liable to become diffuse--a
change which, although attended with considerable risk of gangrene, has
sometimes been the means of bringing about a cure.

The treatment is governed by the same principles as apply to the
pathological varieties, but as the walls of the artery are not diseased,
operative measures dealing with the sac and the adjacent segment of the
affected artery are to be preferred.


ARTERIO-VENOUS ANEURYSM

An abnormal communication between an artery and a vein constitutes an
arterio-venous aneurysm. Two varieties are recognised--one in which the
communication is direct--_aneurysmal varix_; the other in which the
vein communicates with the artery through the medium of a sac--_varicose
aneurysm_.

Either variety may result from pathological causes, but in the majority
of cases they are traumatic in origin, being due to such injuries as
stabs, punctured wounds, and gun-shot injuries which involve both artery
and vein. In former times the most common situation was at the bend of
the elbow, the brachial artery being accidentally punctured in
blood-letting from the median basilic vein. Arterio-venous aneurysm is a
frequent result of injuries by modern high-velocity bullets--for
example, in the neck or groin.

In _aneurysmal varix_ the higher blood pressure in the artery forces
arterial blood into the vein, which near the point of communication with
the artery tends to become dilated, and to form a thick-walled sac,
beyond which the vessel and its tributaries are distended and tortuous.
The clinical features resemble those associated with varicose veins, but
the entrance of arterial blood into the dilated veins causes them to
pulsate, and produces in them a vibratory thrill and a loud murmur. In
those at the groin, the distension of the veins may be so great that
they look like sinuses running through the muscles, a feature that must
be taken into account in any operation.

As the condition tends to remain stationary, the support of an elastic
bandage is all that is required; but when the condition progresses and
causes serious inconvenience, it may be necessary to cut down and expose
the communication between the artery and vein, and, after separating the
vessels, to close the opening in each by suture; this may be difficult
or impossible if the parts are matted from former suppuration. If it is
impossible thus to obliterate the communication, the artery should be
ligated above and below the point of communication; although the risk of
gangrene is considerable unless means are taken to develop the
collateral circulation beforehand (Makins).

_Varicose aneurysm_ usually develops in relation to a traumatic
aneurysm, the sac becoming adherent to an adjacent vein, and ultimately
opening into it. In this way a communication between the artery and the
vein is established, and the clinical features are those of a
combination of aneurysm and aneurysmal varix.

As there is little tendency to spontaneous cure, and as the aneurysm is
liable to increase in size and finally to rupture, operative treatment
is usually called for. This is carried out on the same lines as for
aneurysmal varix, and at the same time incising the sac, turning out the
clots, and ligating any branches which open into the sac. If it can be
avoided, the vein should not be ligated.


ANEURYSMS OF INDIVIDUAL ARTERIES

#Thoracic Aneurysm.#--All varieties of aneurysm occur in the aorta, the
fusiform being the most common, although a sacculated aneurysm
frequently springs from a fusiform dilatation.

The _clinical features_ depend chiefly on the direction in which the
aneurysm enlarges, and are not always well marked even when the sac is
of considerable size. They consist in a pulsatile swelling--sometimes in
the supra-sternal notch, but usually towards the right side of the
sternum--with an increased area of dulness on percussion. With the
X-rays a dark shadow is seen corresponding to the sac. Pain is usually a
prominent symptom, and is largely referable to the pressure of the
aneurysm on the vertebræ or the sternum, causing erosion of these bones.
Pressure on the thoracic veins and on the air-passage causes cyanosis
and dyspnœa. When the œsophagus is pressed upon, the patient may have
difficulty in swallowing. The left recurrent nerve may be stretched or
pressed upon as it hooks round the arch of the aorta, and hoarseness of
the voice and a characteristic "brassy" cough may result from paralysis
of the muscles of the larynx which it supplies. The vagus, the phrenic,
and the spinal nerves may also be pressed upon. When the aneurysm is on
the transverse part of the arch, the trachea is pulled down with each
beat of the heart--a clinical phenomena known as the "tracheal tug."
Aneurysm of the descending aorta may, after eroding the bodies of the
vertebræ (Fig. 71) and posterior portions of the ribs, form a swelling
in the back to the left of the spine.

Inasmuch as obliteration of the sac and the feeding artery is out of the
question, surgical treatment is confined to causing coagulation of the
blood in an extension or pouching of the sac, which, making its way
through the parietes of the chest, threatens to rupture externally. This
may be achieved by Macewen's needles or by the introduction of wire into
the sac. We have had cases under observation in which the treatment
referred to has been followed by such an amount of improvement that the
patient has been able to resume a laborious occupation for one or more
years. Christopher Heath found that improvement followed ligation of the
left common carotid in aneurysm of the transverse part of the aortic
arch.

[Illustration: FIG. 74.--Thoracic Aneurysm, threatening to rupture
externally, but prevented from doing so by Macewen's needling. The
needles were left in for forty-eight hours.]

#Abdominal Aneurysm.#--Aneurysm is much less frequent in the abdominal
than in the thoracic aorta. While any of the large branches in the
abdomen may be affected, the most common seats are in the aorta itself,
just above the origin of the cœliac artery and at the bifurcation.

The _clinical features_ vary with the site of the aneurysm and with its
rapidity and direction of growth. A smooth, rounded swelling, which
exhibits expansile pulsation, forms, usually towards the left of the
middle line. It may extend upwards under cover of the ribs, downwards
towards the pelvis, or backward towards the loin. On palpation a
systolic thrill may be detected, but the presence of a murmur is neither
constant nor characteristic. Pain is usually present; it may be
neuralgic in character, or may simulate renal colic. When the aneurysm
presses on the vertebræ and erodes them, the symptoms simulate those of
spinal caries, particularly if, as sometimes happens, symptoms of
compression paraplegia ensue. In its growth the swelling may press upon
and displace the adjacent viscera, and so interfere with their
functions.

The _diagnosis_ has to be made from solid or cystic tumours overlying
the artery; from a "pulsating aorta"; and from spinal caries; much help
is obtained by the use of the X-rays.

The condition usually proves fatal, either by the aneurysm bursting into
the peritoneal cavity, or by slow leakage into the retro-peritoneal
tissue.

The Moore-Corradi method has been successfully employed, access to the
sac having been obtained by opening the abdomen. Ligation of the aorta
has so far been unsuccessful, but in one case operated upon by Keen the
patient survived forty-eight days.

#Innominate aneurysm# may be of the fusiform or of the sacculated
variety, and is frequently associated with pouching of the aorta. It
usually grows upwards and laterally, projecting above the sternum and
right clavicle, which may be eroded or displaced (Fig. 75). Symptoms of
pressure on the structures in the neck, similar to those produced by
aortic aneurysm, occur. The pulses in the right upper extremity and in
the right carotid and its branches are diminished and delayed. Pressure
on the right brachial plexus causes shooting pain down the arm and
muscular paresis on that side. Vaso-motor disturbances and contraction
of the pupil on the right side may result from pressure on the
sympathetic. Death may take place from rupture, or from pressure on the
air-passage.

[Illustration: FIG. 75.--Innominate Aneurysm in a woman, æt. 47, eight
months after treatment by Moore-Corradi method (cf. Fig. 73).]

The available methods of treatment are ligation of the right common
carotid and third part of the right subclavian (Wardrop's operation), of
which a number of successful cases have been recorded. Those most
suitable for ligation are cases in which the aneurysm is circumscribed
and globular (Sheen). If ligation is found to be impracticable, the
Moore-Corradi method or Macewen's needling may be tried.

#Carotid Aneurysms.#--Aneurysm of the _common carotid_ is more frequent
on the right than on the left side, and is usually situated either at
the root of the neck or near the bifurcation. It is the aneurysm most
frequently met with in women. From its position the swelling is liable
to press on the vagus, recurrent and sympathetic nerves, on the
air-passage, and on the œsophagus, giving rise to symptoms referable to
such pressure. There may be cerebral symptoms from interference with the
blood supply of the brain.

Aneurysm near the origin has to be diagnosed from subclavian,
innominate, and aortic aneurysm, and from other swellings--solid or
fluid--met with in the neck. It is often difficult to determine with
precision the trunk from which an aneurysm at the root of the neck
originates, and not infrequently more than one vessel shares in the
dilatation. A careful consideration of the position in which the
swelling first appeared, of the direction in which it has progressed, of
its pressure effects, and of the condition of the pulses beyond, may
help in distinguishing between aortic, innominate, carotid, and
subclavian aneurysms. Skiagraphy is also of assistance in recognising
the vessel involved.

Tumours of the thyreoid, enlarged lymph glands, and fatty and
sarcomatous tumours can usually be distinguished from aneurysm by the
history of the swelling and by physical examination. Cystic tumours and
abscesses in the neck are sometimes more difficult to differentiate on
account of the apparently expansile character of the pulsation
transmitted to them. The fact that compression of the vessel does not
affect the size and tension of these fluid swellings is useful in
distinguishing them from aneurysm.

_Treatment._--Digital compression of the vessel against the transverse
process of the sixth cervical vertebra--the "carotid tubercle"--has been
successfully employed in the treatment of aneurysm near the bifurcation.
Proximal ligation in the case of high aneurysms, or distal ligation in
those situated at the root of the neck, is more certain. Extirpation of
the sac is probably the best method of treatment, especially in those of
traumatic origin. These operations are attended with considerable risk
of hemiplegia from interference with the blood supply of the brain.

The _external carotid_ and the cervical portion of the _internal
carotid_ are seldom the primary seat of aneurysm, although they are
liable to be implicated by the upward spread of an aneurysm at the
bifurcation of the common trunk. In addition to the ordinary signs of
aneurysm, the clinical manifestations are chiefly referable to pressure
on the pharynx and larynx, and on the hypoglossal nerve. Aneurysm of the
internal carotid is of special importance on account of the way in which
it bulges into the pharynx in the region of the tonsil, in some cases
closely simulating a tonsillar abscess. Cases are on record in which
such an aneurysm has been mistaken for an abscess and incised, with
disastrous results.

_Aneurysmal varix_ may occur in the neck as a result of stabs or bullet
wounds. The communication is usually between the common carotid artery
and the internal jugular vein. The resulting interference with the
cerebral circulation causes headache, giddiness, and other brain
symptoms, and a persistent loud murmur is usually a source of annoyance
to the patient and may be sufficient indication for operative treatment.

#Intracranial aneurysm# involves the internal carotid and its branches,
or the basilar artery, and appears to be more frequently associated with
syphilis and with valvular disease of the heart than are external
aneurysms. It gives rise to symptoms similar to those of other
intracranial tumours, and there is sometimes a loud murmur. It usually
proves fatal by rupture, and intracranial hæmorrhage. The treatment is
to ligate the common carotid or the vertebral artery in the neck,
according to the seat of the aneurysm.

#Orbital Aneurysm.#--The term pulsating exophthalmos is employed to
embrace a number of pathological conditions, including aneurysm, in
which the chief symptoms are pulsation in the orbit and protrusion of
the eyeball. There may be, in addition, congestion and œdema of the
eyelids, and a distinct thrill and murmur, which can be controlled by
compression of the common carotid in the neck. Varying degrees of ocular
paralysis and of interference with vision may also be present.

These symptoms are due, in the majority of cases, to an aneurysmal varix
of the internal carotid artery and cavernous sinus, which is often
traumatic in origin, being produced either by fracture of the base of
the skull or by a punctured wound of the orbit. In other cases they are
due to aneurysm of the ophthalmic artery, to thrombosis of the cavernous
sinus, and, in rare instances, to cirsoid aneurysm.

If compression of the common carotid is found to arrest the pulsation,
ligation of this vessel is indicated.

#Subclavian Aneurysm.#--Subclavian aneurysm is usually met with in men
who follow occupations involving constant use of the shoulder--for
example, dock-porters and coal-heavers. It is more common on the right
side.

The aneurysm usually springs from the third part of the artery, and
appears as a tense, rounded, pulsatile swelling just above the clavicle
and to the outer side of the sterno-mastoid muscle. It occasionally
extends towards the thorax, where it may become adherent to the pleura.
The radial pulse on the same side is small and delayed. Congestion and
œdema of the arm, with pain, numbness, and muscular weakness, may result
from pressure on the veins and nerves as they pass under the clavicle;
and pressure on the phrenic nerve may induce hiccough. The aneurysm is
of slow growth, and occasionally undergoes spontaneous cure.

The conditions most likely to be mistaken for it are a soft, rapidly
growing sarcoma, and a normal artery raised on a cervical rib.

On account of the relations of the artery and of its branches, treatment
is attended with greater difficulty and danger in subclavian than in
almost any other form of external aneurysm. The available operative
measures are proximal ligation of the innominate, and distal ligation.
In some cases it has been found necessary to combine distal ligation
with amputation at the shoulder-joint, to prevent the collateral
circulation maintaining the flow through the aneurysm. Matas' operation
has been successfully performed by Hogarth Pringle.

#Axillary Aneurysm.#--This is usually met with in the right arm of
labouring men and sailors, and not infrequently follows an injury in the
region of the shoulder. The vessel may be damaged by the head of a
dislocated humerus or in attempts to reduce the dislocation, by the
fragments of a fractured bone, or by a stab or cut. Sometimes the vein
also is injured and an arterio-venous aneurysm established.

Owing to the laxity of the tissues, it increases rapidly, and it may
soon attain a large size, filling up the axilla, and displacing the
clavicle upwards. This renders compression of the third part of the
subclavian difficult or impossible. It may extend beneath the clavicle
into the neck, or, extending inwards may form adhesions to the chest
wall, and, after eroding the ribs, to the pleura.

The usual symptoms of aneurysm are present, and the pressure effects on
the veins and nerves are similar to those produced by an aneurysm of the
subclavian. Intra-thoracic complications, such as pleurisy or pneumonia,
are not infrequent when there are adhesions to the chest wall and
pleura. Rupture may take place externally, into the shoulder-joint, or
into the pleura.

Extirpation of the sac is the operation of choice, but, if this is
impracticable, ligation of the third part of the subclavian may be had
recourse to.

#Brachial aneurysm# usually occurs at the bend of the elbow, is of
traumatic origin, and is best treated by excision of the sac.

_Aneurysmal varix_, which was frequently met with in this situation in
the days of the barber-surgeons,--usually as a result of the artery
having been accidentally wounded while performing venesection of the
median basilic vein,--may be treated, according to the amount of
discomfort it causes, by a supporting bandage, or by ligation of the
artery above and below the point of communication.

Aneurysms of the vessels of the #forearm and hand# call for no special
mention; they are almost invariably traumatic, and are treated by
excision of the sac.

#Inguinal Aneurysm# (_Aneurysm of the Iliac and Femoral
Arteries_).--Aneurysms appearing in the region of Poupart's ligament may
have their origin in the external or common iliac arteries or in the
upper part of the femoral. On account of the tension of the fascia lata,
they tend to spread upwards towards the abdomen, and, to a less extent,
downwards into the thigh. Sometimes a constriction occurs across the
sac at the level of Poupart's ligament.

The pressure exerted on the nerves and veins of the lower extremity
causes pain, congestion, and œdema of the limb. Rupture may take place
externally, or into the cellular tissue of the iliac fossa.

These aneurysms have to be diagnosed from pulsating sarcoma growing from
the pelvic bones, and from an abscess or a mass of enlarged lymph glands
overlying the artery and transmitting its pulsation.

The method of treatment that has met with most success is ligation of
the common or external iliac, reached either by reflecting the
peritoneum from off the iliac fossa (extra-peritoneal operation), or by
going through the peritoneal cavity (trans-peritoneal operation).

#Gluteal Aneurysm.#--An aneurysm in the buttock may arise from the
superior or from the inferior gluteal artery, but by the time it forms a
salient swelling it is seldom possible to recognise by external
examination in which vessel it takes origin. The special symptoms to
which it gives rise are pain down the limb from pressure on the sciatic
nerve, and interference with the movements at the hip.

Ligation of the hypogastric (internal iliac) by the trans-peritoneal
route is the most satisfactory method of treatment. Extirpation of the
sac is difficult and dangerous, especially when the aneurysm has spread
into the pelvis.

#Femoral Aneurysm.#--Aneurysm of the femoral artery beyond the origin of
the profunda branch is usually traumatic in origin, and is more common
in Scarpa's triangle than in Hunter's canal. Any of the methods already
described is available for their treatment--the choice lying between
Matas' operation and ligation of the external iliac.

Aneurysm of the _profunda femoris_ is distinguished from that of the
main trunk by the fact that the pulses beyond are, in the former,
unaffected, and by the normal artery being felt pulsating over or
alongside the sac.

In _aneurysmal varix_, a not infrequent result of a bullet wound or a
stab, the communication with the vein may involve the main trunk of the
femoral artery. Should operative interference become necessary as a
result of progressive increase in size of the tumour, or progressive
distension of the veins of the limb, an attempt should be made to
separate the vessels concerned and to close the opening in each by
suture. If this is impracticable, the artery is tied above and below the
communication; gangrene of the limb may supervene, and we have observed
a case in which the gangrene extended up to the junction of the middle
and lower thirds of the thigh, and in which recovery followed upon
amputation of the thigh.

#Popliteal Aneurysm.#--This is the most common surgical aneurysm, and is
not infrequently met with in both limbs. It is generally due to disease
of the artery, and repeated slight strains, which are so liable to occur
at the knee, play an important part in its formation. In former times it
was common in post-boys, from the repeated flexion and extension of the
knee in riding.

The aneurysm is usually of the sacculated variety, and may spring from
the front or from the back of the vessel. It may exert pressure on the
bones and ligaments of the joint, and it has been known to rupture into
the articulation. The pain, stiffness, and effusion into the joint which
accompany these changes often lead to an erroneous diagnosis of joint
disease. The sac may press upon the popliteal artery or vein and their
branches, causing congestion and œdema of the leg, and lead to gangrene.
Pressure on the tibial and common peroneal nerves gives rise to severe
pain, muscular cramp, and weakness of the leg.

The differential diagnosis is to be made from abscess, bursal cyst,
enlarged glands, and sarcoma, especially pulsating sarcoma of one of the
bones entering into the knee joint.

The choice of operation lies between ligation of the femoral artery in
Hunter's canal, and Matas' operation of aneurysmo-arteriorrhaphy. The
success which attends the Hunterian operation is evidenced by the fact
that Syme performed it thirty-seven times without a single failure. If
it fails, the old operation should be considered, but it is a more
serious operation, and one which is more liable to be followed by
gangrene of the limb. Experience shows that ligation of the vein, or
even the removal of a portion of it, is not necessarily followed by
gangrene. The risk of gangrene is diminished by a course of digital
compression of the femoral artery, before operating on the aneurysm.

_Aneurysmal varix_ is sometimes met with in the region of the popliteal
space. It is characterised by the usual symptoms, and is treated by
palliative measures, or by ligation of the artery above and below the
point of communication.

_Aneurysm_ in the #leg and foot# is rare. It is almost always traumatic,
and is treated by excision of the sac.



CHAPTER XV

THE LYMPH VESSELS AND GLANDS


Anatomy and Physiology--INJURIES OF LYMPH VESSELS--_Wounds of
    thoracic duct_--DISEASES OF LYMPH VESSELS--Lymphangitis:
    _Varieties_--Lymphangiectasis--Filarial
    disease--Lymphangioma--DISEASES OF LYMPH
    GLANDS--Lymphadenitis: _Septic_; _Tuberculous_;
    _Syphilitic_--Lymphadenoma--Leucocythæmia--TUMOURS.

#Surgical Anatomy and Physiology.#--Lymph is essentially blood plasma,
which has passed through the walls of capillaries. After bathing
and nourishing the tissues, it is collected by lymph vessels, which
return it to the blood stream by way of the thoracic duct. These lymph
vessels take origin in the lymph spaces of the tissues and in the
walls of serous cavities, and they usually run alongside blood
vessels--_perivascular lymph vessels_. They have a structure similar to
that of veins, but are more abundantly provided with valves. Along the
course of the lymph trunks are the _lymph glands_, which possess a
definite capsule and are composed of a reticulated connective tissue,
the spaces of which are packed with leucocytes. The glands act as
filters, arresting not only inert substances, such as blood pigment
circulating in the lymph, but also living elements, such as cancer cells
or bacteria. As it passes through a gland the lymph is brought into
intimate contact with the leucocytes, and in bacterial infections there
is always a struggle between the organisms and the leucocytes, so that
the glands may be looked upon as an important line of defence, retarding
or preventing the passage of bacteria and their products into the
general circulation. The infective agent, moreover, in order to reach
the blood stream, must usually overcome the resistance of several
glands.

Lymph glands are, for the most part, arranged in groups or chains, such
as those in the axilla, neck, and groin. In any given situation they
vary in number and size in different individuals, and fresh glands may
be formed on comparatively slight stimulus, and disappear when the
stimulus is withdrawn. The best-known example of this is the increase in
the number of glands in the axilla which takes place during lactation;
when this function ceases, many of the glands become involuted and are
transformed into fat, and in the event of a subsequent lactation they
are again developed. After glands have been removed by operation, new
ones may be formed.

The following are the more important groups of glands, and the areas
drained by them in the head and neck and in the extremities.

#Head and Neck.#--_The anterior auricular (parotid and pre-auricular)
glands_ lie beneath the parotid fascia in front of the ear, and some
are partly embedded in the substance of the parotid gland; they drain
the parts about the temple, cheek, eyelids, and auricle, and are
frequently the seat of tuberculous disease. _The occipital gland_,
situated over the origin of the trapezius from the superior curved line,
drains the top and back of the head; it is rarely infected. _The
posterior auricular (mastoid) glands_ lie over the mastoid process, and
drain the side of the head and auricle. These three groups pour their
lymph into the superficial cervical glands. _The submaxillary_--two to
six in number--lie along the lower order of the mandible from the
symphysis to the angle, the posterior ones (paramandibular) being
closely connected with the submaxillary salivary gland. They receive
lymph from the face, lips, floor of the mouth, gums, teeth, anterior
part of tongue, and the alæ nasi, and from the pre-auricular glands. The
lymph passes from them into the deeper cervical glands. They are
frequently infected with tubercle, with epithelioma which has spread to
them from the mouth, and also with pyogenic organisms. _The submental
glands_ lie in or close to the median line between the anterior bellies
of the digastric muscles, and receive lymph from the lips. It is rare
for them to be the seat of tubercle, but in epithelioma of the lower lip
and floor of the mouth they are infected at an early stage of the
disease. _The supra-hyoid gland_ lies a little farther back, immediately
above the hyoid bone, and receives lymph from the tongue. _The
superficial cervical (external jugular) glands_, when present, lie along
the external jugular vein, and receives lymph from the occipital and
auricular glands and from the auricle. _The sterno-mastoid
glands_--glandulæ concatinatæ--form a chain along the posterior edge of
the sterno-mastoid muscle, some of them lying beneath the muscle. They
are commonly enlarged in secondary syphilis. _The superior deep cervical
(internal jugular) glands_--from six to twenty in number--form a
continuous chain along the internal jugular vein, beneath the
sterno-mastoid muscle. They drain the various groups of glands which lie
nearer the surface, also the interior of the skull, the larynx, trachea,
thyreoid, and lower part of the pharynx, and pour their lymph into the
main trunks at the root of the neck. Belonging to this group is one
large gland (the tonsillar gland) which lies behind the posterior belly
of the digastric, and rests in the angle between the internal jugular
and common facial veins. It is commonly enlarged in affections of the
tonsil and posterior part of the tongue. In the same group are three or
four glands which lie entirely under cover of the upper end of the
sterno-mastoid muscle, and surround the accessory nerve before it
perforates the muscle. The deep cervical glands are commonly infected by
tubercle and also by epithelioma secondary to disease in the tongue or
throat. _The inferior deep cervical (supra-clavicular) glands_ lie in
the posterior triangle, above the clavicle. They receive lymph from the
lowest cervical glands, from the upper part of the chest wall, and from
the highest axillary glands. They are frequently infected in cancer of
the breast; those on the left side also in cancer of the stomach. The
removal of diseased supra-clavicular glands is not to be lightly
undertaken, as difficulties are liable to ensue in connection with the
thoracic duct, the pleura, or the junction of the subclavian and
internal jugular veins. _The retro-pharyngeal glands_ lie on each side
of the median line upon the rectus capitis anticus major muscle and in
front of the pre-vertebral layer of the cervical fascia. They receive
part of the lymph from the posterior wall of the pharynx, the interior
of the nose and its accessory cavities, the auditory (Eustachian) tube,
and the tympanum. When they are infected with pyogenic organisms or
with tubercle bacilli, they may lead to the formation of one form of
retro-pharyngeal abscess.

#Upper Extremity.#--_The epi-trochlear and cubital glands_ vary in
number, that most commonly present lying about an inch and a half above
the medial epi-condyle, and other and smaller glands may lie along the
medial (internal) bicipital groove or at the bend of the elbow. They
drain the ulnar side of the hand and forearm, and pour their lymph into
the axillary group. The epi-trochlear gland is sometimes enlarged in
syphilis. _The axillary glands_ are arranged in groups: a central group
lies embedded in the axillary fascia and fat, and is often related to an
opening in it; a posterior or subscapular group lies along the line of
the subscapular vessels; anterior or pectoral groups lie behind the
pectoralis minor, along the medial side of the axillary vein, and an
inter-pectoral group, between the two pectoral muscles. The axillary
glands receive lymph from the arm, mamma, and side of the chest, and
pass it on into the lowest cervical glands and the main lymph trunk.
They are frequently the seat of pyogenic, tuberculous, and cancerous
infection, and their complete removal is an essential part of the
operation for cancer of the breast.

#Lower Extremity.#--_The popliteal glands_ include one superficial gland
at the termination of the small saphenous vein, and several deeper ones
in relation to the popliteal vessels. They receive lymph from the toes
and foot, and transmit it to the inguinal glands. _The femoral glands_
lie vertically along the upper part of the great saphenous vein, and
receive lymph from the leg and foot; from them the lymph passes to the
deep inguinal and external iliac glands. The femoral glands often
participate in pyogenic infections entering through the skin of the toes
and sole of the foot. _The superficial inguinal glands_ lie along the
inguinal (Poupart's) ligament, and receive lymph from the external
genitals, anus, perineum, buttock, and anterior abdominal wall. The
lymph passes on to the deep inguinal and external iliac glands. The
superficial glands through their relations to the genitals are
frequently the subject of venereal infection, and also of epithelioma
when this disease affects the genitals or anus; they are rarely the seat
of tuberculosis. _The deep inguinal glands_ lie on the medial side of
the femoral vein, and sometimes within the femoral canal. They receive
lymph from the deep lymphatics of the lower limb, and some of the
efferent vessels from the femoral and superficial inguinal glands. The
lymph then passes on through the femoral canal to the external iliac
glands. The extension of malignant disease, whether cancer or sarcoma,
can often be traced along these deeper lymphatics into the pelvis, and
as the obstruction to the flow of lymph increases there is a
corresponding increase in the swollen dropsical condition of the lower
limb on the same side.

The glands of the _thorax_ and _abdomen_ will be considered with the
surgery of these regions.


INJURIES OF LYMPH VESSELS

Lymph vessels are divided in all wounds, and the lymph that escapes from
them is added to any discharge that may be present. In injuries of
larger trunks the lymph may escape in considerable quantity as a
colourless, watery fluid--_lymphorrhagia_; and the opening through which
it escapes is known as a _lymphatic fistula_. This has been observed
chiefly after extensive operation for the removal of malignant glands in
the groin where there already exists a considerable degree of
obstruction to the lymph stream, and in such cases the lymph, including
that which has accumulated in the vessels of the limb, may escape in
such abundance as to soak through large dressings and delay healing.
Ultimately new lymph channels are formed, so that at the end of from
four to six weeks the discharge of lymph ceases and the wound heals.

_Lymphatic Œdema._--When the lymphatic return from a limb has been
seriously interfered with,--as, for example, when the axillary contents
has been completely cleared out in operating for cancer of the
breast,--a condition of lymphatic œdema may result, the arm becoming
swollen, tight, and heavy.

Various degrees of the conditions are met with; in the severe forms,
there is pain, as well as incapacity of the limb. As in ordinary œdema,
the condition is relieved by elevation of the limb, but not nearly to
the same degree; in time the tissues become so hard and tense as
scarcely to pit on pressure; this is in part due to the formation of new
connective tissue and hypertrophy of the skin; in advanced cases there
is a gradual transition into one form of elephantiasis.

Handley has devised a method of treatment--_lymphangioplasty_--the
object of which is to drain the lymph by embedding a number of silk
threads in the subcutaneous cellular tissue.

#Wounds of the Thoracic Duct.#--The thoracic duct usually opens at the
angle formed by the junction of the left internal jugular and subclavian
veins, but it may open into either of these vessels by one or by several
channels, or the duct may be double throughout its course. There is a
smaller duct on the right side--the right lymphatic duct. The duct or
ducts may be displaced by a tumour or a mass of enlarged glands, and may
be accidentally wounded in dissections at the root of the neck; jets of
milky fluid--chyle--may at once escape from it. The jets are rhythmical
and coincide with expiration. The injury may, however, not be observed
at the time of operation, but later through the dressings being soaked
with chyle--_chylorrhœa_. If the wound involves the only existing main
duct and all the chyle escapes, the patient suffers from intense thirst,
emaciation, and weakness, and may die of inanition; but if, as is
usually the case, only one of several collateral channels is implicated,
the loss of chyle may be of little moment, as the discharge usually
ceases. If the wound heals so that the chyle is prevented from escaping,
a fluctuating swelling may form beneath the scar; in course of time it
gradually disappears.

An attempt should be made to close the wound in the duct by means of a
fine suture; failing this, the duct must be occluded by a ligature as if
it were a bleeding artery. The tissues are then stitched over it and the
skin wound accurately closed, so as to obtain primary union, firm
pressure being applied by dressings and an elastic webbing bandage. Even
if the main duct is obliterated, a collateral circulation is usually
established. A wound of the right lymphatic duct is of less importance.

_Subcutaneous rupture of the thoracic duct_ may result from a crush of
the thorax. The chyle escapes and accumulates in the cellular tissue of
the posterior mediastinum, behind the peritoneum, in the pleural cavity
(_chylo-thorax_), or in the peritoneal cavity (_chylous ascites_). There
are physical signs of fluid in one or other of these situations, but, as
a rule, the nature of the lesion is only recognised when chyle is
withdrawn by the exploring needle.


DISEASES OF LYMPH VESSELS

#Lymphangitis.#--Inflammation of peripheral lymph vessels usually
results from some primary source of pyogenic infection in the skin. This
may be a wound or a purulent blister, and the streptococcus pyogenes is
the organism most frequently present. _Septic_ lymphangitis is commonly
met with in those who, from the nature of their occupation, handle
infective material. A _gonococcal_ form has been observed in those
suffering from gonorrhœa.

The inflammation affects chiefly the walls of the vessels, and is
attended with clotting of the lymph. There is also some degree of
inflammation of the surrounding cellular tissue--_peri-lymphangitis_.
One or more abscesses may form along the course of the vessels, or a
spreading cellulitis may supervene.

The _clinical features_ resemble those of other pyogenic infections, and
there are wavy red lines running from the source of infection towards
the nearest lymph glands. These correspond to the inflamed vessels, and
are the seat of burning pain and tenderness. The associated glands are
enlarged and painful. In severe cases the symptoms merge into those of
septicæmia. When the deep lymph vessels alone are involved, the
superficial red lines are absent, but the limb becomes greatly swollen
and pits on pressure.

In cases of extensive lymphangitis, especially when there are repeated
attacks, the vessels are obliterated by the formation of new connective
tissue and a persistent solid œdema results, culminating in one form of
elephantiasis.

_Treatment._--The primary source of infection is dealt with on the usual
lines. If the lymphangitis affects an extremity, Bier's elastic bandage
is applied, and if suppuration occurs, the pus is let out through one or
more small incisions; in other parts of the body Klapp's suction bells
are employed. An autogenous vaccine may be prepared and injected. When
the condition has subsided, the limb is massaged and evenly bandaged to
promote the disappearance of œdema.

_Tuberculous Lymphangitis._--Although lymph vessels play an important
rôle in the spread of tuberculosis, the clinical recognition of the
disease in them is exceptional. The infection spreads upwards along the
superficial lymphatics, which become nodularly thickened; at one or more
points, larger, peri-lymphangitic nodules may form and break down into
abscesses and ulcers; the nearest group of glands become infected at an
early stage. When the disease is widely distributed throughout the
lymphatics of the limb, it becomes swollen and hard--a condition
illustrated by lupus elephantiasis.

_Syphilitic lymphangitis_ is observed in cases of primary syphilis, in
which the vessels of the dorsum of the penis can be felt as indurated
cords.

In addition to acting as channels for the conveyance of bacterial
infection, _lymph vessels frequently convey the cells of malignant
tumours_, and especially cancer, from the seat of the primary disease to
the nearest lymph glands, and they may themselves become the seat of
cancerous growth forming nodular cords. The permeation of cancer by way
of the lymphatics, described by Sampson Handley, has already been
referred to.

#Lymphangiectasis# is a dilated or varicose condition of lymph vessels.
It is met with as a congenital affection in the tongue and lips, or it
may be acquired as the result of any condition which is attended with
extensive obliteration or blocking of the main lymph trunks. An
interesting type of lymphangiectasis is that which results from the
presence of the _filaria Bancrofti_ in the vessels, and is observed
chiefly in the groin, spermatic cord, and scrotum of persons who have
lived in the tropics.

_Filarial disease in the lymphatics of the groin_ appears as a soft,
doughy swelling, varying in size from a walnut to a cocoa-nut; it may
partly disappear on pressure and when the patient lies down.

The patient gives a history of feverish attacks of the nature of
lymphangitis during which the swelling becomes painful and tender. These
attacks may show a remarkable periodicity, and each may be followed by
an increase in the size of the swelling, which may extend along the
inguinal canal into the abdomen, or down the spermatic cord into the
scrotum. On dissection, the swelling is found to be made up of dilated,
tortuous, and thickened lymph vessels in which the parent worm is
sometimes found, and of greatly enlarged lymph glands which have
undergone fibrosis, with giant-cell formation and eosinophile
aggregations. The fluid in the dilated vessels is either clear or
turbid, in the latter case resembling chyle. The affection is frequently
bilateral, and may be associated with lymph scrotum, with elephantiasis,
and with chyluria.

The _diagnosis_ is to be made from such other swellings in the groin as
hernia, lipoma, or cystic pouching of the great saphenous vein. It is
confirmed by finding the recently dead or dying worms in the inflamed
lymph glands.

_Treatment._--When the disease is limited to the groin or scrotum,
excision may bring about a permanent cure, but it may result in the
formation of lymphatic sinuses and only afford temporary relief.

#Lymphangioma.#--A lymphangioma is a swelling composed of a series of
cavities and channels filled with lymph and freely communicating with
one another. The cavities result either from the new formation of lymph
spaces or vessels, or from the dilatation of those which already exist;
their walls are composed of fibro-areolar tissue lined by endothelium
and strengthened by non-striped muscle. They are rarely provided with a
definite capsule, and frequently send prolongations of their substance
between and into muscles and other structures in their vicinity. They
are of congenital origin and usually make their appearance at or shortly
after birth. When the tumour is made up of a meshwork of caverns and
channels, it is called a _cavernous lymphangioma_; when it is composed
of one or more cysts, it is called a _cystic lymphangioma_. It is
probable that the cysts are derived from the caverns by breaking down
and absorption of the intervening septa, as transition forms between the
cavernous and cystic varieties are sometimes met with.

The _cavernous lymphangioma_ appears as an ill-defined, soft swelling,
presenting many of the characters of a subcutaneous hæmangioma, but it
is not capable of being emptied by pressure, it does not become tense
when the blood pressure is raised, as in crying, and if the tumour is
punctured, it yields lymph instead of blood. It also resembles a lipoma,
especially the congenital variety which grows from the periosteum, and
the differential diagnosis between these is rarely completed until the
swelling is punctured or explored by operation. If treatment is called
for, it is carried out on the same lines as for hæmangioma, by means of
electrolysis, igni-puncture, or excision. Complete excision is rarely
possible because of the want of definition and encapsulation, but it is
not necessary for cure, as the parts that remain undergo cicatrisation.

[Illustration: FIG. 76.--Congenital Cystic Tumour or Hygroma of Axilla.

(From a photograph lent by Dr. Lediard.)]

The _cystic lymphangioma_, _lymphatic cyst_, or _congenital cystic
hygroma_ is most often met with in the neck--_hydrocele of the neck_; it
is situated beneath the deep fascia, and projects either in front of or
behind the sterno-mastoid muscle. It may attain a large size, the
overlying skin and cyst wall may be so thin as to be translucent, and it
has been known to cause serious impairment of respiration through
pressing on the trachea. In the axilla also the cystic tumour may attain
a considerable size (Fig. 76); less frequent situations are the groin,
and the floor of the mouth, where it constitutes one form of ranula.

The nature of these swellings is to be recognised by their situation, by
their having existed from infancy, and, if necessary, by drawing off
some of the contents of the cyst through a fine needle. They are usually
remarkably indolent, persisting often for a long term of years without
change, and, like the hæmangioma, they sometimes undergo spontaneous
cicatrisation and cure. Sometimes the cystic tumour becomes infected and
forms an abscess--another, although less desirable, method of cure.
Those situated in the neck are most liable to suppurate, probably
because of pyogenic organisms being brought to them by the lymphatics
taking origin in the scalp, ear, or throat.

If operative interference is called for, the cysts may be tapped and
injected with iodine, or excised; the operation for removal may entail a
considerable dissection amongst the deeper structures at the root of the
neck, and should not be lightly undertaken; parts left behind may be
induced to cicatrise by inserting a tube of radium and leaving it for a
few days.

Lymphangiomas are met with in the abdomen in the form of _omental
cysts_.


DISEASES OF LYMPH GLANDS

#Lymphadenitis.#--Inflammation of lymph glands results from the advent
of an irritant, usually bacterial or toxic, brought to the glands by the
afferent lymph vessels. These vessels may share in the inflammation and
be the seat of lymphangitis, or they may show no evidence of the passage
of the noxa. It is exceptional for the irritant to reach the gland
through the blood-stream.

A strain or other form of trauma is sometimes blamed for the onset of
lymphadenitis, especially in the glands of the groin (bubo), but it is
usually possible to discover some source of pyogenic infection which is
responsible for the mischief, or to obtain a history of some antecedent
infection such as gonorrhœa. It is possible for gonococci to lie latent
in the inguinal glands for long periods, and only give rise to
lymphadenitis if the glands be subsequently subjected to injury. The
glands most frequently affected are those in the neck, axilla, and
groin.

The characters of the lymphadenitis vary with the nature of the
irritant. Sometimes it is mild and evanescent, as in the glandular
enlargement in the neck which attends tonsillitis and other forms of
sore throat. Sometimes it is more persistent, as in the enlargement
that is associated with adenoids, hypertrophied tonsils, carious teeth,
eczema of the scalp, and otorrhœa; and it is possible that this indolent
enlargement predisposes to tuberculous infection. A similar enlargement
is met with in the axilla in cases of chronic interstitial mastitis, and
in the groin as a result of chronic irritation about the external
genitals, such as balanitis.

Sometimes the lymphadenitis is of an acute character, and the tendency
is towards the formation of an abscess. This is illustrated in the
axillary glands as a result of infected wounds of the fingers; in the
femoral glands in infected wounds or purulent blisters on the foot; in
the inguinal glands in gonorrhœa and soft sore; and in the cervical
glands in the severer forms of sore throat associated with diphtheria
and scarlet fever. The most acute suppurations result from infection
with streptococci.

Superficial glands, when inflamed and suppurating, become enlarged,
tender, fixed, and matted to one another. In the glands of the groin the
suppurative process is often remarkably sluggish; purulent foci form in
the interior of individual glands, and some time may elapse before the
pus erupts through their respective capsules. In the deeply placed
cervical glands, especially in cases of streptococcal throat infections,
the suppuration rapidly involves the surrounding cellular tissue, and
the clinical features are those of an acute cellulitis and deeply seated
abscess. When this is incised the necrosed glands may be found lying in
the pus, and on bacteriological examination are found to be swarming
with streptococci. In suppuration of the axillary glands the abscess may
be quite superficial, or it may be deeply placed beneath the strong
fascia and pectoral muscles, according to the group of glands involved.

The _diagnosis_ of septic lymphadenitis is usually easy. The indolent
enlargements are not always to be distinguished, however, from
commencing tuberculous disease, except by the use of the tuberculin
test, and by the fact that they usually disappear on removing the
peripheral source of irritation.

_Treatment._--The first indication is to discover and deal with the
source of infection, and in the indolent forms of lymphadenitis this
will usually be followed by recovery. In the acute forms following on
pyogenic infection, the best results are obtained from the hyperæmic
treatment carried out by means of suction bells. If suppuration is not
thereby prevented, or if it has already taken place, each separate
collection of pus is punctured with a narrow-bladed knife and the use of
the suction bell is persevered with. If there is a large periglandular
abscess, as is often the case, in the neck and axilla, the opening may
require to be made by Hilton's method, and it may be necessary to insert
a drainage-tube.

[Illustration: FIG. 77.--Tuberculous Cervical Gland with abscess
formation in subcutaneous cellular tissue, in a boy æt. 10.]

#Tuberculous Disease of Glands.#--This is a disease of great frequency
and importance. The tubercle bacilli usually gain access to the gland
through the afferent lymph vessels, which convey them from some lesion
of the surface within the area drained by them. Tuberculous infection
may supervene in glands that are already enlarged as a result of chronic
septic irritation. While any of the glands in the body may be affected,
the disease is most often met with in the cervical groups which derive
their lymph from the mouth, nose, throat, and ear.

_The appearance of the glands on section_ varies with the stage of the
disease. In the early stages the gland is enlarged, it may be to many
times its natural size, is normal in appearance and consistence, and as
there is no peri-adenitis it is easily shelled out from its
surroundings. On microscopical examination, however, there is evidence
of infection in the shape of bacilli and of characteristic giant and
epithelioid cells. At a later stage, the gland tissue is studded with
minute yellow foci which tend to enlarge and in time to become
confluent, so that the whole gland is ultimately converted into a
caseous mass. This caseous material is surrounded by the thickened
capsule which, as a result of peri-adenitis, tends to become adherent to
and fused with surrounding structures, and particularly with layers of
fascia and with the walls of veins. The caseated tissue often remains
unchanged for long periods; it may become calcified, but more frequently
it breaks down and liquefies.

#Tuberculous disease in the cervical glands# is a common accompaniment
or sequel of adenoids, enlarged tonsils, carious teeth, pharyngitis,
middle-ear disease, and conjunctivitis. These lesions afford the bacilli
a chance of entry into the lymph vessels, in which they are carried to
the glands, where they give rise to disease.

The enlargement may affect only one gland, usually below the angle of
the mandible, and remain confined to it, the gland reaching the size of
a hazel-nut, and being ovoid, firm, and painless. More commonly the
disease affects several glands, on one or on both sides of the neck.
When the disease commences in the pre-auricular or submaxillary glands,
it tends to spread to those along the carotid sheath: when the posterior
auricular and occipital glands are first involved, the spread is to
those along the posterior border of the sterno-mastoid. In many cases
all the chains in front of, beneath, and behind this muscle are
involved, the enlarged glands extending from the mastoid to the
clavicle. They are at first discrete and movable, and may even vary in
size from time to time; but with the addition of peri-adenitis they
become fixed and matted together, forming lobulated or nodular masses
(Fig. 78). They become adherent not only to one another, but also to the
structures in their vicinity,--and notably to the internal jugular
vein,--a point of importance in regard to their removal by operation.

At any stage the disease may be arrested and the glands remain for long
periods without further change. It is possible that the tuberculous
tissue may undergo cicatrisation. More commonly suppuration ensues, and
a cold abscess forms, but if there is a mixed infection, the pyogenic
factor being usually derived from the throat, it may take on active
features.

[Illustration: FIG. 78.--Mass of Tuberculous Glands removed from Axilla
(cf. Fig. 79).]

The transition from the solid to the liquefied stage is attended with
pain and tenderness in the gland, which at the same time becomes fixed
and globular, and finally fluctuation can be elicited.

If left to itself, the softened tubercle erupts through the capsule of
the gland and infects the cellular tissue. The cervical fascia is
perforated and a cold abscess, often much larger than the gland from
which it took origin, forms between the fascia and the overlying skin.
The further stages--reddening, undermining of skin and external rupture,
with the formation of ulcers and sinuses--have been described with
tuberculous abscess. The ulcers and sinuses persist indefinitely, or
they heal and then break out again; sometimes the skin becomes infected,
and a condition like lupus spreads over a considerable area. Spontaneous
healing finally takes place after the caseous tubercle has been
extruded; the resulting scars are extremely unsightly, being puckered or
bridled, or hypertrophied like keloid.

While the disease is most common in childhood and youth, it may be met
with even in advanced life; and although often associated with impaired
health and unhealthy surroundings, it may affect those who are
apparently robust and are in affluent circumstances.

_Diagnosis._--The chief importance lies in differentiating tuberculous
disease from lympho-sarcoma and from lymphadenoma, and this is usually
possible from the history and from the nature of the enlargement. Signs
of liquefaction and suppuration support the diagnosis of tubercle. If
any doubt remains, one of the glands should be removed and submitted to
microscopical examination. Other forms of sarcoma, and the enlargement
of an accessory thyreoid, are less likely to be confused with
tuberculous glands. Calcified tuberculous glands give definite shadows
with the X-rays.

Enlargement of the cervical glands from secondary cancer may simulate
tuberculosis, but is differentiated by its association with cancer in
the mouth or throat, and by the characteristic, stone-like induration of
epithelioma.

The cold abscess which results from tuberculous glands is to be
distinguished from that due to disease in the cervical spine,
retro-pharyngeal abscess, as well as from congenital and other cystic
swellings in the neck.

_Prognosis._--Next to lupus, glandular disease is of all tuberculous
lesions the least dangerous to life; but while it is the rule to recover
from tuberculous disease of glands with or without an operation, it is
unfortunately quite common for such persons to become the subjects of
tuberculosis in other parts of the body at any subsequent period of
life.

_Treatment._--There is considerable difference of opinion regarding the
treatment of glandular tuberculosis. Some authorities, impressed with
the undoubted possibility of natural cure, are satisfied with promoting
this by measures directed towards improving the general health, by the
prolonged administration of tuberculin, and by repeated exposures to the
X-rays and to sunlight. Others again, influenced by the risk of
extension of the disease and by the destruction of tissue and
disfigurement caused by breaking down of the tuberculous tissue and
mixed infection, advocate the removal of the glands by operation.

The conditions vary widely in different cases, and the treatment should
be adapted to the individual requirements. If the disease remains
confined to the glands originally infected and there are no signs of
breaking down, "expectant measures" may be persevered with.

[Illustration: FIG. 79.--Tuberculous Axillary Glands (cf. Fig. 78).]

If, on the other hand, the disease exhibits aggressive tendencies, the
question of operation should be considered. The undesirable results of
the breaking down and liquefaction of the diseased gland may be avoided
by the timely withdrawal of the fluid contents through a hollow needle.

_The excision of tuberculous glands_ is often a difficult operation,
because of the number and deep situation of the glands to be removed,
and of the adhesions to surrounding structures. The skin incision must
be sufficiently extensive to give access to the whole of the affected
area, and to avoid disfigurement should, whenever possible, be made in
the line of the natural creases of the skin. In exposing the glands the
common facial and other venous trunks may require to be clamped and
tied. Care must be taken not to injure the important nerves,
particularly the accessory, the vagus, and the phrenic. The
inframaxillary branches of the facial, the hypoglossal and its
descending branches, and the motor branches of the deep cervical plexus,
are also liable to be injured. The dissection is rendered easier and is
attended with less risk of injury to the nerves, if the patient is
placed in the sitting posture so as to empty the veins, and, instead of
a knife, the conical scissors of Mayo are employed. When the glands are
extensively affected on both sides of the neck, it is advisable to allow
an interval to elapse rather than to operate on both sides at one
sitting. (_Op. Surg._, p. 189.)

If the tonsils are enlarged they should not be removed at the same time,
as, by so doing, there is a risk of pyogenic infection from the throat
being carried to the wound in the neck, but they should be removed,
after an interval, to prevent relapse of disease in the glands.

_When the skin is broken_ and caseous tuberculous tissue is exposed,
healing is promoted by cutting away diseased skin, removing the
granulation tissue with the spoon, scraping sinuses, and packing the
cavity with iodoform worsted and treating it by the open method and
secondary suture if necessary. Exposure to the sunshine on the seashore
and to the X-rays is often beneficial in these cases.

#Tuberculous disease in the axillary glands# may be a result of
extension from those in the neck, from the mamma, ribs, or sternum, or
more rarely from the upper extremity. We have seen it from an infected
wound of a finger. In some cases no source of infection is discoverable.
The individual glands attain a considerable size, and they fuse together
to form a large tumour which fills up the axillary space. The disease
progresses more rapidly than it does in the cervical glands, and almost
always goes on to suppuration with the formation of sinuses.
Conservative measures need not be considered, as the only satisfactory
treatment is excision, and that without delay.

#Tuberculous disease in the glands of the groin# is comparatively rare.
We have chiefly observed it in the femoral glands as a result of
inoculation tubercle on the toes or sole of the foot. The affected
glands nearly always break down and suppurate, and after destroying the
overlying skin give rise to fungating ulcers. The treatment consists in
excising the glands and the affected skin. The dissection may be
attended with troublesome hæmorrhage from the numerous veins that
converge towards the femoral trunk.

Tuberculous disease in the _mesenteric_ and _bronchial glands_ is
described with the surgery of regions.

#Syphilitic Disease of Glands.#--Enlargement of lymph glands is a
prominent feature of acquired syphilis, especially in the form of the
indolent or bullet-bubo which accompanies the primary lesion, and the
general enlargement of glands that occurs in secondary syphilis.
Gummatous disease in glands is extremely rare; the affected gland
rapidly enlarges to the size of a walnut, and may then persist for a
long period without further change; if it breaks down, the overlying
skin is destroyed and the caseated tissue of the gumma exposed.

#Lymphadenoma.#--_Hodgkin's Disease_ (Pseudo-leukæmia of German
authors).--This is a rare disease, the origin of which is as yet
unknown, but analogy would suggest that it is due to infection with a
slowly growing micro-organism. It is chiefly met with in young subjects,
and is characterised by a painless enlargement of a particular group of
glands, most commonly those in the cervical region (Fig. 80).

[Illustration: FIG. 80.--Chronic Hodgkin's Disease in a boy æt. 11.]

The glands are usually larger than in tuberculosis, and they remain
longer discrete and movable; they are firm in consistence, and on
section present a granular appearance due to overgrowth of the
connective-tissue framework. In time the glandular masses may form
enormous projecting tumours, the swelling being added to by lymphatic
œdema of the overlying cellular tissue and skin.

The enlargement spreads along the chain of glands to those above the
clavicle, to those in the axilla, and to those of the opposite side
(Fig. 81). Later, the glands in the groin become enlarged, and it is
probable that the infection has spread from the neck along the
mediastinal, bronchial, retro-peritoneal, and mesenteric glands, and has
branched off to the iliac and inguinal groups.

Two clinical types are recognised, one in which the disease progresses
slowly and remains confined to the cervical glands for two or more
years; the other, in which the disease is more rapidly disseminated and
causes death in from twelve to eighteen months.

[Illustration: FIG. 81.--Lymphadenoma (Hodgkin's Disease) affecting left
side of neck and left axilla, in a woman æt. 44. Three years' duration.]

In the acute form, the health suffers, there is fever, and the glands
may vary in size with variations in the temperature; the blood presents
the characters met with in secondary anæmia. The spleen, liver, testes,
and mammæ may be enlarged; the glandular swellings press on important
structures, such as the trachea, œsophagus, or great veins, and symptoms
referable to such pressure manifest themselves.

_Diagnosis._--Considerable difficulty attends the diagnosis of
lymphadenoma at an early stage. The negative results of tuberculin tests
may assist in the differentiation from tuberculous disease, but the more
certain means of excising one of the suspected glands and submitting it
to microscopical examination should be had recourse to. The sections
show proliferation of endothelial cells, the formation of numerous giant
cells quite unlike those of tuberculosis and a progressive fibrosis.
Lympho-sarcoma can usually be differentiated by the rapid assumption of
the local features of malignant disease, and in a gland removed for
examination, a predominance of small round cells with scanty protoplasm.
The enlargement associated with leucocythæmia is differentiated by the
characteristic changes in the blood.

_Treatment._--In the acute form of lymphadenoma, treatment is of little
avail. Arsenic may be given in full doses either by the mouth or by
subcutaneous injection; the intravenous administration of neo-salvarsan
may be tried. Exposure to the X-rays and to radium has been more
successful than any other form of treatment. Excision of glands,
although sometimes beneficial, seldom arrests the progress of the
disease. The ease and rapidity with which large masses of glands may be
shelled out is in remarkable contrast to what is observed in tuberculous
disease. Surgical interference may give relief when important structures
are being pressed upon--tracheotomy, for example, may be required where
life is threatened by asphyxia.

#Leucocythæmia.#--This is a disease of the blood and of the
blood-forming organs, in which there is a great increase in the number,
and an alteration of the character, of the leucocytes present in the
blood. It may simulate lymphadenoma, because, in certain forms of the
disease, the lymph glands, especially those in the neck, axilla, and
groin, are greatly enlarged.


TUMOURS OF LYMPH GLANDS

#Primary Tumours.#--_Lympho-sarcoma_, which may be regarded as a sarcoma
starting in a lymph gland, appears in the neck, axilla, or groin as a
rapidly growing tumour consisting of one enlarged gland with numerous
satellites. As the tumour increases in size, the sarcomatous tissue
erupts through the capsule of the gland, and infiltrates the surrounding
tissues, whereby it becomes fixed to these and to the skin.

[Illustration: FIG. 82.--Lympho-Sarcoma removed from Groin. It will be
observed that there is one large central parent tumour surrounded by
satellites.]

The prognosis is grave in the extreme, and the only hope is in early
excision, followed by the use of radium and X-rays. We have observed a
case of lympho-sarcoma above the clavicle, in which excision of all that
was removable, followed by the insertion of a tube of radium for ten
days, was followed by a disappearance of the disease over a period which
extended to nearly five years, when death resulted from a tumour in the
mediastinum. In a second case in which the growth was in the groin, the
patient, a young man, remained well for over two years and was then lost
sight of.

#Secondary Tumours.#--Next to tuberculosis, _secondary cancer_ is the
most common disease of lymph glands. In the neck it is met with in
association with epithelioma of the lip, tongue, or fauces. The glands
form tumours of variable size, and are often larger than the primary
growth, the characters of which they reproduce. The glands are at first
movable, but soon become fixed both to each other and to their
surroundings; when fixed to the mandible they form a swelling of
bone-like hardness; in time they soften, liquefy, and burst through the
skin, forming foul, fungating ulcers. A similar condition is met with in
the groin from epithelioma of the penis, scrotum, or vulva. In cancer of
the breast, the infection of the axillary glands is an important
complication.

In _pigmented_ or _melanotic cancers_ of the skin, the glands are early
infected and increase rapidly, so that, when the primary growth is still
of small size--as, for example, on the sole of the foot--the femoral
glands may already constitute large pigmented tumours.

[Illustration: FIG. 83.--Cancerous Glands in Neck secondary to
Epithelioma of Lip.

(Mr. G. L. Chiene's case.)]

The implication of the glands in other forms of cancer will be
considered with regional surgery.

_Secondary sarcoma_ is seldom met with in the lymph glands except when
the primary growth is a lympho-sarcoma and is situated in the tonsil,
thyreoid, or testicle.



CHAPTER XVI

THE NERVES


Anatomy--INJURIES OF NERVES: Changes in nerves after division;
    Repair and its modifications; Clinical features; _Primary and
    secondary suture_--SUBCUTANEOUS INJURIES OF
    NERVES--DISEASES: _Neuritis_; _Tumours_--Surgery of
    the individual nerves: _Brachial neuralgia_; _Sciatica_;
    _Trigeminal neuralgia_.

#Anatomy.#--A nerve-trunk is made up of a variable number of bundles of
nerve fibres surrounded and supported by a framework of connective
tissue. The nerve fibres are chiefly of the medullated type, and they
run without interruption from a nerve cell or _neuron_ in the brain or
spinal medulla to their peripheral terminations in muscle, skin, and
secretory glands.

Each nerve fibre consists of a number of nerve fibrils collected into a
central bundle--the axis cylinder--which is surrounded by an envelope,
the neurolemma or sheath of Schwann. Between the neurolemma and the axis
cylinder is the medullated sheath, composed of a fatty substance known
as myelin. This medullated sheath is interrupted at the nodes of
Ranvier, and in each internode is a nucleus lying between the myelin and
the neurolemma. The axis cylinder is the essential conducting structure
of the nerve, while the neurolemma and the myelin act as insulating
agents. The axis cylinder depends for its nutrition on the central
neuron with which it is connected, and from which it originally
developed, and it degenerates if it is separated from its neuron.

The connective-tissue framework of a nerve-trunk consists of the
_perineurium_, or general sheath, which surrounds all the bundles; the
_epineurium_, surrounding individual groups of bundles; and the
_endoneurium_, a delicate connective tissue separating the individual
nerve fibres. The blood vessels and lymphatics run in these
connective-tissue sheaths.

According to Head and his co-workers, Sherren and Rivers, the afferent
fibres in the peripheral nerves can be divided into three systems:--

1. Those which subserve _deep sensibility_ and conduct the impulses
produced by pressure as well as those which enable the patient to
recognise the position of a joint on passive movement (joint-sensation),
and the kinæsthetic sense, which recognises that active contraction of
the muscle is taking place (active muscle-sensation). The fibres of this
system run with the motor nerves, and pass to muscles, tendons, and
joints. Even division of both the ulnar and the median nerves above the
wrist produces little loss of deep sensibility, unless the tendons are
also cut through. The failure to recognise this form of sensibility has
been largely responsible for the conflicting statements as to the
sensory phenomena following operations for the repair of divided nerves.

2. Those which subserve _protopathic_ sensibility--that is, are capable
of responding to painful cutaneous stimuli and to the extremes of heat
and cold. These also endow the hairs with sensibility to pain. They are
the first to regenerate after division.

3. Those which subserve _epicritic_ sensibility, the most highly
specialised, capable of appreciating light touch, _e.g._ with a wisp of
cotton wool, as a well-localised sensation, and the finer grades of
temperature, called cool and warm (72°–104° F.), and of discriminating
as separate the points of a pair of compasses 2 cms. apart. These are
the last to regenerate.

A nerve also exerts a trophic influence on the tissues in which it is
distributed.

The researches of Stoffel on the minute anatomy of the larger nerves,
and the disposition in them of the bundles of nerve fibres supplying
different groups of muscles, have opened up what promises to be a
fruitful field of clinical investigation and therapeutics. He has shown
that in the larger nerve-trunks the nerve bundles for special groups of
muscles are not, as was formerly supposed, arranged irregularly and
fortuitously, but that on the contrary the nerve fibres to a particular
group of muscles have a typical and practically constant position within
the nerve.

In the large nerve-trunks of the limbs he has worked out the exact
position of the bundles for the various groups of muscles, so that in a
cross section of a particular nerve the component bundles can be
labelled as confidently and accurately as can be the cortical areas in
the brain. In the living subject, by using a fine needle-like electrode
and a very weak galvanic current, he has been able to differentiate the
nerve bundles for the various groups of muscles. In several cases of
spastic paralysis he succeeded in picking out in the nerve-trunk of the
affected limb the nerve bundles supplying the spastic muscles, and, by
resecting portions of them, in relieving the spasm. In a case of spastic
contracture of the pronator muscles of the forearm, for example, an
incision is made along the line of the median nerve above the bend of
the elbow. At the lateral side of the median nerve, where it lies in
contact with the biceps muscle, is situated a well-defined and easily
isolated bundle of fibres which supplies the pronator teres, the flexor
carpi radialis, and the palmaris longus muscles. On incising the sheath
of the nerve this bundle can be readily dissected up and its identity
confirmed by stimulating it with a very weak galvanic current. An inch
or more of the bundle is then resected.


INJURIES OF NERVES

Nerves are liable to be cut or torn across, bruised, compressed,
stretched, or torn away from their connections with the spinal medulla.

#Complete Division of a Mixed Nerve.#--Complete division is a common
result of accidental wounds, especially above the wrist, where the
ulnar, median, and radial nerves are frequently cut across, and in
gun-shot injuries.

_Changes in Structure and Function._--The mere interruption of the
continuity of a nerve results in degeneration of its fibres, the myelin
being broken up into droplets and absorbed, while the axis cylinders
swell up, disintegrate, and finally disappear. Both the conducting and
the insulating elements are thus lost. The degeneration in the central
end of the divided nerve is usually limited to the immediate proximity
of the lesion, and does not even involve all the nerve fibres. In the
distal end, it extends throughout the entire peripheral distribution of
the nerve, and appears to be due to the cutting off of the fibres from
their trophic nerve cells in the spinal medulla. Immediate suturing of
the ends does not affect the degeneration of the distal segment. The
peripheral end undergoes complete degeneration in from six weeks to two
months.

The physiological effects of complete division are that the muscles
supplied by the nerve are immediately paralysed, the area to which it
furnishes the sole cutaneous supply becomes insensitive, and the other
structures, including tendons, bones, and joints, lose sensation, and
begin to atrophy from loss of the trophic influence.

#Nerves divided in Amputation.#--In the case of nerves divided in an
amputation, there is an active, although necessarily abortive, attempt
at regeneration, which results in the formation of bulbous swellings at
the cut ends of the nerves. When there has been suppuration, and
especially if the nerves have been cut so as to be exposed in the wound,
these bulbous swellings may attain an abnormal size, and are then known
as "amputation" or "stump neuromas" (Fig. 84).

When the nerves in a stump have not been cut sufficiently short, they
may become involved in the cicatrix, and it may be necessary, on account
of pain, to free them from their adhesions, and to resect enough of the
terminal portions to prevent them again becoming adherent. When this is
difficult, a portion may be resected from each of the nerve-trunks at a
higher level; and if this fails to give relief, a fresh amputation may
be performed. When there is agonising pain dependent upon an ascending
neuritis, it may be necessary to resect the corresponding posterior
nerve roots within the vertebral canal.

[Illustration: FIG. 84.--Stump Neuromas of Sciatic Nerve, excised forty
years after the original amputation by Mr. A. G. Miller.]

#Other Injuries of Nerves.#--_Contusion_ of a nerve-trunk is attended
with extravasation of blood into the connective-tissue sheaths, and is
followed by degeneration of the contused nerve fibres. Function is
usually restored, the conducting paths being re-established by the
formation of new nerve fibres.

When a nerve is _torn across_ or badly _crushed_--as, for example, by a
fractured bone--the changes are similar to those in a divided nerve, and
the ultimate result depends on the amount of separation between the ends
and the possibility of the young axis cylinders bridging the gap.

_Involvement of Nerves in Scar Tissue._--Pressure or traction may be
exerted upon a nerve by contracting scar tissue, or a process of
neuritis or perineuritis may be induced.

When terminal filaments are involved in a scar, it is best to dissect
out the scar, and along with it the ends of the nerves pressed upon.
When a nerve-trunk, such as the sciatic, is involved in cicatricial
tissue, the nerve must be exposed and freed from its surroundings
(_neurolysis_), and then stretched so as to tear any adhesions that may
be present above or below the part exposed. It may be advisable to
displace the liberated nerve from its original position so as to
minimise the risk of its incorporation in the scar of the original wound
or in that resulting from the operation--for example, the radial nerve
may be buried in the substance of the triceps, or it may be surrounded
by a segment of vein or portion of fat-bearing fascia.

_Injuries of nerves resulting from_ #gun-shot wounds# include: (1) those
in which the nerve is directly damaged by the bullet, and (2) those in
which the nerve-trunk is involved secondarily either by scar tissue in
its vicinity or by callus following fracture of an adjacent bone. The
primary injuries include contusion, partial or complete division, and
perforation of the nerve-trunk. One of the most constant symptoms is the
early occurrence of severe neuralgic pain, and this is usually
associated with marked hyperæsthesia.

#Regeneration.#--_Process of Repair when the Ends are in Contact._--_If
the wound is aseptic_, and the ends of the divided nerve are sutured or
remain in contact, they become united, and the conducting paths are
re-established by a regeneration of nerve fibres. There is a difference
of opinion as to the method of regeneration. The Wallerian doctrine is
that the axis cylinders in the central end grow downwards, and enter the
nerve sheaths of the distal portion, and continue growing until they
reach the peripheral terminations in muscle and skin, and in course of
time acquire a myelin sheath; the cells of the neurolemma multiply and
form long chains in both ends of the nerve, and are believed to provide
for the nourishment and support of the actively lengthening axis
cylinders. Another view is that the formation of new axis cylinders is
not confined to the central end, but that it goes on also in the
peripheral segment, in which, however, the new axis cylinders do not
attain maturity until continuity with the central end has been
re-established.

_If the wound becomes infected_ and suppuration occurs, the young nerve
fibres are destroyed and efficient regeneration is prevented; the
formation of scar tissue also may constitute a permanent obstacle to new
nerve fibres bridging the gap.

_When the ends are not in contact_, reunion of the divided nerve fibres
does not take place whether the wound is infected or not. At the
proximal end there forms a bulbous swelling, which becomes adherent to
the scar tissue. It consists of branching axis cylinders running in all
directions, these having failed to reach the distal end because of the
extent of the gap. The peripheral end is completely degenerated, and is
represented by a fibrous cord, the cut end of which is often slightly
swollen or bulbous, and is also incorporated with the scar tissue of
the wound.

#Clinical Features.#--The symptoms resulting from division and non-union
of a nerve-trunk necessarily vary with the functions of the affected
nerve. The following description refers to a mixed sensori-motor trunk,
such as the median or radial (musculo-spiral) nerve.

_Sensory Phenomena._--Superficial touch is tested by means of a wisp of
cotton wool stroked gently across the skin; the capacity of
discriminating two points as separate, by a pair of blunt-pointed
compasses; the sensation of pressure, by means of a pencil or other
blunt object; of pain, by pricking or scratching with a needle; and of
sensibility to heat and cold, by test-tubes containing water at
different temperatures. While these tests are being carried out, the
patient's eyes are screened off.

After division of a nerve containing sensory fibres, there is an area of
absolute cutaneous insensibility to touch (anæsthesia), to pain
(analgesia), and to all degrees of temperature--_loss of protopathic
sensibility_; surrounded by an area in which there is loss of sensation
to light touch, inability to recognise minor differences of temperature
(72°–104° F.), and to appreciate as separate impressions the contact of
the two points of a compass--_loss of epicritic sensibility_ (Head and
Sherren) (Figs. 91, 92).

_Motor Phenomena._--There is immediate and complete loss of voluntary
power in the muscles supplied by the divided nerve. The muscles rapidly
waste, and within from three to five days, they cease to react to the
faradic current. When tested with the galvanic current, it is found that
a stronger current must be used to call forth contraction than in a
healthy muscle, and the contraction appears first at the closing of the
circuit when the anode is used as the testing electrode. The loss of
excitability to the interrupted current, and the specific alteration in
the type of contraction with the constant current, is known as the
_reaction of degeneration_. After a few weeks all electric excitability
is lost. The paralysed muscles undergo fatty degeneration, which attains
its maximum three or four months after the division of the nerve.
Further changes may take place, and result in the transformation of the
muscle into fibrous tissue, which by undergoing shortening may cause
deformity known as _paralytic contracture_.

_Vaso-motor Phenomena._--In the majority of cases there is an initial
rise in the temperature of the part (2° to 3° F.), with redness and
increased vascularity. This is followed by a fall in the local
temperature, which may amount to 8° or 10° F., the parts becoming pale
and cold. Sometimes the hyperæmia resulting from vaso-motor paralysis is
more persistent, and is associated with swelling of the parts from
œdema--the so-called _angio-neurotic œdema_. The vascularity varies with
external influences, and in cold weather the parts present a bluish
appearance.

_Trophic Phenomena._--Owing to the disappearance of the subcutaneous
fat, the skin is smooth and thin, and may be abnormally dry. The hair is
harsh, dry, and easily shed. The nails become brittle and furrowed, or
thick and curved, and the ends of the fingers become club-shaped. Skin
eruptions, especially in the form of blisters, occur, or there may be
actual ulcers of the skin, especially in winter. In aggravated cases the
tips of the fingers disappear from progressive ulceration, and in the
sole of the foot a perforating ulcer may develop. Arthropathies are
occasionally met with, the joints becoming the seat of a painless
effusion or hydrops, which is followed by fibrous thickening of the
capsular and other ligaments, and terminates in stiffness and fibrous
ankylosis. In this way the fingers are seriously crippled and deformed.

#Treatment of Divided Nerves.#--The treatment consists in approximating
the divided ends of the nerve and placing them under the most favourable
conditions for repair, and this should be done at the earliest possible
opportunity. (_Op. Surg._, pp. 45, 46.)

#Primary Suture.#--The reunion of a recently divided nerve is spoken of
as primary suture, and for its success asepsis is essential. As the
suturing of the ends of the nerve is extremely painful, an anæsthetic is
required.

When the wound is healed and while waiting for the restoration of
function, measures are employed to maintain the nutrition of the damaged
nerve and of the parts supplied by it. The limb is exercised, massaged,
and douched, and protected from cold and other injurious influences. The
nutrition of the paralysed muscles is further improved by electricity.
The galvanic current is employed, using at first a mild current of not
more than 5 milliampères for about ten minutes, the current being made
to flow downwards in the course of the nerve, with the positive
electrode applied to the spine, and the negative over the affected nerve
near its termination. It is an advantage to have a metronome in the
circuit whereby the current is opened and closed automatically at
intervals, so as to cause contraction of the muscles.

_The results_ of primary suture, when it has been performed under
favourable conditions, are usually satisfactory. In a series of cases
investigated by Head and Sherren, the period between the operation and
the first return of sensation averaged 65 days. According to Purves
Stewart protopathic sensation commences to appear in about six weeks and
is completely restored in six months; electric sensation and motor power
reappear together in about six months, and restoration is complete in a
year. When sensation returns, the area of insensibility to pain steadily
diminishes and disappears; sensibility to extremes of temperature
appears soon after; and last of all, after a considerable interval,
there is simultaneous return of appreciation of light touch, moderate
degrees of temperature, and the points of a compass.

A clinical means of estimating how regeneration in a divided nerve is
progressing has been described by Tinel. He found that a tingling
sensation, similar to that experienced in the foot, when it is
recovering from the "sleeping" condition induced by prolonged pressure
on the sciatic nerve from sitting on a hard bench, can be elicited on
percussing over _growing_ axis cylinders. Tapping over the proximal end
of a _newly divided nerve_, _e.g._ the common peroneal behind the head
of the fibula, produces no tingling, but when in about three weeks
axis cylinders begin to grow in the proximal end-bulb, local tingling is
induced by tapping there. The downward growth of the axis cylinders can
be traced by tapping over the distal segment of the nerve, the tingling
sensation being elicited as far down as the young axis cylinders have
reached. When the regeneration of the axis cylinders is complete,
tapping no longer causes tingling. It usually takes about one hundred
days for this stage to be reached.

Tinel's sign is present before voluntary movement, muscular tone, or the
normal electrical reactions reappear.

In cases of complete nerve paralysis that have not been operated upon,
the tingling test is helpful in determining whether or not regeneration
is taking place. Its detection may prevent an unnecessary operation
being performed.

Primary suture should not be attempted so long as the wound shows signs
of infection, as it is almost certain to end in failure. The ends should
be sutured, however, as soon as the wound is aseptic or has healed.

#Secondary Suture.#--The term secondary suture is applied to the
operation of stitching the ends of the divided nerve after the wound has
healed.

_Results of Secondary Suture._--When secondary suture has been performed
under favourable conditions, the prognosis is good, but a longer time is
required for restoration of function than after primary suture. Purves
Stewart says protopathic sensation is sometimes observed much earlier
than in primary suture, because partial regeneration of axis cylinders
in the peripheral segment has already taken place. Sensation is
recovered first, but it seldom returns before three or four months.
There then follows an improvement or disappearance of any trophic
disturbances that may be present. Recovery of motion may be deferred for
long periods--rather because of the changes in the muscles than from
want of conductivity in the nerve--and if the muscles have undergone
complete degeneration, it may never take place at all. While waiting for
recovery, every effort should be made to maintain the nutrition of the
damaged nerve, and of the parts which it supplies.

When suture is found to be impossible, recourse must be had to other
methods, known as nerve bridging and nerve implantation.

#Incomplete Division of a Mixed Nerve.#--The effects of partial division
of a mixed nerve vary according to the destination of the nerve bundles
that have been interrupted. Within their area of distribution the
paralysis is as complete as if the whole trunk had been cut across. The
uninjured nerve-bundles continue to transmit impulses with the result
that there is a _dissociated paralysis_ within the distribution of the
affected nerve, some muscles continuing to act and to respond normally
to electric stimulation, while others behave as if the whole nerve-trunk
had been severed.

In addition to vasomotor and trophic changes, there is often severe pain
of a burning kind (_causalgia_ or _thermalgia_) which comes on about a
fortnight after the injury and causes intense and continuous suffering
which may last for months. Paroxysms of pain may be excited by the
slightest touch or by heat, and the patient usually learns for himself
that the constant application of cold wet cloths allays the pain. The
thermalgic area sweats profusely.

Operative treatment is indicated where there is no sign of improvement
within three months, when recovery is arrested before complete
restoration of function is attained, or when thermalgic pain is
excessive.

#Subcutaneous Injuries of Nerves.#--Several varieties of subcutaneous
injuries of nerves are met with. One of the best known is the
compression paralysis of the nerves of the upper arm which results from
sleeping with the arm resting on the back of a chair or the edge of a
table--the so-called "drunkard's palsy"; and from the pressure of a
crutch in the axilla--"crutch paralysis." In some of these injuries,
notably "drunkard's palsy," the disability appears to be due not to
damage of the nerve, but to overstretching of the extensors of the wrist
and fingers (Jones). A similar form of paralysis is sometimes met with
from the pressure of a tourniquet, from tight bandages or splints, from
the pressure exerted by a dislocated bone or by excessive callus, and
from hyper-extension of the arm during anæsthesia.

In all these forms there is impaired sensation, rarely amounting to
anæsthesia, marked muscular wasting, and diminution or loss of voluntary
motor power, while--and this is a point of great importance--the normal
electrical reactions are preserved. There may also develop trophic
changes such as blisters, superficial ulcers, and clubbing of the tips
of the fingers. The prognosis is usually favourable, as recovery is the
rule within from one to three months. If, however, neuritis supervenes,
the electrical reactions are altered, the muscles degenerate, and
recovery may be retarded or may fail to take place.

Injuries which act abruptly or instantaneously are illustrated in the
crushing of a nerve by the sudden displacement of a sharp-edged fragment
of bone, as may occur in comminuted fractures of the humerus. The
symptoms include perversion or loss of sensation, motor paralysis, and
atrophy of muscles, which show the reaction of degeneration from the
eighth day onwards. The presence of the reaction of degeneration
influences both the prognosis and the treatment, for it implies a lesion
which is probably incapable of spontaneous recovery, and which can only
be remedied by operation.

The _treatment_ varies with the cause and nature of the lesion. When,
for example, a displaced bone or a mass of callus is pressing upon the
nerve, steps must be taken to relieve the pressure, by operation if
necessary. When there is reason to believe that the nerve is severely
crushed or torn across, it should be exposed by incision, and, after
removal of the damaged ends, should be united by sutures. When it is
impossible to make a definite diagnosis as to the state of the nerve, it
is better to expose it by operation, and thus learn the exact state of
affairs without delay; in the event of the nerve being torn, the ends
should be united by sutures.

#Dislocation of Nerves.#--This injury, which resembles the dislocation
of tendons from their grooves, is seldom met with except in the ulnar
nerve at the elbow, and is described with injuries of that nerve.


DISEASES OF NERVES

#Traumatic Neuritis.#--This consists in an overgrowth of the
connective-tissue framework of a nerve, which causes irritation and
pressure upon the nerve fibres, sometimes resulting in their
degeneration. It may originate in connection with a wound in the
vicinity of a nerve, as, for example, when the brachial nerves are
involved in scar tissue subsequent to an operation for clearing out the
axilla for cancer; or in contusion and compression of a nerve--for
example, by the pressure of the head of the humerus in a dislocation of
the shoulder. Some weeks or months after the injury, the patient
complains of increasing hyperæsthesia and of neuralgic pains in the
course of the nerve. The nerve is very sensitive to pressure, and, if
superficial, may be felt to be swollen. The associated muscles are
wasted and weak, and are subject to twitchings. There are also trophic
disturbances. It is rare to have complete sensory and motor paralysis.
The disease is commonest in the nerves of the upper extremity, and the
hand may become crippled and useless.

_Treatment._--Any constitutional condition which predisposes to
neuritis, such as gout, diabetes, or syphilis, must receive appropriate
treatment. The symptoms may be relieved by rest and by soothing
applications, such as belladonna, ichthyol, or menthol, by the use of
hot-air and electric baths, and in obstinate cases by blistering or by
the application of Corrigan's button. When such treatment fails the
nerve may be stretched, or, in the case of a purely sensory trunk, a
portion may be excised. Local causes, such as involvement of the nerve
in a scar or in adhesions, may afford indications for operative
treatment.

#Multiple Peripheral Neuritis.#--Although this disease mainly comes
under the cognizance of the physician, it may be attended with phenomena
which call for surgical interference. In this country it is commonly due
to alcoholism, but it may result from diabetes or from chronic poisoning
with lead or arsenic, or from bacterial infections and intoxications
such as occur in diphtheria, gonorrhœa, syphilis, leprosy, typhoid,
influenza, beri-beri, and many other diseases.

It is, as a rule, widely distributed throughout the peripheral nerves,
but the distribution frequently varies with the cause--the alcoholic
form, for example, mainly affecting the legs, the diphtheritic form the
soft palate and pharynx, and that associated with lead poisoning the
forearms. The essential lesion is a degeneration of the conducting
fibres of the affected nerves, and the prominent symptoms are the result
of this. In alcoholic neuritis there is great tenderness of the muscles.
When the legs are affected the patient may be unable to walk, and the
toes may droop and the heel be drawn up, resulting in one variety of pes
equino-varus. Pressure sores and perforating ulcer of the foot are the
most important trophic phenomena.

Apart from the medical _treatment_, measures must be taken to prevent
deformity, especially when the legs are affected. The bedclothes are
supported by a cage, and the foot maintained at right angles to the leg
by sand-bags or splints. When the disease is subsiding, the nutrition of
the damaged nerves and muscles should be maintained by massage, baths,
passive movements, and the use of the galvanic current. When deformity
has been allowed to take place, operative measures may be required for
its correction.


NEUROMA[5]

[5] We have followed the classification adopted by Alexis Thomson in his
work _On Neuroma, and Neuro-fibromatosis_ (Edinburgh: 1900).

Neuroma is a clinical term applied to all tumours, irrespective of their
structure, which have their seat in nerves.

A tumour composed of newly formed nerve tissue is spoken of as a #true
neuroma#; when ganglionic cells are present in addition to nerve fibres,
the name _ganglionic neuroma_ is applied. These tumours are rare, and
are chiefly met with in the main cords or abdominal plexuses of the
sympathetic system of children or young adults. They are quite
insensitive, and their removal is only called for if they cause pain or
show signs of malignancy.

A #false neuroma# is an overgrowth of the sheath of a nerve. This
overgrowth may result in the formation of a circumscribed tumour, or may
take the form of a diffuse fibromatosis.

_The circumscribed or solitary tumour_ grows from the sheath of a nerve
which is otherwise healthy, and it may be innocent or malignant.

_The innocent_ form is usually fibrous or myxomatous, and is definitely
encapsulated. It may become cystic as a result of hæmorrhage or of
myxomatous degeneration. It grows very slowly, is usually elliptical in
shape, and the solid form is rarely larger than a hazel-nut. The nerve
fibres may be spread out all round the tumour, or may run only on one
side of it. When subcutaneous and related to the smaller unnamed
cutaneous nerves, it is known as a _painful subcutaneous nodule_ or
_tubercle_. It is chiefly met with about the ankle, and most often in
women. It is remarkably sensitive, even gentle handling causing intense
pain, which usually radiates to the periphery of the nerve affected.
When related to a deeper, named nerve-trunk, it is known as a
_trunk-neuroma_. It is usually less sensitive than the "subcutaneous
nodule," and rarely gives rise to motor symptoms unless it involves the
nerve roots where they pass through bony canals.

A trunk-neuroma is recognised clinically by its position in the line of
a nerve, by the fact that it is movable in the transverse axis of the
nerve but not in its long axis, and by being unduly painful and
sensitive.

[Illustration: FIG. 85.--Amputation Stump of Upper Arm, showing bulbous
thickening of the ends of the nerves, embedded in scar tissue at the
apex of the stamp.]

_Treatment._--If the tumour causes suffering it should be removed,
preferably by shelling it out from the investing nerve sheath or
capsule. In the subcutaneous nodule the nerve is rarely recognisable,
and is usually sacrificed. When removal of the tumour is incomplete, a
tube of radium should be inserted into the cavity, to prevent recurrence
of the tumour in a malignant form.

_The malignant neuroma_ is a sarcoma growing from the sheath of a nerve.
It has the same characters and clinical features as the innocent
variety, only it grows more rapidly, and by destroying the nerve fibres
causes motor symptoms--jerkings followed by paralysis. The sarcoma tends
to spread along the lymph spaces in the long axis of the nerve, as well
as to implicate the surrounding tissues, and it is liable to give rise
to secondary growths. The malignant neuroma is met with chiefly in the
sciatic and other large nerves of the limbs.

The _treatment_ is conducted on the same lines as sarcoma in other
situations; the insertion of a tube of radium after removal of the
tumour diminishes the tendency to recurrence; a portion of the
nerve-trunk being sacrificed, means must be taken to bridge the gap. In
inoperable cases it may be possible to relieve pain by excising a
portion of the nerve above the tumour, or, when this is impracticable,
by resecting the posterior nerve roots and their ganglia within the
vertebral canal.

The so-called _amputation neuroma_ has already been referred to (p. 344).

_Diffuse or Generalised Neuro-Fibromatosis--Recklinghausen's
Disease._--These terms are now used to include what were formerly known
as "multiple neuromata," as well as certain other overgrowths related to
nerves. The essential lesion is an overgrowth of the endoneural
connective tissue throughout the nerves of both the cerebro-spinal and
sympathetic systems. The nerves are diffusely and unequally thickened,
so that small twigs may become enlarged to the size of the median, while
at irregular intervals along their course the connective-tissue
overgrowth is exaggerated so as to form tumour-like swellings similar to
the trunk-neuroma already described. The tumours, which vary greatly in
size and number--as many as a thousand have been counted in one
case--are enclosed in a capsule derived from the perineurium. The
fibromatosis may also affect the cranial nerves, the ganglia on the
posterior nerve roots, the nerves within the vertebral canal, and the
sympathetic nerves and ganglia, as well as the continuations of the
motor nerves within the muscles. The nerve fibres, although mechanically
displaced and dissociated by the overgrown endoneurium, undergo no
structural change except when compressed in passing through a bony
canal.

The disease probably originates before birth, although it may not make
its appearance till adolescence or even till adult life. It is sometimes
met with in several members of one family. It is recognised clinically
by the presence of multiple tumours in the course of the nerves, and
sometimes by palpable enlargement of the superficial nerve-trunks
(Fig. 86). The tumours resemble the solitary trunk-neuroma, are usually
quite insensitive, and many of them are unknown to the patient. As a
result of injury or other exciting cause, however, one or other tumour
may increase in size and become extremely sensitive; the pain is then
agonising; it is increased by handling, and interferes with sleep. In
these conditions, a malignant transformation of the fibroma into sarcoma
is to be suspected. Motor disturbances are exceptional, unless in the
case of tumours within the vertebral canal, which press on the spinal
medulla and cause paraplegia.

[Illustration: FIG. 86.--Diffuse enlargement of Nerves in generalised
Neuro-fibromatosis.

(After R. W. Smith.)]

Neuro-fibromatosis is frequently accompanied by _pigmentation of the
skin_ in the form of brown spots or patches scattered over the trunk.

The disease is often stationary for long periods. In progressive cases
the patient becomes exhausted, and usually dies of some intercurrent
affection, particularly phthisis. The treatment is restricted to
relieving symptoms and complications; removal of one of the tumours is
to be strongly deprecated.

In a considerable proportion of cases one of the multiple tumours takes
on the characters of a malignant growth ("secondary malignant neuroma,"
Garrè). This malignant transformation may follow upon injury, or on an
unsuccessful attempt to remove the tumour. The features are those of a
rapidly growing sarcoma involving a nerve-trunk, with agonising pain
and muscular cramps, followed by paralysis from destruction of the
nerve fibres. The removal of the tumour is usually followed by
recurrence, so that high amputation is the only treatment to be
recommended. Metastasis to internal organs is exceptional.

[Illustration: FIG. 87.--Plexiform Neuroma of small Sciatic Nerve, from
a girl æt. 16.

(Mr. Annandale's case.)]

There are other types of neuro-fibromatosis which require brief mention.

_The plexiform neuroma_ (Fig. 87) is a fibromatosis confined to the
distribution of one or more contiguous nerves or of a plexus of nerves,
and it may occur either by itself or along with multiple tumours of the
nerve-trunks and with pigmentation of the skin. The clinical features
are those of an ill-defined swelling composed of a number of tortuous,
convoluted cords, lying in a loose areolar tissue and freely movable on
one another. It is rarely the seat of pain or tenderness. It most often
appears in the early years of life, sometimes in relation to a pigmented
or hairy mole. It is of slow growth, may remain stationary for long
periods, and has little or no tendency to become malignant. It is
usually subcutaneous, and is frequently situated on the head or neck in
the distribution of the trigeminal or superficial cervical nerves. There
is no necessity for its removal, but this may be indicated because of
disfigurement, especially on the face or scalp or because its bulk
interferes with function. When involving the ophthalmic division of the
trigeminus, for example, it may cause enlargement of the upper lid and
proptosis, with danger to the function of the globe. The results of
excision are usually satisfactory, even if the removal is not complete.

[Illustration: FIG. 88.--Multiple Neuro-fibromas of Skin (Molluscum
fibrosum, or Recklinghausen's disease).]

_The cutaneous neuro-fibroma_ or _molluscum fibrosum_ has been shown by
Recklinghausen to be a soft fibroma related to the terminal filaments of
one of the cutaneous nerves (Fig. 88). The disease appears in the form
of multiple, soft, projecting tumours, scattered all over the body,
except the palms of the hands and soles of the feet. The tumours are of
all sizes, some being no larger than a pin's head, whilst many are as
big as a filbert and a few even larger. Many are sessile and others are
distinctly pedunculated, but all are covered with skin. They are mobile,
soft to the touch, and of the consistence of firm fat. In exceptional
cases one of the skin tumours may attain an enormous size and cause a
hideous deformity, hanging down by its own weight in lobulated or folded
masses (pachy-dermatocele). The treatment consists in removing the
larger swellings. In some cases molluscum fibrosum is associated with
pigmentation of the skin and with multiple tumours of the nerve-trunks.
The small multiple tumours rarely call for interference.

[Illustration: FIG. 89.--Elephantiasis Neuromatosa in a woman æt. 28]

_Elephantiasis neuromatosa_ is the name applied by Virchow to a
condition in which a limb is swollen and misshapen as a result of the
extension of a neuro-fibromatosis to the skin and subcutaneous cellular
tissue of the extremity as a whole (Fig. 89). It usually begins in early
life without apparent cause, and it may be associated with multiple
tumours of the nerve-trunks. The inconvenience caused by the bulk and
weight of the limb may justify its removal.


SURGERY OF THE INDIVIDUAL NERVES[6]

[6] We desire here to acknowledge our indebtedness to Mr. James
Sherren's work on _Injuries of Nerves and their Treatment_.

#The Brachial Plexus.#--Lesions of the brachial plexus may be divided
into those above the clavicle and those below that bone.

In the #supra-clavicular injuries#, the violence applied to the head or
shoulder causes over-stretching of the anterior branches (primary
divisions) of the cervical nerves, the fifth, or the fifth and sixth
being those most liable to suffer. Sometimes the traction is exerted
upon the plexus from below, as when a man in falling from a height
endeavours to save himself by clutching at some projection, and the
lesion then mainly affects the first dorsal nerve. There is tearing of
the nerve sheaths, with hæmorrhage, but in severe cases partial or
complete severance of nerve fibres may occur and these give way at
different levels. During the healing process an excess of fibrous tissue
is formed, which may interfere with regeneration.

_Post-anæsthetic paralysis_ occurs in patients in whom, during the
course of an operation, the arm is abducted and rotated laterally or
extended above the head, causing over-stretching of the plexus,
especially of the fifth, or fifth and sixth, anterior branches.

A _cervical rib_ may damage the plexus by direct pressure, the part
usually affected being the medial cord, which is made up of fibres from
the eighth cervical and first dorsal nerves.

When a lesion of the plexus complicates a _fracture of the clavicle_,
the nerve injury is due, not to pressure on or laceration of the nerves
by fragments of bone, but to the violence causing the fracture, and this
is usually applied to the point of the shoulder.

Penetrating _wounds_, apart from those met with in military practice,
are rare.

In the #infra-clavicular injuries#, the lesion most often results from
the pressure of the dislocated head of the humerus; occasionally from
attempts made to reduce the dislocation by the heel-in-the-axilla
method, or from fracture of the upper end of the humerus or of the neck
of the scapula. The whole plexus may suffer, but more frequently the
medial cord is alone implicated.

_Clinical Features._--Three types of lesion result from indirect
violence: the whole plexus; the upper-arm type; and the lower-arm type.

_When the whole plexus is involved_, sensibility is lost over the entire
forearm and hand and over the lateral surface of the arm in its distal
two-thirds. All the muscles of the arm, forearm, and hand are paralysed,
and, as a rule, also the pectorals and spinati, but the rhomboids and
serratus anterior escape. There is paralysis of the sympathetic fibres
to the eye and orbit, with narrowing of the palpebral fissure, recession
of the globe, and the pupil is slow to dilate when shaded from the
light.

The _upper-arm type_--Erb-Duchenne paralysis--is that most frequently
met with, and it is due to a lesion of the fifth anterior branch, or, it
may be, also of the sixth. The position of the upper limb is typical:
the arm and forearm hang close to the side, with the forearm extended
and pronated; the deltoid, spinati, biceps, brachialis, and supinators
are paralysed, and in some cases the radial extensors of the wrist and
the pronator teres are also affected. The patient is unable to supinate
the forearm or to abduct the arm, and in most cases to flex the forearm.
He may, however, regain some power of flexing the forearm when it is
fully pronated, the extensors of the wrist becoming feeble flexors of
the elbow. There is, as a rule, no loss of sensibility, but complaint
may be made of tickling and of pins-and-needles over the lateral aspect
of the arm. The abnormal position of the limb may persist although the
muscles regain the power of voluntary movement, and as the condition
frequently follows a fall on the shoulder, great care is necessary in
diagnosis, as the condition is apt to be attributed to an injury to the
axillary (circumflex) nerve.

The _lower-arm type_ of paralysis, associated with the name of Klumpke,
is usually due to over-stretching of the plexus, and especially affects
the anterior branch of the first dorsal nerve. In typical cases all the
intrinsic muscles of the hand are affected, and the hand assumes the
claw shape. Sensibility is usually altered over the medial side of the
arm and forearm, and there is paralysis of the sympathetic.

_Infra-clavicular injuries_, as already stated, are most often produced
by a sub-coracoid dislocation of the humerus; the medial cord is that
most frequently injured, and the muscles paralysed are those supplied by
the ulnar nerve, with, in addition, those intrinsic muscles of the hand
supplied by the median. Sensibility is affected over the medial surface
of the forearm and ulnar area of the hand. Injury of the lateral and
posterior cords is very rare.

_Treatment_ is carried out on the lines already laid down for nerve
injuries in general. It is impossible to diagnose between complete and
incomplete rupture of the nerve cords, until sufficient time has elapsed
to allow of the establishment of the reaction of degeneration. If this
is present at the end of fourteen days, operation should not be delayed.
Access to the cords of the plexus is obtained by a dissection similar to
that employed for the subclavian artery, and the nerves are sought for
as they emerge from under cover of the scalenus anterior, and are then
traced until the seat of injury is found. In the case of the first
dorsal nerve, it may be necessary temporarily to resect the clavicle.
The usual after-treatment must be persisted in until recovery ensues,
and care must be taken that the paralysed muscles do not become
over-stretched. The prognosis is less favourable in the supra-clavicular
lesions than in those below the clavicle, which nearly always recover
without surgical intervention.

In the _brachial birth-paralysis_ met with in infants, the lesion is due
to over-stretching of the plexus, and is nearly always of the
Erb-Duchenne type. The injury is usually unilateral, it occurs with
almost equal frequency in breech and in vertex presentations, and the
left arm is more often affected than the right. The lesion is seldom
recognised at birth. The first symptom noticed is tenderness in the
supra-clavicular region, the child crying when this part is touched or
the arm is moved. The attitude may be that of the Erb-Duchenne type, or
the whole of the muscles of the upper limb may be flaccid, and the arm
hangs powerless. A considerable proportion of the cases recover
spontaneously. The arm is to be kept at rest, with the affected muscles
relaxed, and, as soon as tenderness has disappeared, daily massage and
passive movements are employed. The reaction of degeneration can rarely
be satisfactorily tested before the child is three months old, but if it
is present, an operation should be performed. After operation, the
shoulder should be elevated so that no traction is exerted on the
affected cords.

#The long thoracic nerve# (nerve of Bell), which supplies the serratus
anterior, is rarely injured. In those whose occupation entails carrying
weights upon the shoulder it may be contused, and the resulting
paralysis of the serratus is usually combined with paralysis of the
lower part of the trapezius, the branches from the third and fourth
cervical nerves which supply this muscle also being exposed to pressure
as they pass across the root of the neck. There is complaint of pain
above the clavicle, and winging of the scapula; the patient is unable to
raise the arm in front of the body above the level of the shoulder or to
perform any forward pushing movements; on attempting either of these the
winging of the scapula is at once increased. If the scapula is compared
with that on the sound side, it is seen that, in addition to the lower
angle being more prominent, the spine is more horizontal and the lower
angle nearer the middle line. The majority of these cases recover if the
limb is placed at absolute rest, the elbow supported, and massage and
galvanism persevered with. If the paralysis persists, the sterno-costal
portion of the pectoralis major may be transplanted to the lower angle
of the scapula.

The long thoracic nerve may be cut across while clearing out the axilla
in operating for cancer of the breast. The displacement of the scapula
is not so marked as in the preceding type, and the patient is able to
perform pushing movements below the level of the shoulder. If the
reaction of degeneration develops, an operation may be performed, the
ends of the nerve being sutured, or the distal end grafted into the
posterior cord of the brachial plexus.

#The Axillary (Circumflex) Nerve.#--In the majority of cases in which
paralysis of the deltoid follows upon an injury of the shoulder, it is
due to a lesion of the fifth cervical nerve, as has already been
described in injuries of the brachial plexus. The axillary nerve itself
as it passes round the neck of the humerus is most liable to be injured
from the pressure of a crutch, or of the head of the humerus in
sub-glenoid dislocation, or in fracture of the neck of the scapula or of
the humerus. In miners, who work for long periods lying on the side, the
muscle may be paralysed by direct pressure on the terminal filaments of
the nerve, and the nerve may also be involved as a result of disease in
the sub-deltoid bursa.

The deltoid is wasted, and the acromion unduly prominent. In recent
cases paralysis of the muscle is easily detected. In cases of long
standing it is not so simple, because other muscles, the spinati, the
clavicular fibres of the pectoral and the serratus, take its place and
elevate the arm; there is always loss of sensation on the lateral aspect
of the shoulder. There is rarely any call for operative treatment, as
the paralysis is usually compensated for by other muscles.

When the _supra-scapular nerve_ is contused or stretched in injuries of
the shoulder, the spinati muscles are paralysed and wasted, the spine of
the scapula is unduly prominent, and there is impairment in the power of
abducting the arm and rotating it laterally.

The _musculo-cutaneous nerve_ is very rarely injured; when cut across,
there is paralysis of the coraco-brachialis, biceps, and part of the
brachialis, but no movements are abolished, the forearm being flexed, in
the pronated position, by the brachio-radialis and long radial extensor
of the wrist; in the supinated position, by that portion of the
brachialis supplied by the radial nerve. Supination is feebly performed
by the supinator muscle. Protopathic and epicritic sensibility are lost
over the radial side of the forearm.

#Radial (Musculo-Spiral) Nerve.#--From its anatomical relationships this
trunk is more exposed to injury than any other nerve in the body. It is
frequently compressed against the humerus in sleeping with the arm
resting on the back of a chair, especially in the deep sleep of
alcoholic intoxication (drunkard's palsy). It may be pressed upon by a
crutch in the axilla, by the dislocated head of the humerus, or by
violent compression of the arm, as when an elastic tourniquet is applied
too tightly. The most serious and permanent injuries of this nerve are
associated with fractures of the humerus, especially those from direct
violence attended with comminution of the bone. The nerve may be crushed
or torn by one of the fragments at the time of the injury, or at a later
period may be compressed by callus.

_Clinical Features._--Immediately after the injury it is impossible to
tell whether the nerve is torn across or merely compressed. The patient
may complain of numbness and tingling in the distribution of the
superficial branch of the nerve, but it is a striking fact, that so long
as the nerve is divided below the level at which it gives off the dorsal
cutaneous nerve of the forearm (external cutaneous branch), there is no
loss of sensation. When it is divided above the origin of the dorsal
cutaneous branch, or when the dorsal branch of the musculo-cutaneous
nerve is also divided, there is a loss of sensibility on the dorsum
of the hand.

The motor symptoms predominate, the muscles affected being the extensors
of the wrist and fingers, and the supinators. There is a characteristic
"drop-wrist"; the wrist is flexed and pronated, and the patient is
unable to dorsiflex the wrist or fingers (Fig. 90). If the hand and
proximal phalanges are supported, the second and third phalanges may be
partly extended by the interossei and lumbricals. There is also
considerable impairment of power in the muscles which antagonise those
that are paralysed, so that the grasp of the hand is feeble, and the
patient almost loses the use of it; in some cases this would appear to
be due to the median nerve having been injured at the same time.

[Illustration: FIG. 90.--Drop-wrist following Fracture of Shaft of
Humerus.]

If the lesion is high up, as it is, for example, in crutch paralysis,
the triceps and anconeus may also suffer.

_Treatment._--The slighter forms of injury by compression recover under
massage, douching, and electricity. If there is drop-wrist, the hand and
forearm are placed on a palmar splint, with the hand dorsiflexed to
nearly a right angle, and this position is maintained until voluntary
dorsiflexion at the wrist returns to the normal. Recovery is sometimes
delayed for several months.

In the more severe injuries associated with fracture of the humerus and
attended with the reaction of degeneration, it is necessary to cut down
upon the nerve and free it from the pressure of a fragment of bone or
from callus or adhesions. If the nerve is torn across, the ends must be
sutured, and if this is impossible owing to loss of tissue, the gap may
be bridged by a graft taken from the superficial branch of the radial
nerve, or the ends may be implanted into the median.

Finally, in cases in which the paralysis is permanent and incurable, the
disability may be relieved by operation. A fascial graft can be employed
to act as a ligament permanently extending the wrist; it is attached to
the third and fourth metacarpal bones distally and to the radius or ulna
proximally. The flexor carpi radialis can then be joined up with the
extensor digitorum communis by passing its tendon through an aperture in
the interosseous membrane, or better still, through the pronator
quadratus, as there is less likelihood of the formation of adhesions
when the tendon passes through muscle than through interosseous
membrane. The palmaris longus is anastomosed with the abductor pollicis
longus (extensor ossis metacarpi pollicis), thus securing a fair amount
of abduction of the thumb. The flexor carpi ulnaris may also be
anastomosed with the common extensor of the fingers. The extensors of
the wrist may be shortened, so as to place the hand in the position of
dorsal flexion, and thus improve the attitude and grasp of the hand.

_The superficial branch of the radial_ (radial nerve) _and the deep
branch_ (posterior interosseous), apart from suffering in lesions of the
radial, are liable to be contused or torn is dislocation of the head of
the radius, and in fracture of the neck of the bone. The deep branch may
be divided as it passes through the supinator in operations on old
fractures and dislocations in the region of the elbow. Division of the
superficial branch in the upper two-thirds of the forearm produces no
loss of sensibility; division in the lower third after the nerve has
become associated with branches from the musculo-cutaneous is followed
by a loss of sensibility on the radial side of the hand and thumb. Wounds
on the dorsal surface of the wrist and forearm are often followed by
loss of sensibility over a larger area, because the musculo-cutaneous
nerve is divided as well, and some of the fibres of the lower lateral
cutaneous branch of the radial.

[Illustration: FIG. 91.--To illustrate the Loss of Sensation produced by
Division of the Median Nerve. The area of complete cutaneous
insensibility is shaded black. The parts insensitive to light touch and
to intermediate degrees of temperature are enclosed within the dotted
line.

(After Head and Sherren.)]

#The Median Nerve# is most frequently injured in wounds made by broken
glass in the region of the wrist. It may also be injured in fractures of
the lower end of the humerus, in fractures of both bones of the forearm,
and as a result of pressure by splints. After _division at the elbow_,
there is impairment of mobility which affects the thumb, and to a less
extent the index finger: the terminal phalanx of the thumb cannot be
flexed owing to the paralysis of the flexor pollicis longus, and the
index can only be flexed at its metacarpo-phalangeal joint by the
interosseous muscles attached to it. Pronation of the forearm is feeble,
and is completed by the weight of the hand. After _division at the
wrist_, the abductor-opponens group of muscles and the two lateral
lumbricals only are affected; the abduction of the thumb can be feebly
imitated by the short extensor and the long abductor (ext. ossis
metacarpi pollicis), while opposition may be simulated by contraction of
the long flexor and the short abductor of the thumb; the paralysis of
the two medial lumbricals produces no symptoms that can be recognised.
It is important to remember that when the median nerve is divided at the
wrist, deep touch can be appreciated over the whole of the area
supplied by the nerve; the injury, therefore, is liable to be over
looked. If, however, the tendons are divided as well as the nerve, there
is insensibility to deep touch. The areas of epicritic and of
protopathic insensibility are illustrated in Fig. 91. The division of
the nerve at the elbow, or even at the axilla, does not increase the
extent of the loss of epicritic or protopathic sensibility, but usually
affects deep sensibility.

[Illustration: FIG. 92.--To illustrate Loss of Sensation produced by
complete Division of Ulnar Nerve. Loss of all forms of cutaneous
sensibility is represented by the shaded area. The parts insensitive to
light touch and to intermediate degrees of heat and cold are enclosed
within the dotted line.

(Head and Sherren.)]

#The Ulnar Nerve.#--The most common injury of this nerve is its division
in transverse accidental wounds just above the wrist. In the arm it may
be contused, along with the radial, in crutch paralysis; in the region
of the elbow it may be injured in fractures or dislocations, or it may
be accidentally divided in the operation for excising the elbow-joint.

When it is injured _at or above the elbow_, there is paralysis of the
flexor carpi ulnaris, the ulnar half of the flexor digitorum profundus,
all the interossei, the two medial lumbricals, and the adductors of the
thumb. The hand assumes a characteristic attitude: the index and middle
fingers are extended at the metacarpo-phalangeal joints owing to
paralysis of the interosseous muscles attached to them; the little and
ring fingers are hyper-extended at these joints in consequence of the
paralysis of the lumbricals; all the fingers are flexed at the
inter-phalangeal joints, the flexion being most marked in the little and
ring fingers--claw-hand or _main en griffe_. On flexing the wrist, the
hand is tilted to the radial side, but the paralysis of the flexor carpi
ulnaris is often compensated for by the action of the palmaris longus.
The little and ring fingers can be flexed to a slight degree by the
slips of the flexor sublimis attached to them and supplied by the median
nerve; flexion of the terminal phalanx of the little finger is almost
impossible. Adduction and abduction movements of the fingers are lost.
Adduction of the thumb is carried out, not by the paralysed adductor
pollicis, but the movement may be simulated by the long flexor and
extensor muscles of the thumb. Epicritic sensibility is lost over the
little finger, the ulnar half of the ring finger, and that part of the
palm and dorsum of the hand to the ulnar side of a line drawn
longitudinally through the ring finger and continued upwards.
Protopathic sensibility is lost over an area which varies in different
cases. Deep sensibility is usually lost over an area almost as extensive
as that of protopathic insensibility.

When the nerve is _divided at the wrist_, the adjacent tendons are also
frequently severed. If divided below the point at which its dorsal
branch is given off, the sensory paralysis is much less marked, and the
injury is therefore liable to be overlooked until the wasting of muscles
and typical _main en griffe_ ensue. The loss of sensibility after
division of the nerve before the dorsal branch is given off resembles
that after division at the elbow, except that in uncomplicated cases
deep sensibility is usually retained. If the tendons are divided as
well, however, deep touch is also lost.

Care must be taken in all these injuries to prevent deformity; a splint
must be worn, at least during the night, until the muscles regain their
power of voluntary movement, and then exercises should be instituted.

#Dislocation of the ulnar nerve# at the elbow results from sudden and
violent flexion of the joint, the muscular effort causing stretching or
laceration of the fascia that holds the nerve in its groove; it is
predisposed to if the groove is shallow as a result of imperfect
development of the medial condyle of the humerus, and by cubitus valgus.

The nerve slips forward, and may be felt lying on the medial aspect of
the condyle. It may retain this position, or it may slip backwards and
forwards with the movements of the arm. The symptoms at the time of the
displacement are some disability at the elbow, and pain and tingling
along the nerve, which are exaggerated by movement and by pressure. The
symptoms may subside altogether, or a neuritis may develop, with severe
pain shooting up the nerve.

The dislocated nerve is easily replaced, but is difficult to retain in
position. In recent cases the arm may be placed in the extended position
with a pad over the condyle, care being taken to avoid pressure on the
nerve. Failing relief, it is better to make a bed for the nerve by
dividing the deep fascia behind the medial condyle and to stitch the
edges of the fascia over the nerve. This operation has been successful
in all the recorded cases.

#The Sciatic Nerve.#--When this nerve is compressed, as by sitting on a
fence, there is tingling and powerlessness in the limb as a whole, known
as "sleeping" of the limb, but these phenomena are evanescent. _Injuries
to the great sciatic nerve_ are rare except in war. Partial division is
more common than complete, and it is noteworthy that the fibres destined
for the peroneal nerve are more often and more severely injured than
those for the tibial (internal popliteal). After complete division, all
the muscles of the leg are paralysed; if the section is in the upper
part of the thigh, the hamstrings are also paralysed. The limb is at
first quite powerless, but the patient usually recovers sufficiently to
be able to walk with a little support, and although the hamstrings are
paralysed the knee can be flexed by the sartorius and gracilis. The
chief feature is drop-foot. There is also loss of sensation below the
knee except along the course of the long saphenous nerve on the medial
side of the leg and foot. Sensibility to deep touch is only lost over a
comparatively small area on the dorsum of the foot.

#The Common Peroneal (external popliteal) nerve# is exposed to injury
where it winds round the neck of the fibula, because it is superficial
and lies against the unyielding bone. It may be compressed by a
tourniquet, or it may be bruised or torn in fractures of the upper end
of the bone. It has been divided in accidental wounds,--by a scythe, for
example,--in incising for cellulitis, and in performing subcutaneous
tenotomy of the biceps tendon. Cases have been observed of paralysis of
the nerve as a result of prolonged acute flexion of the knee in certain
occupations.

When the nerve is divided, the most obvious result is "drop-foot"; the
patient is unable to dorsiflex the foot and cannot lift his toes off the
ground, so that in walking he is obliged to jerk the foot forwards and
laterally. The loss of sensibility depends upon whether the nerve is
divided above or below the origin of the large cutaneous branch which
comes off just before it passes round the neck of the fibula. In course
of time the foot becomes inverted and the toes are pointed--pes
equino-varus--and trophic sores are liable to form.

#The Tibial (internal popliteal) nerve# is rarely injured.

#The Cranial nerves# are considered with affections of the head and neck
(Vol. II.).


NEURALGIA

The term neuralgia is applied clinically to any pain which follows the
course of a nerve, and is not referable to any discoverable cause. It
should not be applied to pain which results from pressure on a nerve by
a tumour, a mass of callus, an aneurysm, or by any similar gross lesion.
We shall only consider here those forms of neuralgia which are amenable
to surgical treatment.

#Brachial Neuralgia.#--The pain is definitely located in the
distribution of one of the branches or nerve roots, is often
intermittent, and is usually associated with tingling and disturbance of
tactile sensation. The root of the neck should be examined to exclude
pressure as the cause of the pain by a cervical rib, a tumour, or an
aneurysm. When medical treatment fails, the nerve-trunks may be injected
with saline solution or recourse may be had to operative measures, the
affected cords being exposed and stretched through an incision in the
posterior triangle of the neck. If this fails to give relief, the more
serious operation of resecting the posterior roots of the affected
nerves within the vertebral canal may be considered.

_Neuralgia of the sciatic nerve_--#sciatica#--is the most common form of
neuralgia met with in surgical practice.

It is chiefly met with in adults of gouty or rheumatic tendencies who
suffer from indigestion, constipation, and oxaluria--in fact, the same
type of patients who are liable to lumbago, and the two affections are
frequently associated. In hospital practice it is commonly met with in
coal-miners and others who assume a squatting position at work. The
onset of the pain may follow over-exertion and exposure to cold and wet,
especially in those who do not take regular exercise. Any error of diet
or indulgence in beer or wine may contribute to its development.

The essential symptom is paroxysmal or continuous pain along the course
of the nerve in the buttock, thigh, or leg. It may be comparatively
slight, or it may be so severe as to prevent sleep. It is aggravated by
movement, so that the patient walks lame or is obliged to lie up. It is
aggravated also by any movement which tends to put the nerve on the
stretch, as in bending down to put on the shoes, such movements also
causing tingling down the nerve, and sometimes numbness in the foot.
This may be demonstrated by flexing the thigh on the abdomen, the knee
being kept extended; there is no pain if the same manœuvre is repeated
with the knee flexed. The nerve is sensitive to pressure, the most
tender points being its emergence from the greater sciatic foramen, the
hollow between the trochanter and the ischial tuberosity, and where the
common peroneal nerve winds round the neck of the fibula. The muscles of
the thigh are often wasted and are liable to twitch.

The clinical features vary a good deal in different cases; the affection
is often obstinate, and may last for many weeks or even months.

In the sciatica that results from neuritis and perineuritis, there is
marked tenderness on pressure due to the involvement of the nerve
filaments in the sheath of the nerve, and there may be patches of
cutaneous anæsthesia, loss of tendon reflexes, localised wasting of
muscles, and vaso-motor and trophic changes. The presence of the
reaction of degeneration confirms the diagnosis of neuritis. In
long-standing cases the pain and discomfort may lead to a postural
scoliosis (_ischias-scoliotica_).

_Diagnosis._--Pain referred along the course of the sciatic nerve on one
side, or, as is sometimes the case, on both sides, is a symptom of
tumours of the uterus, the rectum, or the pelvic bones. It may result
also from the pressure of an abscess or an aneurysm either inside the
pelvis or in the buttock, and is sometimes associated with disease of
the spinal medulla, such as tabes. Gluteal fibrositis may be mistaken
for sciatica. It is also necessary to exclude such conditions as disease
in the hip or sacro-iliac joint, especially tuberculous disease and
arthritis deformans, before arriving at a diagnosis of sciatica. A
digital examination of the rectum or vagina is of great value in
excluding intra-pelvic tumours.

_Treatment_ is both general and local. Any constitutional tendency, such
as gout or rheumatism, must be counteracted, and indigestion, oxaluria,
and constipation should receive appropriate treatment. In acute cases
the patient is confined to bed between blankets, the limb is wrapped in
thermogene wool, and the knee is flexed over a pillow; in some cases
relief is experienced from the use of a long splint, or slinging the leg
in a Salter's cradle. A rubber hot-bottle may be applied over the seat
of greatest pain. The bowels should be well opened by castor oil or by
calomel followed by a saline. Salicylate of soda in full doses, or
aspirin, usually proves effectual in relieving pain, but when this is
very intense it may call for injections of heroin or morphin. Potassium
iodide is of benefit in chronic cases.

Relief usually results from bathing, douching, and massage, and from
repeated gentle stretching of the nerve. This may be carried out by
passive movements of the limb--the hip being flexed while the knee is
kept extended; and by active movements--the patient flexing the limb at
the hip, the knee being maintained in the extended position. These
exercises, which may be preceded by massage, are carried out night and
morning, and should be practised systematically by those who are liable
to sciatica.

Benefit has followed the injection into the nerve itself, or into the
tissues surrounding it, of normal saline solution; from 70–100 c.c. are
injected at one time. If the pain recurs, the injection may require to
be repeated on many occasions at different points up and down the nerve.
Needling or acupuncture consists in piercing the nerve at intervals in
the buttock and thigh with long steel needles. Six or eight needles are
inserted and left in position for from fifteen to thirty minutes.

In obstinate and severe cases the nerve may be _forcibly stretched_.
This may be done bloodlessly by placing the patient on his back with the
hip flexed to a right angle, and then gradually extending the knee until
it is in a straight line with the thigh (Billroth). A general anæsthetic
is usually required. A more effectual method is to expose the nerve
through an incision at the fold of the buttock, and forcibly pull upon
it. This operation is most successful when the pain is due to the nerve
being involved in adhesions.

#Trigeminal Neuralgia.#--A severe form of epileptiform neuralgia occurs
in the branches of the fifth nerve, and is one of the most painful
affections to which human flesh is liable. So far as its pathology is
known, it is believed to be due to degenerative changes in the semilunar
(Gasserian) ganglion. It is met with in adults, is almost invariably
unilateral, and develops without apparent cause. The pain, which occurs
in paroxysms, is at first of moderate severity, but gradually becomes
agonising. In the early stages the paroxysms occur at wide intervals,
but later they recur with such frequency as to be almost continuous.
They are usually excited by some trivial cause, such as moving the jaws
in eating or speaking, touching the face as in washing, or exposure to a
draught of cold air. Between the paroxysms the patient is free from
pain, but is in constant terror of its return, and the face wears an
expression of extreme suffering and anxiety. When the paroxysm is
accompanied by twitching of the facial muscles, it is called _spasmodic
tic_.

The skin of the affected area may be glazed and red, or may be pale and
moist with inspissated sweat, the patient not daring to touch or wash
it.

There is excessive tenderness at the points of emergence of the
different branches on the face, and pressure over one or other of these
points may excite a paroxysm. In typical cases the patient is unable to
take any active part in life. The attempt to eat is attended with such
severe pain that he avoids taking food. In some cases the suffering is
so great that the patient only obtains sleep by the use of hypnotics,
and he is often on the verge of suicide.

_Diagnosis._--There is seldom any difficulty in recognising the disease.
It is important, however, to exclude the hysterical form of neuralgia,
which is characterised by its occurrence earlier in life, by the pain
varying in situation, being frequently bilateral, and being more often
constant than paroxysmal.

_Treatment._--Before having recourse to the measures described below, it
is advisable to give a thorough trial to the medical measures used in
the treatment of neuralgia.

_The Injection of Alcohol into the Nerve._--The alcohol acts by
destroying the nerve fibres, and must be brought into direct contact
with them; if the nerve has been properly struck the injection is
followed by complete anæsthesia in the distribution of the nerve. The
relief may last for from six months to three years; if the pain returns,
the injection may be repeated. The strength of the alcohol should be 85
per cent., and the amount injected about 2 c.c.; a general, or
preferably a local, anæsthetic (novocain) should be employed
(Schlösser); the needle is 8 cm. long, and 0.7 mm. in diameter. The
severe pain which the alcohol causes may be lessened, after the needle
has penetrated to the necessary depth, by passing a few cubic
centimetres of a 2 per cent. solution of _novocain-suprarenin_ through
it before the alcohol is injected. The treatment by injection of alcohol
is superior to the resection of branches of the nerve, for though
relapses occur after the treatment with alcohol, renewed freedom from
pain may be obtained by its repetition. The ophthalmic division should
not, however, be treated in this manner, for the alcohol may escape into
the orbit and endanger other nerves in this region. Harris recommends
the injection of alcohol into the semilunar ganglion.

_Operative Treatment._--This consists in the removal of the affected
nerve or nerves, either by resection--_neurectomy_; or by a combination
of resection with twisting or tearing of the nerve from its central
connections--_avulsion_. To prevent the regeneration of the nerve after
these operations, the canal of exit through the bone should be
obliterated; this is best accomplished by a silver screw-nail driven
home by an ordinary screw-driver (Charles H. Mayo).

When the neuralgia involves branches of two or of all three trunks, or
when it has recurred after temporary relief following resection of
individual branches, the _removal of the semilunar ganglion_, along with
the main trunks of the maxillary and mandibular divisions, should be
considered.

The operation is a difficult and serious one, but the results are
satisfactory so far as the cure of the neuralgia is concerned. There is
little or no disability from the unilateral paralysis of the muscles of
mastication; but on account of the insensitiveness of the cornea, the
eye must be protected from irritation, especially during the first month
or two after the operation; this may be done by fixing a large
watch-glass around the edge of the orbit with adhesive plaster.

If the ophthalmic branch is not involved, neither it nor the ganglion
should be interfered with; the maxillary and mandibular divisions should
be divided within the skull, and the foramen rotundum and foramen ovale
obliterated.



CHAPTER XVII

THE SKIN AND SUBCUTANEOUS TISSUE


Structure of skin--_Blisters_--_Callosities_--_Corns_--_Chilblains_
    --_Boils_--_Carbuncle_--_Abscess_--_Veldt sores_--Tuberculosis of
    skin: _Inoculation tubercle_--_Lupus_: _Varieties_--Sporotrichosis
    --Elephantiasis--Sebaceous cysts or wens--Moles--Horns--New growths:
    _Fibroma_; _Papilloma_; _Adenoma_; _Epithelioma_; _Rodent cancer_;
    _Melanotic cancer_; _Sarcoma_--AFFECTIONS OF CICATRICES--_Varieties
    of scars_--_Keloid_--_Tumours_--AFFECTIONS OF NAILS.

#Structure of Skin.#--The skin is composed of a superficial cellular
layer--the epidermis, and the corium or true skin. The _epidermis_ is
differentiated from without inwards into the stratum corneum, the
stratum lucidum, the stratum granulosum, and the rete Malpighii or
germinal layer, from which all the others are developed. The _corium_ or
_true skin_ consists of connective tissue, in which ramify the blood
vessels, lymphatics, and nerves. That part of the corium immediately
adjoining the epidermis is known as the papillary portion, and contains
the terminal loops of the cutaneous blood vessels and the terminations
of the cutaneous nerves. The deeper portion of the true skin is known as
the reticular portion, and is largely composed of adipose tissue.

#Blisters# result from the exudation of serous fluid beneath the horny
layer of the epidermis. The fluid may be clear, as in the blisters of a
recent burn, or blood-stained, as in the blisters commonly accompanying
fractures of the leg. It may become purulent as a result of infection,
and this may be the starting-point of lymphangitis or cellulitis.

The skin should be disinfected and the blisters punctured. When
infected, the separated horny layer must be cut away with scissors to
allow of the necessary purification.

#Callosities# are prominent, indurated masses of the horny layer of the
epidermis, where it has been exposed to prolonged friction and pressure.
They occur on the fingers and hand as a result of certain occupations
and sports, but are most common under the balls of the toes or heel. A
bursa may form beneath a callosity, and if it becomes inflamed may cause
considerable suffering; if suppuration ensues, a sinus may form,
resembling a perforating ulcer of the foot.

The _treatment_ of callosities on the foot consists in removing pressure
by wearing properly fitting boots, and in applying a ring pad around the
callosity; another method is to fit a sock of spongiopilene with a hole
cut out opposite the callosity. After soaking in hot water, the
overgrown horny layer is pared away, and the part painted daily with a
saturated solution of salicylic acid in flexile collodion.

[Illustration: FIG. 93.--Callosities and Corns on the Sole and Plantar
Aspect of the Toes in a woman who was also the subject of flat-foot.]

#Corns.#--A corn is a localised overgrowth of the horny layer of the
epidermis, which grows downwards, pressing upon and displacing the
sensitive papillæ of the corium. Corns are due to the friction and
pressure of ill-fitting boots, and are met with chiefly on the toes and
sole of the foot. A corn is usually hard, dry, and white; but it may be
sodden from moisture, as in "soft corns" between the toes. A bursa may
form beneath a corn, and if inflamed constitutes one form of bunion.
When suppuration takes place in relation to a corn, there is great pain
and disability, and it may prove the starting-point of lymphangitis.

The _treatment_ consists in the wearing of properly fitting boots and
stockings, and, if the symptoms persist, the corn should be removed.
This is done after the manner of chiropodists by digging out the corn
with a suitably shaped knife. A more radical procedure is to excise,
under local anæsthesia, the portion of skin containing the corn and
the underlying bursa. The majority of so-called corn solvents consist of
a solution of salicylic acid in collodion; if this is painted on daily,
the epidermis dies and can then be pared away. The unskilful paring of
corns may determine the occurrence of senile gangrene in those who are
predisposed to it by disease of the arteries.

[Illustration: FIG. 94.--Ulcerated Chilblains on Fingers of a Child.]

#Chilblains.#--Chilblain or _erythema pernio_ is a vascular disturbance
resulting from the alternate action of cold and heat on the distal parts
of the body. Chilblains are met with chiefly on the fingers and toes in
children and anæmic girls. In the mild form there is a sensation of
burning and itching, the part becomes swollen, of a dusky red colour,
and the skin is tense and shiny. In more severe cases the burning and
itching are attended with pain, and the skin becomes of a violet or
wine-red colour. There is a third degree, closely approaching
frost-bite, in which the skin tends to blister and give way, leaving an
indolent raw surface popularly known as a "broken chilblain."

Those liable to chilblains should take open-air exercise, nourishing
food, cod-liver oil, and tonics. Woollen stockings and gloves should be
worn in cold weather, and sudden changes of temperature avoided. The
symptoms may be relieved by ichthyol ointment, glycerin and belladonna,
or a mixture of Venice turpentine, castor oil, and collodion applied on
lint which is wrapped round the toe. Another favourite application is
one of equal parts of tincture of capsicum and compound liniment of
camphor, painted over the area night and morning. Balsam of Peru or
resin ointment spread on gauze should be applied to broken chilblains.
The most effective treatment is Bier's bandage applied for about six
hours twice daily; it can be worn while the patient is following his
occupation; in chronic cases this may be supplemented with hot-air
baths.

#Boils and Carbuncles.#--These result from infection with the
staphylococcus aureus, which enters the orifices of the ducts of the
skin under the influence of friction and pressure, as was demonstrated
by the well-known experiment of Garrè, who produced a crop of pustules
and boils on his own forearm by rubbing in a culture of the
staphylococcus aureus.

A #boil# results when the infection is located in a hair follicle or
sebaceous gland. A hard, painful, conical swelling develops, to which,
so long as the skin retains its normal appearance, the term "blind
boil" is applied. Usually, however, the skin becomes red, and after a
time breaks, giving exit to a drop or two of thick pus. After an
interval of from six to ten days a soft white slough is discharged; this
is known as the "core," and consists of the necrosed hair follicle or
sebaceous gland. After the separation of the core the boil heals
rapidly, leaving a small depressed scar.

Boils are most frequently met with on the back of the neck and the
buttocks, and on other parts where the skin is coarse and thick and is
exposed to friction and pressure. The occurrence of a number or a
succession of boils is due to spread of the infection, the cocci from
the original boil obtaining access to adjacent hair follicles. The
spread of boils may be unwittingly promoted by the use of a domestic
poultice or the wearing of infected underclothing.

While boils are frequently met with in debilitated persons, and
particularly in those suffering from diabetes or Bright's disease, they
also occur in those who enjoy vigorous health. They seldom prove
dangerous to life except in diabetic subjects, but when they occur on
the face there is a risk of lymphatic and of general pyogenic infection.
Boils may be differentiated from syphilitic lesions of the skin by
their acute onset and progress, and by the absence of other evidence of
syphilis; and from the malignant or anthrax pustule by the absence of
the central black eschar and of the circumstances which attend upon
anthrax infection.

_Treatment._--The skin of the affected area should be painted with
iodine, and a Klapp's suction bell applied thrice daily. If pus forms,
the skin is frozen with ethyl-chloride and a small incision made, after
which the application of the suction bell is persevered with. The
further treatment consists in the use of diluted boracic or resin
ointment. In multiple boils on the trunk and limbs, lysol or boracic
baths are of service; the underclothing should be frequently changed,
and that which is discarded must be disinfected. In patients with
recurrence of boils about the neck, re-infection frequently takes place
from the scalp, to which therefore treatment should be directed.

Any impaired condition of health should be corrected; when, there is
sugar or albumen in the urine the conditions on which these depend must
receive appropriate treatment. When there are successive crops of boils,
recourse should be had to vaccines. In refractory cases benefit has
followed the subcutaneous injection of lipoid solution containing tin.

#Carbuncle# may be looked upon as an aggregation of boils, and is
characterised by a densely hard base and a brownish-red discoloration of
the skin. It is usually about the size of a crown-piece, but it may
continue to enlarge until it attains the size of a dinner-plate. The
patient is ill and feverish, and the pain may be so severe as to prevent
sleep. As time goes on several points of suppuration appear, and when
these burst there are formed a number of openings in the skin, giving it
a cribriform appearance; these openings exude pus. The different
openings ultimately fuse and the large adherent greyish-white slough is
exposed. The separation of the slough is a tedious process, and the
patient may become exhausted by pain, discharge, and toxin absorption.
When the slough is finally thrown off, a deep gap is left, which takes a
long time to heal. A large carbuncle is a grave disease, especially in a
weakly person suffering from diabetes or chronic alcoholism; we have on
several occasions seen diabetic coma supervene and the patient die
without recovering consciousness. In the majority of cases the patient
is laid aside for several months. It is most common in male adults over
forty years of age, and is usually situated on the back between the
shoulders. When it occurs on the face or anterior part of the neck it is
especially dangerous, because of the greater risk of dissemination of
the infection.

A carbuncle is to be differentiated from an ulcerated gumma and from
anthrax pustule.

[Illustration: FIG. 95.--Carbuncle of seventeen days' duration in a
woman æt. 57.]

_Treatment._--Pain is relieved by full doses of opium or codein, and
these drugs are specially indicated when sugar is present in the urine.
Vaccines may be given a trial. The diet should be liberal and easily
digested, and strychnin and other stimulants may be of service. Locally
the treatment is carried out on the same lines as for boils.

In some cases it is advisable to excise the carbuncle or to make
incisions across it in different directions, so that the resulting wound
presents a stellate appearance.

#Acute Abscesses of the Skin and Subcutaneous Tissue in Young
Children.#--In young infants, abscesses are not infrequently met with
scattered over the trunk and limbs, and are probably the result of
infection of the sebaceous glands from dirty underclothing. The
abscesses should be opened, and the further spread of infection
prevented by cleansing of the skin and by the use of clean under-linen.
Similar abscesses are met with on the scalp in association with eczema,
impetigo, and pediculosis.

#Veldt Sore.#--This sore usually originates in an abrasion of the
epidermis, such as a sun blister, the bite of an insect, or a scratch. A
pustule forms and bursts, and a brownish-yellow scab forms over it. When
this is removed, an ulcer is left which has little tendency to heal.
These sores are most common about the hands, arms, neck, and feet, and
are most apt to occur in those who have had no opportunities of washing,
and who have lived for a long time on tinned foods.

#Tuberculosis of the Skin.#--Interest attaches chiefly to the primary
forms of tuberculosis of the skin in which the bacilli penetrate from
without--inoculation tubercle and lupus.

#Inoculation Tubercle.#--The appearances vary with the conditions under
which the inoculation takes place. As observed on the fingers of adults,
the affection takes the form of an indolent painless swelling, the
epidermis being red and glazed, or warty, and irregularly fissured.
Sometimes the epidermis gives way, forming an ulcer with flabby
granulations. The infection rarely spreads to the lymphatics, but we
have seen inoculation tubercle of the index-finger followed by a large
cold abscess on the median side of the upper arm and by a huge mass of
breaking down glands in the axilla.

In children who run about barefooted in towns, tubercle may be
inoculated into wounds in the sole or about the toes, and although the
local appearances may not be characteristic, the nature of the infection
is revealed by its tendency to spread up the limb along the lymph
vessels, giving rise to abscesses and fungating ulcers in relation to
the femoral glands.

#Tuberculous Lupus.#--This is an extremely chronic affection of the
skin. It rarely extends to the lymph glands, and of all tuberculous
lesions is the least dangerous to life. The commonest form of
lupus--_lupus vulgaris_--usually commences in childhood or youth, and is
most often met with on the nose or cheek. The early and typical
appearance is that of brownish-yellow or pink nodules in the skin, about
the size of hemp seed. Healing frequently occurs in the centre of the
affected area while the disease continues to extend at the margin.

When there is actual destruction of tissue and ulceration--the so-called
"_lupus excedens_" or "_ulcerans_"--healing is attended with
cicatricial contraction, which may cause unsightly deformity. When the
cheek is affected, the lower eyelid may be drawn down and everted; when
the lips are affected, the mouth may be distorted or seriously
diminished in size. When the nose is attacked, both the skin and mucous
surfaces are usually involved, and the nasal orifices may be narrowed or
even obliterated; sometimes the soft parts, including the cartilages,
are destroyed, leaving only the bones covered by tightly stretched scar
tissue.

The disease progresses slowly, healing in some places and spreading at
others. The patient complains of a burning sensation, but little of
pain, and is chiefly concerned about the disfigurement. Nothing is more
characteristic of lupus than the appearance of fresh nodules in parts
which have already healed. In the course of years large tracts of the
face and neck may become affected. From the lips it may spread to the
gum and palate, giving to the mucous membrane the appearance of a
raised, bright-red, papillary or villous surface. When the disease
affects the gums, the teeth may become loose and fall out.

[Illustration: FIG. 96.--Tuberculous Elephantiasis in a woman æt. 35.]

On parts of the body other than the face, the disease is even more
chronic, and is often attended with a considerable production of dense
fibrous tissue--the so-called _fibroid lupus_. Sometimes there is a
warty thickening of the epidermis--_lupus verrucosus_. In the fingers
and toes it may lead to a progressive destruction of tissue like that
observed in leprosy, and from the resulting loss of portions of the
digits it has been called _lupus mutilans_. In the lower extremity a
remarkable form of the disease is sometimes met with, to which the term
_lupus elephantiasis_ (Fig. 96) has been applied. It commences as an
ordinary lupus of the toes or dorsum of the foot, from which the
tuberculous infection spreads to the lymph vessels, and the limb as a
whole becomes enormously swollen and unshapely.

Finally, a long-standing lupus, especially on the cheek, may become the
seat of epithelioma--_lupus epithelioma_--usually of the exuberant or
cauliflower type, which, like other epitheliomas that originate in scar
tissue, presents little tendency to infect the lymphatics.

The _diagnosis_ of lupus is founded on the chronic progress and long
duration, and the central scarring with peripheral extension of the
disease. On the face it is most liable to be confused with syphilis and
with rodent cancer. The syphilitic lesion belongs to the tertiary
period, and although presenting a superficial resemblance to
tuberculosis, its progress is more rapid, so that within a few months it
may involve an area of skin as wide as would be affected by lupus in as
many years. Further, it readily yields to anti-syphilitic treatment. In
cases of tertiary syphilis in which the nose is destroyed, it will be
noticed that the bones have suffered most, while in lupus the
destruction of tissue involves chiefly the soft parts.

Rodent cancer is liable to be mistaken for lupus, because it affects the
same parts of the face; it is equally chronic, and may partly heal. It
begins later in life, however, the margin of the ulcer is more sharply
defined, and often presents a "rolled" appearance.

_Treatment._--When the disease is confined to a limited area, the most
rapid and certain cure is obtained by _excision_; larger areas are
scraped with the sharp spoon. The _ray treatment_ includes the use of
luminous, Röntgen, or radium rays, and possesses the advantage of being
comparatively painless and of being followed by the least amount of
scarring and deformity.

Encouraging results have also been obtained by the application of carbon
dioxide snow.

#Multiple subcutaneous tuberculous nodules# are met with chiefly in
children. They are indolent and painless, and rarely attract attention
until they break down and form abscesses, which are usually about the
size of a cherry, and when these burst sinuses or ulcers result. If the
overlying skin is still intact, the best treatment is excision. If the
abscess has already infected the skin, each focus should be scraped and
packed.

#Sporotrichosis# is a mycotic infection due to the sporothrix Shenkii.
It presents so many features resembling syphilis and tubercle that it is
frequently mistaken for one or other of these affections. It occurs
chiefly in males between fifteen and forty-five, who are farmers, fruit
and vegetable dealers, or florists. There is usually a history of trauma
of the nature of a scratch or a cut, and after a long incubation period
there develop a series of small, hard, round nodules in the skin and
subcutaneous tissue which, without pain or temperature, soften into
cold abscesses and leave indolent ulcers or sinuses. The infection is
of slow progress and follows the course of the lymphatics. From the
gelatinous pus the organism is cultivated without difficulty, and this
is the essential step in arriving at a diagnosis. The disease yields in
a few weeks to full doses of iodide of potassium.

#Elephantiasis.#--This term is applied to an excessive enlargement of a
part depending upon an overgrowth of the skin and subcutaneous cellular
tissue, and it may result from a number of causes, acting independently
or in combination. The condition is observed chiefly in the extremities
and in the external organs of generation.

_Elephantiasis from Lymphatic or Venous Obstruction._--Of this the
best-known example is _tropical elephantiasis_ (E. arabum), which is
endemic in Samoa, Barbadoes, and other places. It attacks the lower
extremity or the genitals in either sex (Figs. 97, 98). The disease is
usually ushered in with fever, and signs of lymphangitis in the part
affected. After a number of such attacks, the lymph vessels appear to
become obliterated, and the skin and subcutaneous cellular tissue, being
bathed in stagnant lymph--which possibly contains the products of
streptococci--take on an overgrowth, which continues until the part
assumes gigantic proportions. In certain cases the lymph trunks have
been found to be blocked with the parent worms of the filaria Bancrofti.
Cases of elephantiasis of the lower extremity are met with in this
country in which there are no filarial parasites in the lymph vessels,
and these present features closely resembling the tropical variety, and
usually follow upon repeated attacks of lymphangitis or erysipelas.

The part affected is enormously increased in size, and causes
inconvenience from its bulk and weight. In contrast to ordinary dropsy,
there is no pitting on pressure, and the swelling does not disappear on
elevation of the limb. The skin becomes rough and warty, and may hang
down in pendulous folds. Blisters form on the surface and yield an
abundant exudate of clear lymph. From neglect of cleanliness, the skin
becomes the seat of eczema or even of ulceration attended with foul
discharge.

Samson Handley has sought to replace the blocked lymph vessels by
burying in the subcutaneous tissue of the swollen part a number of stout
silk threads--_lymphangioplasty_. By their capillary action they drain
the lymph to a healthy region above, and thus enable it to enter the
circulation. It has been more successful in the face and upper limb than
in the lower extremity. If the tissues are infected with pus organisms,
a course of vaccines should precede the operation.

[Illustration: FIG. 97.--Elephantiasis in a woman æt. 45.]

A similar type of elephantiasis may occur after extirpation of the lymph
glands in the axilla or groin; in the leg in long-standing standing
varix and phlebitis with chronic ulcer; in the arm as a result of
extensive cancerous disease of the lymphatics in the axilla secondarily
to cancer of the breast; and in extensive tuberculous disease of the
lymphatics. The last-named is chiefly observed in the lower limb in
young adult women, and from its following upon lupus of the toes or foot
it has been called _lupus elephantiasis_. The tuberculous infection
spreads slowly up the limb by way of the lymph vessels, and as these are
obliterated the skin and cellular tissues become hypertrophied, and the
surface is studded over with fungating tuberculous masses of a livid
blue colour. As the more severe forms of the disease may prove dangerous
to life by pyogenic complications inducing gangrene of the limb, the
question of amputation may have to be considered.

[Illustration: FIG. 98.--Elephantiasis of Penis and Scrotum in native of
Demerara.

(Mr. Annandale's case.)]

Belonging to this group also is a form of _congenital elephantiasis_
resulting from the circular constriction of a limb _in utero_ by
amniotic bands.

_Elephantiasis occurring apart from lymphatic or venous obstruction_ is
illustrated by _elephantiasis nervorum_, in which there is an overgrowth
of the skin and cellular tissue of an extremity in association with
neuro-fibromatosis of the cutaneous nerves (Fig. 89); and by
_elephantiasis Græcorum_--a form of leprosy in which the skin of the
face becomes the seat of tumour-like masses consisting of leprous
nodules. It is also illustrated by _elephantiasis involving the scrotum_
as a result of prolonged irritation by the urine in cases in which the
penis has been amputated and the urine has infiltrated the scrotal
tissues over a period of years.

#Sebaceous Cysts.#--Atheromatous cysts or wens are formed in relation to
the sebaceous glands and hair follicles. They are commonly met with in
adults, on the scalp (Fig. 99), face, neck, back, and external genitals.
Sometimes they are multiple, and they may be met with in several members
of the same family. They are smooth, rounded, or discoid cysts, varying
in size from a split-pea to a Tangerine orange. In consistence they are
firm and elastic, or fluctuating, and are incorporated with the
overlying skin, but movable on the deeper structures. The orifice of the
partly blocked sebaceous follicle is sometimes visible, and the contents
of the cyst can be squeezed through the opening. The wall of the cyst is
composed of a connective-tissue capsule lined by stratified squamous
epithelium. The contents consist of accumulated epithelial cells, and
are at first dry and pearly white in appearance, but as a result of
fatty degeneration they break down into a greyish-yellow pultaceous and
semi-fluid material having a peculiar stale odour. It is probable that
the decomposition of the contents is the result of the presence of
bacteria, and that from the surgical point of view they should be
regarded as infective. A sebaceous cyst may remain indefinitely without
change, or may slowly increase in size, the skin over it becoming
stretched and closely adherent to the cyst wall as a result of friction
and pressure. The contents may ooze from the orifice of the duct and dry
on the skin surface, leading to the formation of a sebaceous horn
(Fig. 100). As a result of injury the cyst may undergo sudden
enlargement from hæmorrhage into its interior.

Recurrent attacks of inflammation frequently occur, especially in wens
of the face and scalp. Suppuration may ensue and be followed by cure of
the cyst, or an offensive fungating ulcer forms which may be mistaken
for epithelioma. True cancerous transformation is rare.

Wens are to be _diagnosed_ from dermoids, from fatty tumours, and from
cold abscesses. Dermoids usually appear before adult life, and as they
nearly always lie beneath the fascia, the skin is movable over them. A
fatty tumour is movable, and is often lobulated. The confusion with a
cold abscess is most likely to occur in wens of the neck or back, and it
may be impossible without the use of an exploring needle to
differentiate between them.

[Illustration: FIG. 99.--Multiple Sebaceous Cysts or Wens; the larger
ones are of many years' duration.]

_Treatment._--The removal of wens is to be recommended while they are
small and freely movable, as they are then easily shelled out after
incising the overlying skin; sometimes splitting the cyst makes its
removal easier. Local anæsthesia is to be preferred. It is important
that none of the cyst wall be left behind. In large and adherent wens an
ellipse of skin is removed along with the cyst. When inflamed, it may be
impossible to dissect out the cyst, and the wall should be destroyed
with carbolic acid, the resulting wound being treated by the open
method.

#Moles.#--The term mole is applied to a pigmented, and usually hairy,
patch of skin, present at or appearing shortly after birth. The colour
varies from brown to black, according to the amount of melanin pigment
present. The lesion consists in an overgrowth of epidermis which often
presents an alveolar arrangement. Moles vary greatly in size: some are
mere dots, others are as large as the palm of the hand, and occasionally
a mole covers half the face. In addition to being unsightly, they bleed
freely when abraded, are liable to ulcerate from friction and pressure,
and occasionally become the starting-point of melanotic cancer. Rodent
cancer sometimes originates in the slightly pigmented moles met with on
the face. Overgrowths in relation to the cutaneous nerves, especially
the plexiform neuroma, occasionally originate in pigmented moles. Soldau
believes that the pigmentation and overgrowth of the epidermis in moles
are associated with, and probably result from, a fibromatosis of the
cutaneous nerves.

_Treatment._--The quickest way to get rid of a mole is to excise it; if
the edges of the gap cannot be brought together with sutures, recourse
should be had to grafting. In large hairy moles of the face whose size
forbids excision, radium or the X-rays should be employed. Excellent
results have been obtained by refrigeration with solid carbon dioxide.
In children and women with delicate skin, applications of from ten to
thirty seconds suffice. In persons with coarse skin an application of
one minute may be necessary, and it may have to be repeated.

#Horns.#--The _sebaceous_ horn results from the accumulation of the
dried contents of a wen on the surface of the skin: the sebaceous
material after drying up becomes cornified, and as fresh material is
added to the base the horn increases in length (Fig. 100). The _wart_
horn grows from a warty papilloma of the skin. _Cicatrix_ horns are
formed by the heaping up of epidermis in the scars that result from
burns. _Nail_ horns are overgrown nails (keratomata of the nail bed),
and are met with chiefly in the great toe of elderly bedridden patients.
If an ulcer forms at the base of a horn, it may prove the starting-point
of epithelioma, and for this reason, as well as for others, horns should
be removed.

[Illustration: FIG. 100.--Sebaceous Horn growing from Auricle.

(Dr. Kenneth Maclachan's case.)]

#New Growths in the Skin and Subcutaneous Tissue.#--The _Angioma_ has
been described with diseases of blood vessels. _Fibroma._--Various types
of fibroma occur in the skin. A soft pedunculated fibroma, about the
size of a pea, is commonly met with, especially on the neck and trunk;
it is usually solitary, and is easily removed with scissors. The
multiple, soft fibroma known as _molluscum fibrosum_, which depends upon
a neuro-fibromatosis of the cutaneous nerves, is described with the
tumours of nerves. Hard fibromas occurring singly or in groups may be
met with, especially in the skin of the buttock, and may present a local
malignancy, recurring after removal like the "recurrent fibroid" of
Paget. The "painful subcutaneous nodule" is a solitary fibroma related
to one of the cutaneous nerves. The hard fibroma known as _keloid_ is
described with the affections of scars.

#Papilloma.#--The _common wart_ or verruca is an outgrowth of the
surface epidermis. It may be sessile or pedunculated hard or soft. The
surface may be smooth, or fissured and foliated like a cauliflower, or
it may be divided up into a number of spines. Warts are met with chiefly
on the hands, and are often multiple, occurring in clusters or in
successive crops. Multiple warts appear to result from some contagion,
the nature of which is unknown; they sometimes occur in an epidemic form
among school-children, and show a remarkable tendency to disappear
spontaneously. The solitary flat-topped wart which occurs on the face
of old people may, if irritated, become the seat of epithelioma. A warty
growth of the epidermis is a frequent accompaniment of moles and of that
variety of lupus known as _lupus verrucosus_.

_Treatment._--In the multiple warts of children the health should be
braced up by a change to the seaside. A dusting-powder, consisting of
boracic acid with 5 per cent. salicylic acid, may be rubbed into the
hands after washing and drying. The persistent warts of young adults
should be excised after freezing with chloride of ethyl. When cutting is
objected to, they may be painted night and morning with salicylic
collodion, the epidermis being dehydrated with alcohol before each
application.

_Venereal warts_ occur on the genitals of either sex, and may form large
cauliflower-like masses on the inner surface of the prepuce or of the
labia majora. Although frequently co-existing with gonorrhœa or
syphilis, they occur independently of these diseases, being probably
acquired by contact with another individual suffering from warts
(C. W. Cathcart). They give rise to considerable irritation and
suffering, and when cleanliness is neglected there may be an offensive
discharge.

In the female, the cauliflower-like masses are dissected from the labia;
in the male, the prepuce is removed and the warts on the glans are
snipped off with scissors. In milder cases, the warts usually disappear
if the parts are kept absolutely dry and clean. A useful dusting-powder
is one consisting of calamine and 5 per cent. salicylic acid; the
exsiccated sulphate of iron, in the form of a powder, may be employed in
cases which resist this treatment.

#Adenoma.#--This is a comparatively rare tumour growing from the glands
of the skin. One variety, known as the "tomato tumour," which apparently
originates from _the sweat glands_, is met with on the scalp and face in
women past middle life. These growths are often multiple; the individual
tumours vary in size, and the skin, which is almost devoid of hairs, is
glistening and tightly stretched over them. A similar tumour may occur
on the nose. The _sebaceous adenoma_, which originates from the
sebaceous glands, forms a projecting tumour on the face or scalp, and
when the skin is irritated it may ulcerate and fungate. The treatment
consists in the removal of the tumour along with the overlying skin.

The exuberant masses on the nose known as "rhinophyma," "lipoma nasi,"
or "potato nose" are of the nature of sebaceous adenoma, and are removed
by shaving them off with a knife until the normal shape of the nose is
restored Healing takes place with remarkable rapidity.

#Cancer.#--There are several types of primary cancer of the skin, the
most important being squamous epithelioma, rodent cancer, and melanotic
cancer.

[Illustration: FIG. 101.--Paraffin Epithelioma.]

#Epithelioma# occurs in a variety of forms. When originating in a small
ulcer or wart-for example on the face in old people--it presents the
features of a chronic indurated ulcer. A more exuberant and rapidly
growing form of epithelial cancer, described by Hutchinson as the
_crateriform ulcer_, commences on the face as a small red pimple which
rapidly develops into an elevated mass shaped like a bee-hive, and
breaks down in the centre. Epithelioma may develop anywhere on the body
in relation to long-standing ulcers, especially that resulting from a
burn or from lupus; this form usually presents an exuberant outgrowth of
epidermis not unlike a cauliflower. An interesting example of
epithelioma has been described by Neve of Kashmir. The natives in that
province are in the habit of carrying a fire-basket suspended from the
waist, which often burns the skin and causes a chronic ulcer, and many
of these ulcers become the seat of epithelioma, due, in Neve's opinion,
to the actual contact of the sooty pan with the skin.

The term _trade epithelioma_ has been applied to that form met with in
those who follow certain occupations, such as paraffin workers and
chimney-sweeps. The most recent member of this group is the _X-ray
carcinoma_, which is met with in those who are constantly exposed to the
irritation of the X-rays; there is first a chronic dermatitis with warty
overgrowth of the surface epithelium, pigmentation, and the formation of
fissures and warts. The trade epithelioma varies a good deal in
malignancy, but it tends to cause death in the same manner as other
epitheliomas.

Epithelial cancer has also been observed in those who have taken arsenic
over long periods for medicinal purposes.

[Illustration: FIG. 102.--Rodent Cancer of Inner Canthus.]

#Rodent Cancer# (Rodent Ulcer).--This is a cancer originating in the
sweat glands or sebaceous follicles, or in the fœtal residues of
cutaneous glands. The cells are small and closely packed together in
alveoli or in reticulated columns; cell nests are rare. It is remarkably
constant in its seat of origin, being nearly always located on the
lateral aspect of the nose or in the vicinity of the lower eyelid
(Fig. 102). It is rare on the trunk or limbs. It commences as a small
flattened nodule in the skin, the epidermis over it being stretched and
shining. The centre becomes depressed, while the margins extend in the
form of an elevated ridge. Sooner or later the epidermis gives way in
the centre, exposing a smooth raw surface devoid of granulations.

[Illustration: FIG. 103.--Rodent Cancer of fifteen years' duration,
which has destroyed the contents of the Orbit.

(Sir Montagu Cotterill's case)]

The margin, while in parts irregular, is typically represented by a
well-defined "rolled" border which consists of the peripheral portion of
the cancer that has not broken down. The central ulcer may temporarily
heal. There is itching but little pain, and the condition progresses
extremely slowly; rodent cancers which have existed for many years are
frequently met with. The disease attacks and destroys every structure
with which it comes in contact, such as the eyelids, the walls of the
nasal cavities, and the bones of the face; hence it may produce the most
hideous deformities (Fig. 103). The patient may succumb to hæmorrhage or
to infective complications such as erysipelas or meningitis.

Secondary growths in the lymph glands, while not unknown, are extremely
rare. We have only seen them once--in a case of rodent cancer in the
groin.

_Diagnosis._--Lupus is the disease most often mistaken for rodent
cancer. Lupus usually begins earlier in life, it presents apple-jelly
nodules, and lacks the rounded, elevated border. Syphilitic lesions
progress more rapidly, and also lack the characteristic margin. The
differentiation from squamous epithelioma is of considerable importance,
as the latter affection spreads more rapidly, involves the lymph glands
early, and is much more dangerous to life.

_Treatment._--In rodent cancers of limited size--say less than one inch
in diameter--free excision is the most rapid and certain method of
treatment. The alternative is the application of radium or of the
Röntgen rays, which, although requiring many exposures, results in cure
with the minimum of disfigurement. If the cancer already covers an
extensive area, or has invaded the cavity of the orbit or nose, radium
or X-rays yield the best results. The effect is soon shown by the
ingrowth of healthy epithelium from the surrounding skin, and at the
same time the discharge is lessened. Good results are also reported from
the application of carbon dioxide snow, especially when this follows
upon a course of X-ray treatment.

#Paget's disease# of the nipple is an epithelioma occurring in women
over forty years of age: a similar form of epithelioma is sometimes met
with at the umbilicus or on the genitals.

#Melanotic Cancer.#--Under this head are included all new growths which
contain an excess of melanin pigment. Many of these were formerly
described as melanotic sarcoma. They nearly always originate in a
pigmented mole which has been subjected to irritation. The primary
growth may remain so small that its presence is not even suspected, or
it may increase in size, ulcerate, and fungate. The amount of pigment
varies: when small in amount the growth is brown, when abundant it is a
deep black. The most remarkable feature is the rapidity with which the
disease becomes disseminated along the lymphatics, the first evidence of
which is an enlargement of the lymph glands. As the primary growth is
often situated on the sole of the foot or in the matrix of the nail of
the great toe, the femoral and inguinal glands become enlarged in
succession, forming tumours much larger than the primary growth.
Sometimes the dissemination involves the lymph vessels of the limb,
forming a series of indurated pigmented cords and nodules (Fig. 104).
Lastly, the dissemination may be universal throughout the body, and this
usually occurs at a comparatively early stage. The secondary growths are
deeply pigmented, being usually of a coal-black colour, and melanin
pigment may be present in the urine. When recurrence takes place in or
near the scar left by the operation, the cancer nodules are not
necessarily pigmented.

[Illustration: FIG. 104.--Diffuse Melanotic Cancer of Lymphatics of Skin
secondary to a Growth in the Sole of the Foot.]

To extirpate the disease it is necessary to excise the tumour, with a
zone of healthy skin around it and a somewhat large zone of the
underlying subcutaneous tissue and deep fascia. Hogarth Pringle
recommends that a broad strip of subcutaneous fascia up to and including
the nearest anatomical group of glands should be removed with the tumour
in one continuous piece.

#Secondary Cancer of the Skin.#--Cancer may spread to the skin from a
subjacent growth by direct continuity or by way of the lymphatics. Both
of these processes are so well illustrated in cases of mammary cancer
that they will be described in relation to that disease.

#Sarcoma# of various types is met with in the skin. The fibroma, after
excision, may recur as a fibro-sarcoma. The alveolar sarcoma commences
as a hard lump and increases in size until the epidermis gives way and
an ulcer is formed.

[Illustration: FIG. 105.--Melanotic Cancer of Forehead with Metastases
in Lymph Vessels and Glands.

(Mr. D. P. D. Wilkie's case.)]

A number of fresh tumours may spring up around the original growth.
Sometimes the primary growth appears in the form of multiple nodules
which tend to become confluent. Excision, unless performed early, is of
little avail, and in any case should be followed up by exposure to
radium.


AFFECTIONS OF CICATRICES

A cicatrix or scar consists of closely packed bundles of white fibres
covered by epidermis; the skin glands and hair follicles are usually
absent. The size, shape, and level of the cicatrix depend upon the
conditions which preceded healing.

A healthy scar, when recently formed, has a smooth, glossy surface of a
pinkish colour, which tends to become whiter as a result of obliteration
of the blood vessels concerned in its formation.

_Weak Scars._--A scar is said to be weak when it readily breaks down as
a result of irritation or pressure. The scars resulting from severe
burns and those over amputation stumps are especially liable to break
down from trivial causes. The treatment is to excise the weak portion of
the scar and bring the edges of the gap together.

_Contracted scars_ frequently cause deformity either by displacing
parts, such as the eyelid or lip, or by fixing parts and preventing the
normal movements--for example, a scar on the flexor aspect of a joint
may prevent extension of the forearm (Fig. 63). These are treated by
dividing the scar, correcting the deformity, and filling up the gap with
epithelial grafts, or with a flap of the whole thickness of the skin.
When deformity results from _depression of a scar_, as is not uncommon
after the healing of a sinus, the treatment is to excise the scar.
Depressed scars may be raised by the injection of paraffin into the
subcutaneous tissue.

_Painful Scars._--Pain in relation to a scar is usually due to nerve
fibres being compressed or stretched in the cicatricial tissue; and in
some cases to ascending neuritis. The treatment consists in excising the
scar or in stretching or excising a portion of the nerve affected.

_Pigmented or Discoloured Scars._--The best-known examples are the blue
coloration which results from coal-dust or gunpowder, the brown scars
resulting from chronic ulcer with venous congestion of the leg, and the
variously coloured scars caused by tattooing. The only satisfactory
method of getting rid of the coloration is to excise the scar; the edges
are brought together by sutures, or the raw surface is covered with
skin-grafts according to the size of the gap.

_Hypertrophied Scars._--Scars occasionally broaden out and become
prominent, and on exposed parts this may prove a source of
disappointment after operations such as those for goitre or tuberculous
glands in the neck. There is sometimes considerable improvement from
exposure to the X-rays.

_Keloid._--This term is applied to an overgrowth of scar tissue which
extends beyond the area of the original wound, and the name is derived
from the fact that this extension occurs in the form of radiating
processes, suggesting the claws of a crab. It is essentially a fibroma
or new growth of fibrous tissue, which commences in relation to the
walls of the smaller blood vessels; the bundles of fibrous tissue are
for the most part parallel with the surface, and the epidermis is
tightly stretched over them. It is more frequent in the negro and in
those who are, or have been, the subjects of tuberculous disease.

[Illustration: FIG. 106.--Recurrent Keloid in scar left by operation for
tuberculous glands in a girl æt. 7.]

Keloid may attack scars of any kind, such as those resulting from
leech-bites, acne pustules, boils or blisters; those resulting from
operation or accidental wounds; and the scars resulting from burns,
especially when situated over the sternum, appear to be specially
liable. The scar becomes more and more conspicuous, is elevated above
the surface, of a pinkish or brownish-pink pink colour, and sends out
irregular prolongations around its margins. The patient may complain of
itching and burning, and of great sensitiveness of the scar, even to
contact with the clothing.

There is a natural hesitation to excise keloid because of the fear of
its returning in the new scar. The application of radium is, so far as
we know, the only means of preventing such return. The irritation
associated with keloid may be relieved by the application of salicylic
collodion or of salicylic and creosote plaster.

_Epithelioma_ is liable to attack scars in old people, especially those
which result from burns sustained early in childhood and have never
really healed. From the absence of lymphatics in scar tissue, the
disease does not spread to the glands until it has invaded the tissues
outside the scar; the prognosis is therefore better than in epithelioma
in general. It should be excised widely; in the lower extremity when
there is also extensive destruction of tissue from an antecedent chronic
ulcer or osteomyelitis, it may be better to amputate the limb.


AFFECTION OF THE NAILS

_Injuries._--When a nail is contused or crushed, blood is extravasated
beneath it, and the nail is usually shed, a new one growing in its
place. A splinter driven underneath the nail causes great pain, and if
organisms are carried in along with it, may give rise to infective
complications. The free edge of the nail should be clipped away to allow
of the removal of the foreign body and the necessary disinfection.

_Trophic Changes._--The growth of the nails may be interfered with in
any disturbance of the general health. In nerve lesions, such as a
divided nerve-trunk, the nails are apt to suffer, becoming curved,
brittle, or furrowed, or they may be shed.

_Onychia_ is the term applied to an infection of the soft parts around
the nail or of the matrix beneath it. The commonest form of onychia has
already been referred to with whitlow. There is a superficial variety
resulting from the extension of a purulent blister beneath the nail
lifting it up from its bed, the pus being visible through the nail. The
nail as well as the raised horny layer of the epidermis should be
removed. A deeper and more troublesome onychia results from infection at
the nail-fold; the infection spreads slowly beneath the fold until it
reaches the matrix, and a drop or two of pus forms beneath the nail,
usually in the region of the lunule. This affection entails a
disability of the finger which may last for weeks unless it is properly
treated. Treatment by hyperæmia, using a suction bell, should first be
tried, and, failing improvement, the nail-fold and lunule should be
frozen, and a considerable portion removed with the knife; if only a
small portion of the nail is removed, the opening is blocked by
granulations springing from the matrix. A new nail is formed, but it is
liable to be misshapen.

_Tuberculous onychia_ is met with in children and adolescents. It
appears as a livid or red swelling at the root of the nail and spreading
around its margins. The epidermis, which is thin and shiny, gives way,
and the nail is usually shed.

[Illustration: FIG. 107.--Subungual Exostosis growing from Distal
Phalanx of Great Toe, showing Ulceration of Skin and Displacement of
Nail.

_a._ Surface view.   _b._ On section.]

_Syphilitic_ affections of the nails assume various aspects. A primary
chancre at the edge of the nail may be mistaken for a whitlow,
especially if it is attended with much pain. Other forms of onychia
occur during secondary syphilis simultaneously with the skin eruptions,
and may prove obstinate and lead to shedding of the nails. They also
occur in inherited syphilis. In addition to general treatment, an
ointment containing 5 per cent. of oleate of mercury should be applied
locally.

_Ingrowing Toe-nail._--This is more accurately described as an
overgrowth of the soft tissues along the edge of the nail. It is most
frequently met with in the great toe in young adults with flat-foot
whose feet perspire freely, who wear ill-fitting shoes, and who cut
their toe-nails carelessly or tear them with their fingers. Where the
soft tissues are pressed against the edge of the nail, the skin gives
way and there is the formation of exuberant granulations and of
discharge which is sometimes fœtid. The affection is a painful one and
may unfit the patient for work. In mild cases the condition may be
remedied by getting rid of contributing causes and by disinfecting the
skin and nail; the nail is cut evenly, and the groove between it and the
skin packed with an antiseptic dusting-powder, such as boracic acid. In
more severe cases it may be necessary to remove an ellipse of tissue
consisting of the edge of the nail, together with the subjacent matrix
and the redundant nail-fold.

_Subungual exostosis_ is an osteoma growing from the terminal phalanx of
the great toe (Fig. 107). It raises the nail and may be accompanied by
ulceration of the skin over the most prominent part of the growth. The
soft parts, including the nail, should be reflected towards the dorsum
in the form of a flap, the base of the exostosis divided with the
chisel, and the exostosis removed.

_Malignant disease_ in relation to the nails is rare. Squamous
epithelioma and melanotic cancer are the forms met with. Treatment
consists in amputating the digit concerned, and in removing the
associated lymph glands.



CHAPTER XVIII

THE MUSCLES, TENDONS, AND TENDON SHEATHS


INJURIES: _Contusion_; _Sprain_; _Rupture_--Hernia of
    muscle--Dislocation of tendons--Wounds--Avulsion of tendon.
    DISEASES OF MUSCLE AND OF TENDONS: _Atrophy_; _"Muscular
    rheumatism"_--_Fibrositis_; _Contracture_; _Myositis_;
    _Calcification and Ossification_; _Tumours_. DISEASES OF TENDON
    SHEATHS: _Teno-synovitis_.


INJURIES

#Contusion of Muscle.#--Contusion of muscle, which consists in bruising
of its fibres and blood vessels, may be due to violence acting from
without, as in a blow, a kick, or a fall; or from within, as by the
displacement of bone in a fracture or dislocation.

The symptoms are those common to all contusions, and the patient
complains of severe pain on attempting to use the muscle, and maintains
an attitude which relaxes it. If the sheath of the muscle also is torn,
there is subcutaneous ecchymosis, and the accumulation of blood may
result in the formation of a hæmatoma.

Restoration of function is usually complete; but when the nerve
supplying the muscle is bruised at the same time, as may occur in the
deltoid, wasting and loss of function may be persistent. In exceptional
cases the process of repair may be attended with the formation of bone
in the substance of the muscle, and this may likewise impair its
function.

A contused muscle should be placed at rest and supported by cotton wool
and a bandage; after an interval, massage and appropriate exercises are
employed.

#Sprain and Partial Rupture of Muscle.#--This lesion consists in
overstretching and partial rupture of the fibres of a muscle or its
aponeurosis. It is of common occurrence in athletes and in those who
follow laborious occupations. It may follow upon a single or repeated
effort--especially in those who are out of training. Familiar examples
of muscular sprain are the "labourer's" or "golfer's back," affecting
the latissimus dorsi or the sacrospinalis (erector spinæ); the
"tennis-player's elbow," and the "sculler's sprain," affecting the
muscles and ligaments about the elbow; the "angler's elbow," affecting
the common origin of the extensors and supinators; the "sprinter's
sprain," affecting the flexors of the hip; and the "jumper's and
dancer's sprain," affecting the muscles of the calf. The patient
complains of pain, often sudden in onset, of tenderness on pressure, and
of inability to carry out the particular movement by which the sprain
was produced. The disability varies in different cases, and it may
incapacitate the patient from following his occupation or sport for
weeks or, if imperfectly treated, even for months.

The _treatment_ consists in resting the muscle from the particular
effort concerned in the production of the sprain, in gently exercising
it in other directions, in the use of massage, and the induction of
hyperæmia by means of heat. In neglected cases, that is, where the
muscle has not been exercised, the patient shrinks from using it and the
disablement threatens to be permanent; it is sometimes said that
adhesions have formed and that these interfere with the recovery of
function. The condition may be overcome by graduated movements or by a
sudden forcible movement under an anæsthetic. These cases afford a
fruitful field for the bone-setter.

#Rupture of Muscle or Tendon.#--A muscle or a tendon may be ruptured in
its continuity or torn from its attachment to bone. The site of rupture
in individual muscles is remarkably constant, and is usually at the
junction of the muscular and tendinous portions. When rupture takes
place through the belly of a muscle, the ends retract, the amount of
retraction depending on the length of the muscle, and the extent of its
attachment to adjacent aponeurosis or bone. The biceps in the arm, and
the sartorius in the thigh, furnish examples of muscles in which the
separation between the ends may be considerable.

The gap in the muscle becomes filled with blood, and this in time is
replaced by connective tissue, which forms a bond of union between the
ends. When the space is considerable the connecting medium consists of
fibrous tissue, but when the ends are in contact it contains a number of
newly formed muscle fibres. In the process of repair, one or both ends
of the muscle or tendon may become fixed by adhesions to adjacent
structures, and if the distal portion of a muscle is deprived of its
nerve supply it may undergo degeneration and so have its function
impaired.

Rupture of a muscle or tendon is usually the result of a sudden, and
often involuntary, movement. As examples may be cited the rupture of
the quadriceps extensor in attempting to regain the balance when falling
backwards; of the gastrocnemius, plantaris, or tendo-calcaneus in
jumping or dancing; of the adductors of the thigh in gripping a horse
when it swerves--"rider's sprain"; of the abdominal muscles in vomiting,
and of the biceps in sudden movements of the arm. Sometimes the effort
is one that would scarcely be thought likely to rupture a muscle, as in
the case recorded by Pagenstecher, where a professional athlete, while
sitting at table, ruptured his biceps in a sudden effort to catch a
falling glass. It would appear that the rupture is brought about not so
much by the contraction of the muscle concerned, as by the contraction
of the antagonistic muscles taking place before that of the muscle which
undergoes rupture is completed. The violent muscular contractions of
epilepsy, tetanus, or delirium rarely cause rupture.

The _clinical features_ are usually characteristic. The patient
experiences a sudden pain, with the sensation of being struck with a
whip, and of something giving way; sometimes a distant snap is heard.
The limb becomes powerless. At the seat of rupture there is tenderness
and swelling, and there may be ecchymosis. As the swelling subsides, a
gap may be felt between the retracted ends, and this becomes wider when
the muscle is thrown into contraction. If untreated, a hard, fibrous
cord remains at the seat of rupture.

_Treatment._--The ends are approximated by placing the limb in an
attitude which relaxes the muscle, and the position is maintained by
bandages, splints, or special apparatus. When it is impossible thus to
approximate the ends satisfactorily, the muscle or tendon is exposed by
incision, and the ends brought into accurate contact by catgut sutures.
This operation of primary suture yields the most satisfactory results,
and is most successful when it is done within five or six days of the
accident. Secondary suture after an interval of months is rendered
difficult by the retraction of the ends and by their adhesion to
adjacent structures.

_Rupture of the biceps of the arm_ may involve the long or the short
head, or the belly of the muscle. Most interest attaches to rupture of
the long tendon of origin. There is pain and tenderness in front of the
upper end of the humerus, the patient is unable to abduct or to elevate
the arm, and he may be unable to flex the elbow when the forearm is
supinated. The long axis of the muscle, instead of being parallel with
the humerus, inclines downwards and outwards. When the patient is asked
to contract the muscle, its belly is seen to be drawn towards the
elbow.

The _adductor longus_ may be ruptured, or torn from the pubes, by a
violent effort to adduct the limb. A swelling forms in the upper and
medial part of the thigh, which becomes smaller and harder when the
muscle is thrown into contraction.

The _quadriceps femoris_ is usually ruptured close to its insertion into
the patella, in the attempt to avoid falling backwards. The injury is
sometimes bilateral. The injured limb is rendered useless for
progression, as it suddenly gives way whenever the knee is flexed.
Treatment is conducted on the same lines as in transverse fracture of
the patella; in the majority of cases the continuity of the quadriceps
should be re-established by suture within five or six days of the
accident.

The _tendo calcaneus_ (Achillis) is comparatively easily ruptured, and
the symptoms are sometimes so slight that the nature of the injury may
be overlooked. The limb should be put up with the knee flexed and the
toes pointed. This may be effected by attaching one end of an elastic
band to the heel of a slipper, and securing the other to the lower third
of the thigh. If this is not sufficient to bring the ends into
apposition they should be approximated by an open operation.

The _plantaris_ is not infrequently ruptured from trivial causes, such
as a sudden movement in boxing, tennis, or hockey. A sharp stinging pain
like the stroke of a whip is felt in the calf; there is marked
tenderness at the seat of rupture, and the patient is unable to raise
the heel without pain. The injury is of little importance, and if the
patient does not raise the heel from the ground in walking, it is
recovered from in a couple of weeks or so, without it being necessary to
lay him up.

#Hernia of Muscle.#--This is a rare condition, in which, owing to the
fascia covering a muscle becoming stretched or torn, the muscular
substance is protruded through the rent. It has been observed chiefly in
the adductor longus. An oval swelling forms in the upper part of the
thigh, is soft and prominent when the muscle is relaxed, less prominent
when it is passively extended, and disappears when the muscle is thrown
into contraction. It is liable to be mistaken, according to its
situation, for a tumour, a cyst, a pouched vein, or a femoral or
obturator hernia. Treatment is only called for when it is causing
inconvenience, the muscle being exposed by a suitable incision, the
herniated portion excised, and the rent in the sheath closed by sutures.

#Dislocation of Tendons.#--Tendons which run in grooves may be displaced
as a result of rupture of the confining sheath. This injury is met with
chiefly in the tendons at the ankle and in the long tendon of the
biceps.

Dislocation of the _peronei tendons_ may occur, for example, from a
violent twist of the foot. There is severe pain and considerable
swelling on the lateral aspect of the ankle; the peroneus longus by
itself, or together with the brevis, can be felt on the lateral aspect
or in front of the lateral malleolus; the patient is unable to move the
foot. By a little manipulation the tendons are replaced in their
grooves, and are retained there by a series of strips of plaster. At the
end of three weeks massage and exercises are employed.

In other cases there is no history of injury, but whenever the foot is
everted the tendon of the peroneus longus is liable to be jerked
forwards out of its groove, sometimes with an audible snap. The patient
suffers pain and is disabled until the tendon is replaced. Reduction is
easy, but as the displacement tends to recur, an operation is required
to fix the tendon in its place. An incision is made over the tendon; if
the sheath is slack or torn, it is tightened up or closed with catgut
sutures; or an artificial sheath is made by raising up a quadrilateral
flap of periosteum from the lateral aspect of the fibula, and stitching
it over the tendon.

Similarly the _tibialis posterior_ may be displaced over the medial
malleolus as a result of inversion of the foot.

The _long tendon of the biceps_ may be dislocated laterally--or more
frequently medially--as a result of violent or repeated rotation
movements of the arm, such as are performed in wringing clothes. The
patient is aware of the displacement taking place, and is unable to
extend the forearm until the displaced tendon has been reduced by
abducting the arm. In recurrent cases the patient may be able to
dislocate the tendon at will, but the disability is so inconsiderable
that there is rarely any occasion for interference.

#Wounds of Muscles and Tendons.#--When a muscle is cut across in a
wound, its ends should be brought together with sutures. If the ends are
allowed to retract, and especially if the wound suppurates, they become
united by scar tissue and fixed to bone or other adjacent structure. In
a limb this interferes with the functions of the muscle; in the
abdominal wall the scar tissue may stretch, and so favour the
development of a ventral hernia.

Tendons may be cut across accidentally, especially in those wounds so
commonly met with above the wrist as a result, for example, of the hand
being thrust through a pane of glass. It is essential that the ends
should be sutured to each other, and as the proximal end is retracted
the original wound may require to be enlarged in an upward direction.
When primary suture has been omitted, or has failed in consequence of
suppuration, the separated ends of the tendon become adherent to
adjacent structures, and the function of the associated muscle is
impaired or lost. Under these conditions the operation of secondary
suture is indicated.

A free incision is necessary to discover and isolate the ends of the
tendon; if the interval is too wide to admit of their being approximated
by sutures, means must be taken to lengthen the tendon, or one from some
other part may be inserted in the gap. A new sheath may be provided for
the tendon by resecting a portion of the great saphenous vein.

_Injuries of the tendons of the fingers_ are comparatively common. One
of the best known is the partial or complete rupture of the aponeurosis
of the extensor tendon close to its insertion into the terminal
phalanx--_drop-_ or _mallet-finger_. This may result from comparatively
slight violence, such as striking the tip of the extended finger against
an object, or the violence may be more severe, as in attempting to catch
a cricket ball or in falling. The terminal phalanx is flexed towards the
palm and the patient is unable to extend it. The treatment consists in
putting up the finger with the middle joint strongly flexed. In
neglected cases, a perfect functional result can only be obtained by
operation; under a local anæsthetic, the ruptured tendon is exposed and
is sutured to the base of the phalanx, which may be drilled for the
passage of the sutures.

_Subcutaneous rupture_ of one or other _of the digital tendons_ in the
hand or at the wrist can be remedied only by operation. When some time
has elapsed since the accident, the proximal end may be so retracted
that it cannot be brought down into contact with the distal end, in
which case a slip may be taken from an adjacent tendon; in the case of
one of the extensors of the thumb, the extensor carpi radialis longus
may be detached from its insertion and stitched to the distal end of the
tendon of the thumb.

Subcutaneous _rupture of the tendon of the extensor pollicis longus_ at
the wrist takes place just after its emergence from beneath the annular
ligament; the actual rupture may occur painlessly, more frequently a
sharp pain is felt over the back of the wrist. The prominence of the
tendon, which normally forms the ulnar border of the snuff-box,
disappears. This lesion is chiefly met with in drummer-boys and is the
cause of drummer's palsy. The only chance of restoring function is in
uniting the ruptured tendon by open operation.

[Illustration: FIG. 108.--Avulsion of Tendon with Terminal Phalanx of
Thumb.

(Surgical Museum, University of Edinburgh.)]

_Avulsion of Tendons._--This is a rare injury, in which the tendons of a
finger or toe are torn from their attachments along with a portion of
the digit concerned. In the hand, it is usually brought about by the
fingers being caught in the reins of a runaway horse, or being seized in
a horse's teeth, or in machinery. It is usually the terminal phalanx
that is separated, and with it the tendon of the deep flexor, which
ruptures at its junction with the belly of the muscle (Fig. 108). The
treatment consists in disinfecting the wound, closing the tendon-sheath,
and trimming the mutilated finger so as to provide a useful stump.


DISEASES OF MUSCLES AND TENDONS

_Congenital absence_ of muscles is sometimes met with, usually in
association with other deformities. The pectoralis major, for example,
may be absent on one or on both sides, without, however, causing any
disability, as other muscles enlarge and take on its functions.

_Atrophy of Muscle._--Simple atrophy, in which the muscle elements are
merely diminished in size without undergoing any structural alteration,
is commonly met with as a result of disuse, as when a patient is
confined to bed for a long period.

In cases of joint disease, the muscles acting on the joint become
atrophied more rapidly than is accounted for by disuse alone, and this
is attributed to an interference with the trophic innervation of the
muscles reflected from centres in the spinal medulla. It is more marked
in the extensor than in the flexor groups of muscles. Those affected
become soft and flaccid, exhibit tremors on attempted movement, and
their excitability to the faradic current is diminished.

_Neuropathic atrophy_ is associated with lesions of the nervous system.
It is most pronounced in lesions of the motor nerve-trunks, probably
because vaso-motor and trophic fibres are involved as well as those that
are purely motor in function. It is attended with definite structural
alterations, the muscle elements first undergoing fatty degeneration,
and then being absorbed, and replaced to a large extent by ordinary
connective tissue and fat. At a certain stage the muscles exhibit the
reaction of degeneration. In the common form of paralysis resulting from
poliomyelitis, many fibres undergo fatty degeneration and are replaced
by fat, while at the same time there is a regeneration of muscle fibres.

#Fibrositis# or "#Muscular Rheumatism#."--This clinical term is applied
to a group of affections of which lumbago is the best-known example. The
group includes lumbago, stiff-neck, and pleurodynia--conditions which
have this in common, that sudden and severe pain is excited by movement
of the affected part. The lesion consists in inflammatory hyperplasia of
the connective tissue; the new tissue differs from normal fibrous tissue
in its tendency to contract, in being swollen, painful and tender on
pressure, and in the fact that it can be massaged away (Stockman). It
would appear to involve mainly the fibrous tissue of muscles, although
it may extend from this to aponeuroses, ligaments, periosteum, and the
sheaths of nerves. The term _fibrositis_ was applied to it by Gowers in
1904.

In _lumbago_--_lumbo-sacral fibrositis_--the pain is usually located
over the sacrum, the sacro-iliac joint, or the aponeurosis of the lumbar
muscles on one or both sides. The amount of tenderness varies, and so
long as the patient is still he is free from pain. The slightest
attempt to alter his position, however, is attended by pain, which may
be so severe as to render him helpless for the moment. The pain is most
marked on rising from the stooping or sitting posture, and may extend
down the back of the hip, especially if, as is commonly the case,
lumbago and gluteal fibrosis coexist. Once a patient has suffered from
lumbago, it is liable to recur, and an attack may be determined by
errors of diet, changes of weather, exposure to cold or unwonted
exertion. It is met with chiefly in male adults, and is most apt to
occur in those who are gouty or are the subjects of oxaluric dyspepsia.

_Gluteal fibrositis_ usually follows exposure to wet, and affects the
gluteal muscles, particularly the medius, and their aponeurotic
coverings. When the condition has lasted for some time, indurated
strands or nodules can be detected on palpating the relaxed muscles. The
patient complains of persistent aching and stiffness over the buttock,
and sometimes extending down the lateral aspect of the thigh. The pain
is aggravated by such movements as bring the affected muscles into
action. It is not referred to the line of the sciatic nerve, nor is
there tenderness on pressing over the nerve, or sensations of tingling
or numbness in the leg or foot.

If untreated, the morbid process may implicate the sheath of the sciatic
nerve and cause genuine sciatic neuralgia (Llewellyn and Jones). A
similar condition may implicate the fascia lata of the thigh, or the
calf muscles and their aponeuroses--_crural fibrositis_.

In _painful stiff-neck_, or "rheumatic torticollis," the pain is located
in one side of the neck, and is excited by some inadvertent movement.
The head is held stiffly on one side as in wry-neck, the patient
contracting the sterno-mastoid. There may be tenderness over the
vertebral spines or in the lines of the cervical nerves, and the
sterno-mastoid may undergo atrophy. This affection is more often met
with in children.

In _pleurodynia_--_intercostal fibrositis_--the pain is in the line of
the intercostal nerves, and is excited by movement of the chest, as in
coughing, or by any bodily exertion. There is often marked tenderness.

A similar affection is met with in the _shoulder and arm_--_brachial
fibrositis_--especially on waking from sleep. There is acute pain on
attempting to abduct the arm, and there may be localised tenderness in
the region of the axillary nerve.

_Treatment._--The general treatment is concerned with the diet,
attention to the stomach, bowels, and kidneys and with the correction
of any gouty tendencies that may be present. Remedies such as
salicylates are given for the relief of pain, and for this purpose drugs
of the aspirin type are to be preferred, and these may be followed by
large doses of iodide of potassium. Great benefit is derived from
massage, and from the induction of hyperæmia by means of heat. Cupping
or needling, or, in exceptional cases, hypodermic injections of
antipyrin or morphin, may be called for. To prevent relapses of lumbago,
the patient must take systematic exercises of all kinds, especially such
as bring out the movements of the vertebral column and hip-joints.

[Illustration: FIG. 109.--Volkmann's Ischæmic Contracture. When the
wrist is flexed to a right angle it is possible to extend the fingers.

(Photographs lent by Mr. Lawford Knaggs)]

#Contracture of Muscles.#--Permanent shortening of muscles results from
the prolonged approximation of their points of attachment, or from
structural changes in their substance produced by injury or by disease.
It is a frequent accompaniment and sometimes a cause of deformities, in
the treatment of which lengthening of the shortened muscles or their
tendons may be an essential step.

#Myositis.#--_Ischæmic Myositis._--Volkmann was the first to describe a
form of myositis followed by contracture, resulting from interference
with the arterial blood supply. It is most frequently observed in the
flexor muscles of the forearm in children and young persons under
treatment for fractures in the region of the elbow, the splints and
bandages causing compression of the blood vessels. There is considerable
effusion of blood, the skin is tense, and the muscles, vessels, and
nerves are compressed; this is further increased if the elbow is flexed
and splints and tight bandages are applied. The muscles acquire a
board-like hardness and no longer contract under the will, and passive
motion is painful and restricted. Slight contracture of the fingers is
usually the first sign of the malady; in time the muscles undergo
further contraction, and this brings about a claw-like deformity of the
hand. The affected muscles usually show the reaction of degeneration. In
severe cases the median and ulnar nerves are also the seat of
cicatricial changes (ischæmic neuritis).

By means of splints, the interphalangeal, metacarpo-phalangeal, and
wrist joints should be gradually extended until the deformity is
over-corrected (R. Jones). Murphy advises resection of the radius and
ulna sufficient to admit of dorsiflexion of the joints and lengthening
of the flexor tendons.

Various forms of _pyogenic_ infection are met with in muscle, most
frequently in relation to pyæmia and to typhoid fever. These may result
in overgrowth of the connective-tissue framework of the muscle and
degeneration of its fibres, or in suppuration and the formation of one
or more abscesses in the muscle substance. Repair may be associated with
contracture.

A _gonorrhœal_ form of myositis is sometimes met with; it is painful,
but rarely goes on to suppuration.

In the early secondary period of _syphilis_, the muscles may be the seat
of dull, aching, nocturnal pains, especially in the neck and back.
_Syphilitic contracture_ is a condition which has been observed chiefly
in the later secondary period; the biceps of the arm and the hamstrings
in the thigh are the muscles more commonly affected. The striking
feature is a gradually increasing difficulty of extending the limb at
the elbow or knee, and progressive flexion of the joint. The affected
muscle is larger and firmer than normal, and its electric excitability
is diminished. In tertiary syphilis, individual muscles may become the
seat of interstitial myositis or of gummata, and these affections
readily yield to anti-syphilitic remedies.

_Tuberculous disease_ in muscle, while usually due to extension from
adjacent tissues, is sometimes the result of a primary infection through
the blood-stream. Tuberculous nodules are found disseminated throughout
the muscle; the surrounding tissues are indurated, and central caseation
may take place and lead to abscess formation and sinuses. We have
observed this form of tuberculous disease in the gastrocnemius and in
the psoas--in the latter muscle apart from tuberculous disease in the
vertebræ.

#Tendinitis.#--German authors describe an inflammation of tendon as
distinguished from inflammation of its sheath, and give it the name
tendinitis. It is met with most frequently in the tendo-calcaneus in
gouty and rheumatic subjects who have overstrained the tendon,
especially during cold and damp weather. There is localised pain which
is aggravated by walking, and the tendon is sensitive and swollen from a
little above its insertion to its junction with the muscle. Gouty
nodules may form in its substance. Constitutional measures, massage, and
douching should be employed, and the tendon should be protected from
strain.

#Calcification and Ossification in Muscles, Tendons, and
Fasciæ.#--_Myositis ossificans._--Ossifications in muscles, tendons,
fasciæ, and ligaments, in those who are the subjects of arthritis
deformans, are seldom recognised clinically, but are frequently met with
in dissecting-rooms and museums. Similar localised ossifications are met
with in Charcot's disease of joints, and in fractures which have
repaired with exuberant callus. The new bone may be in the form of
spicules, plates, or irregular masses, which, when connected with a
bone, are called _false exostoses_ (Fig. 110).

[Illustration: FIG. 110.--Ossification in Tendon of Ilio-psoas Muscle.]

_Traumatic Ossification in Relation to Muscle._--Various forms of
ossification are met with in muscle as the result of a single or of
repeated injury. Ossification in the crureus or vastus lateralis muscle
has been frequently observed as a result of a kick from a horse. Within
a week or two a swelling appears at the site of injury, and becomes
progressively harder until its consistence is that of bone. If the mass
of new bone moves with the affected muscle, it causes little
inconvenience. If, as is commonly the case, it is fixed to the femur,
the action of the muscle is impaired, and the patient complains of pain
and difficulty in flexing the knee. A skiagram shows the extent of the
mass and its relationship to the femur. The treatment consists in
excising the bony mass.

Difficulty may arise in differentiating such a mass of bone from
sarcoma; the ossification in muscle is uniformly hard, while the sarcoma
varies in consistence at different parts, and the X-ray picture shows a
clear outline of the bone in the vicinity of the ossification in
muscle, whereas in sarcoma the involvement of the bone is shown by
indentations and irregularity in its contour.

A similar ossification has been observed in relation to the insertion of
the brachialis muscle as a sequel of dislocation of the elbow. After
reduction of the dislocation, the range of movement gradually diminishes
and a hard swelling appears in front of the lower end of the humerus.
The lump continues to increase in size and in three to four weeks the
disability becomes complete. A radiogram shows a shadow in the muscle,
attached at one part as a rule to the coronoid process. During the next
three or four months, the lump in front of the elbow remains stationary
in size; a gradual decrease then ensues, but the swelling persists, as a
rule, for several years.

[Illustration: FIG. 111.--Calcification and Ossification in Biceps and
Triceps.

(From a radiogram lent by Dr. C. A. Adair Dighton.)]

Ossification in the adductor longus was first described by Billroth
under the name of "rider's bone." It follows bruising and partial
rupture of the muscle, and has been observed chiefly in cavalry
soldiers. If it causes inconvenience the bone may be removed by
operation.

Ossification in the deltoid and pectoral muscles has been observed in
foot-soldiers in the German army, and has received the name of
"drill-bone"; it is due to bruising of the muscle by the recoil of the
rifle.

_Progressive Ossifying Myositis._--This is a rare and interesting
disease, in which the muscles, tendons, and fasciæ throughout the body
become the seat of ossification. It affects almost exclusively the male
sex, and usually begins in childhood or youth, sometimes after an
injury, sometimes without apparent cause. The muscles of the back,
especially the trapezius and latissimus, are the first to be affected,
and the initial complaint is limitation of movement.

[Illustration: FIG. 112.--Ossification in Muscles of Trunk in a case of
generalised Ossifying Myositis.

(Photograph lent by Dr. Rustomjee.)]

The affected muscles show swellings which are rounded or oval, firm and
elastic, sharply defined, without tenderness and without discoloration
of the overlying skin. Skiagrams show that a considerable deposit of
lime salts may precede the formation of bone, as is seen in Fig. 111. In
course of time the vertebral column becomes rigid, the head is bent
forward, the hips are flexed, and abduction and other movements of the
arms are limited. The disease progresses by fits and starts, until all
the striped muscles of the body are replaced by bone, and all movements,
even those of the jaws, are abolished. The subjects of this disease
usually succumb to pulmonary tuberculosis.

There is no means of arresting the disease, and surgical treatment is
restricted to the removal or division of any mass of bone that
interferes with an important movement.

A remarkable feature of this disease is the frequent presence of a
deformity of the great toe, which usually takes the form of hallux
valgus, the great toe coming to lie beneath the second one; the
shortening is usually ascribed to absence of the first phalanx, but it
has been shown to depend also on a synostosis and imperfect development
of the phalanges. A similar deformity of the thumb is sometimes met
with.

Microscopical examination of the muscles shows that, prior to the
deposition of lime salts and the formation of bone, there occurs a
proliferation of the intra-muscular connective tissue and a gradual
replacement and absorption of the muscle fibres. The bone is spongy in
character, and its development takes place along similar lines to those
observed in ossification from the periosteum.

#Tumours of Muscle.#--With the exception of congenital varieties, such
as the rhabdomyoma, tumours of muscle grow from the connective-tissue
framework and not from the muscle fibres. Innocent tumours, such as the
fibroma, lipoma, angioma, and neuro-fibroma, are rare. Malignant tumours
may be primary in the muscle, or may result from extension from adjacent
growths--for example, implication of the pectoral muscle in cancer of
the breast--or they may be derived from tumours situated elsewhere. The
diagnosis of an intra-muscular tumour is made by observing that the
swelling is situated beneath the deep fascia, that it becomes firm and
fixed when the muscle contracts, and that, when the muscle is relaxed,
it becomes softer, and can be moved in the transverse axis of the
muscle, but not in its long axis.

Clinical interest attaches to that form of slowly growing
fibro-sarcoma--_the recurrent fibroid of Paget_--which is most
frequently met with in the muscles of the abdominal wall. A rarer
variety is the ossifying chondro-sarcoma, which undergoes ossification
to such an extent as to be visible in skiagrams.

In primary sarcoma the treatment consists in removing the muscle. In the
limbs, the function of the muscle that is removed may be retained by
transplanting an adjacent muscle in its place.

_Hydatid cysts_ of muscle resemble those developing in other tissues.


DISEASES OF TENDON SHEATHS

Tendon sheaths have the same structure and function as the synovial
membranes of joints, and are liable to the same diseases. Apart from the
tendon sheaths displayed in anatomical dissections, there is a loose
peritendinous and perimuscular cellular tissue which is subject to the
same pathological conditions as the tendon sheaths proper.

#Teno-synovitis.#--The toxic or infective agent is conveyed to the
tendon sheaths through the blood-stream, as in the gouty, gonorrhœal,
and tuberculous varieties, or is introduced directly through a wound, as
in the common pyogenic form of teno-synovitis.

_Teno-synovitis Crepitans._--In the simple or traumatic form of
teno-synovitis, although the most prominent etiological factor is a
strain or over-use of the tendon, there would appear to be some other,
probably a toxic, factor in its production, otherwise the affection
would be much more common than it is: only a small proportion of those
who strain or over-use their tendons become the subjects of
teno-synovitis. The opposed surfaces of the tendon and its sheath are
covered with fibrinous lymph, so that there is friction when they move
on one another.

The _clinical features_ are pain on movement, tenderness on pressure
over the affected tendon, and a sensation of crepitation or friction
when the tendon is moved in its sheath. The crepitation may be soft like
the friction of snow, or may resemble the creaking of new
leather--"saddle-back creaking." There may be swelling in the long axis
of the tendon, and redness and œdema of the skin. If there is an
effusion of fluid into the sheath, the swelling is more marked and
crepitation is absent. There is little tendency to the formation of
adhesions.

In the upper extremity, the sheath of the long tendon of the biceps may
be affected, but the condition is most common in the tendons about the
wrist, particularly in the extensors of the thumb, and it is most
frequently met with in those who follow occupations which involve
prolonged use or excessive straining of these tendons--for example,
washerwomen or riveters. It also occurs as a result of excessive
piano-playing, fencing, or rowing.

At the ankle it affects the peronei, the extensor digitorum longus, or
the tibialis anterior. It is most often met with in relation to the
tendo-calcaneus--_Achillo-dynia_--and results from the pressure of
ill-fitting boots or from the excessive use and strain of the tendon in
cycling, walking, or dancing. There is pain in raising the heel from the
ground, and creaking can be felt on palpation.

The _treatment_ consists in putting the affected tendon at rest, and
with this object a splint may be helpful; the usual remedies for
inflammation are indicated: Bier's hyperæmia, lead and opium
fomentations, and ichthyol and glycerine. The affection readily subsides
under treatment, but is liable to relapse on a repetition of the
exciting cause.

_Gouty Teno-synovitis._--A deposit of urate of soda beneath the
endothelial covering of tendons or of that lining their sheaths is
commonly met with in gouty subjects. The accumulation of urates may
result in the formation of visible nodular swellings, varying in size
from a pea to a cherry, attached to the tendon and moving with it. They
may be merely unsightly, or they may interfere with the use of the
tendon. Recurrent attacks of inflammation are prone to occur. We have
removed such gouty masses with satisfactory results.

_Suppurative Teno-synovitis._--This form usually follows upon infected
wounds of the fingers--especially of the thumb or little finger--and is
a frequent sequel to whitlow; it may also follow amputation of a finger.
Once the infection has gained access to the sheath, it tends to spread,
and may reach the palm or even the forearm, being then associated with
cellulitis. In moderately acute cases the tendon and its sheath become
covered with granulations, which subsequently lead to the formation of
adhesions; while in more acute cases the tendon sloughs. The pus may
burst into the cellular tissue outside the sheath, and the suppuration
is liable to spread to neighbouring sheaths or to adjacent bones or
joints--for example, those of the wrist.

The _treatment_ consists in inducing hyperæmia and making small
incisions for the escape of pus. The site of incision is determined by
the point of greatest tenderness on pressure. After the inflammation has
subsided, active and passive movements are employed to prevent the
formation of adhesions between the tendon and its sheath. If the tendon
sloughs, the dead portion should be cut away, as its separation is
extremely slow and is attended with prolonged suppuration.

_Gonorrhœal Teno-synovitis._--This is met with especially in the tendon
sheaths about the wrist and ankle. It may occur in a mild form, with
pain, impairment of movement, and œdema, and sometimes an elongated,
fluctuating swelling, the result of serous effusion into the sheath.
This condition may alternate with a gonorrhœal affection of one of the
larger joints. It may subside under rest and soothing applications, but
is liable to relapse. In the more severe variety the skin is red, and
the swelling partakes of the characters of a phlegmon with threatening
suppuration; it may result in crippling from adhesions. Even if pus
forms in the sheath, the tendon rarely sloughs. The treatment consists
in inducing hyperæmia by Bier's method; and a vaccine may be employed
with satisfactory results.

#Tuberculous Disease of Tendon Sheaths.#--This is a comparatively common
affection, and is analogous to tuberculous disease of the synovial
membrane of joints. It may originate in the sheath, or may spread to it
from an adjacent bone.

The commonest form--hydrops--is that in which the synovial sheath is
distended with a viscous fluid, and the fibrinous material on the free
surface becomes detached and is moulded into melon-seed bodies by the
movement of the tendon. The sheath itself is thickened by the growth of
tuberculous granulation tissue. The bodies are smooth and of a
dull-white colour, and vary greatly in size and shape. There may be an
overgrowth of the fatty fringes of the synovial sheath, a condition
described as "arborescent lipoma."

The _clinical features_ vary with the tendon sheath affected. In the
common flexor sheath of the hand an hour-glass-shaped swelling is
formed, bulging above and below the transverse carpal (anterior annular)
ligament--formerly known as _compound palmar ganglion_. There is little
or no pain, but the fingers tend to be stiff and weak, and to become
flexed. On palpation, it is usually possible to displace the contents of
the sheath from one compartment to the other, and this may yield
fluctuation, and, what is more characteristic, a peculiar soft crepitant
sensation from the movement of the melon-seed bodies. In the sheath of
the peronei or other tendons about the ankle, the swelling is
sausage-shaped, and is constricted opposite the annular ligament.

The onset and progress of the affection are most insidious, and the
condition may remain stationary for long periods. It is aggravated by
use or strain of the tendons involved. In exceptional cases the skin is
thinned and gives way, resulting in the formation of a sinus.

_Treatment._--In the common flexor sheath of the palm, an attempt may be
made to cure the condition by removing the contents through a small
incision and filling the cavity with iodoform glycerine, followed by the
use of Bier's bandage. If this fails, the distended sheath is laid open,
the contents removed, the wall scraped, and the wound closed.

A less common form of tuberculous disease is that in which the sheath
becomes the seat of _a diffuse tuberculous thickening_, not unlike the
white swelling met with in joints, and with a similar tendency to
caseation. A painless swelling of an elastic character forms in relation
to the tendon sheath. It is hour-glass-shaped in the common flexor
sheath of the palm, elongated or sausage-shaped in the extensors of the
wrist and in the tendons at the ankle. The tuberculous granulation
tissue is liable to break down and lead to the formation of a cold
abscess and sinuses, and in our experience is often associated with
disease in an adjacent bone or joint. In the peronei tendons, for
example, it may result from disease of the fibula or of the ankle-joint.

When conservative measures fail, excision of the affected sheath should
be performed; the whole of the diseased area being exposed by free
incision of the overlying soft parts, the sheath is carefully isolated
from the surrounding tissues and is cut across above and below. Any
tuberculous tissue on the tendon itself is removed with a sharp spoon.
Associated bone or joint lesions are dealt with at the same time. In the
after-treatment the functions of the tendons must be preserved by
voluntary and passive movements.

#Syphilitic Affections of Tendon Sheaths.#--These closely resemble the
syphilitic affections of the synovial membrane of joints. During the
secondary period the lesion usually consists in effusion into the
sheath; gummata are met with during the tertiary period.

Arborescent lipoma has been found in the sheaths of tendons about the
wrist and ankle, sometimes in a multiple and symmetrical form,
unattended by symptoms and disappearing under anti-syphilitic treatment.

#Tumours of Tendon Sheaths.#--Innocent tumours, such as _lipoma_,
_fibroma_, and _myxoma_, are rare. Special mention should be made of the
_myeloma_ which is met with at the wrist or ankle as an elongated
swelling of slow development, or over the phalanx of a finger as a small
rounded swelling. The tumour tissue, when exposed by dissection, is of a
chocolate or chamois-yellow colour, and consists almost entirely of
giant cells. The treatment consists in dissecting the tumour tissue off
the tendons, and this is usually successful in bringing about a
permanent cure.

All varieties of _sarcoma_ are met with, but their origin from tendon
sheaths is not associated with special features.



CHAPTER XIX

THE BURSÆ


Anatomy--Normal and adventitious bursæ--Injuries: Bursal
    hæmatoma--DISEASES: Infective bursitis; Traumatic or trade
    bursitis; Bursal hydrops; Solid bursal tumour; Gonorrhœal and
    suppurative forms of bursitis; Tuberculous and syphilitic
    disease--Tumours--_Diseases of individual bursæ in the upper and
    lower extremities_.

A bursa is a closed sac lined by endothelium and containing synovia.
Some are normally present--for instance, that between the skin and the
patella, and that between the aponeurosis of the gluteus maximus and the
great trochanter. _Adventitious bursæ_ are developed as a result of
abnormal pressure--for example, over the tarsal bones in cases of
club-foot.

#Injuries of Bursæ.#--As a result of contusion, especially in bleeders,
hæmorrhage may occur into the cavity of a bursa and give rise to a
_bursal hæmatoma_. Such a hæmatoma may mask a fracture of the bone
beneath--for example, fracture of the olecranon.

#Diseases of Bursæ.#--The lining membrane of bursæ resembles that of
joints and tendon sheaths, and is liable to the same forms of disease.

#Infective bursitis# frequently follows abrasions, scratches, and wounds
of the skin over the prepatellar or olecranon bursa, and in neglected
cases the infection transgresses the wall of the bursa and gives rise to
a spreading cellulitis.

#Traumatic or Trade Bursitis.#--This term may be conveniently applied to
those affections of bursæ which result from repeated slight traumatism
incident to particular occupations. The most familiar examples of these
are the enlargement of the prepatellar bursa met with in housemaids--the
"housemaid's knee" (Fig. 113); the enlargement of the olecranon
bursa--"miner's elbow"; and of the ischial bursa--"weaver's" or
"tailor's bottom" (Fig. 116). These affections are characterised by an
effusion of fluid into the sac of the bursa with thickening of its
lining membrane. While friction and pressure are the most evident
factors in their production, it is probable that there is also some
toxic agent concerned, otherwise these affections would be much more
common than they are. Of the countless housemaids in whom the
prepatellar bursa is subjected to friction and pressure, only a small
proportion become the subjects of housemaid's knee.

_Clinical Features._--As these are best illustrated in the different
varieties of prepatellar bursitis, it is convenient to take this as the
type. In a number of cases the inflammation is acute and the patient is
unable to use the limb; the part is hot, swollen, and tender, and
fluctuation can be detected in the bursa. In the majority the condition
is chronic, and the chief feature is the gradual accumulation of fluid
constituting the _bursal hydrops_ or _hygroma_. When the affection has
lasted some time, or has frequently relapsed, the wall of the bursa
becomes thickened by fibrous tissue, which may be deposited irregularly,
so that septa, bands, or fringes are formed, not unlike those met with
in arthritis deformans. These fringes may be detached and form loose
bodies like those met with in joints; less frequently there are
fibrinous bodies of the melon-seed type, sometimes moulded into circular
discs like wafers. The presence of irregular thickenings of the wall, or
of loose bodies, may be recognised on palpation, especially in
superficial bursæ, if the sac is not tensely filled with fluid. The
thickening of the wall may take place in a uniform and concentric
fashion, resulting in the formation of a fibrous tumour--_the solid
bursal tumour_--a small cavity remaining in the centre which serves to
distinguish it from a new growth or neoplasm.

[Illustration: FIG. 113.--Hydrops of Prepatellar Bursa in a housemaid.]

The _treatment_ varies according to the variety and stage of the
affection. In recent cases the symptoms subside under rest and the
application of fomentations. Hydrops may be got rid of by blistering,
by tapping, or by incision and drainage. When the wall is thickened, the
most satisfactory treatment is to excise the bursa; the overlying skin
being reflected in the shape of a horse-shoe flap or being removed along
with the bursa.

#Other Diseases of Bursæ# are associated with _gonorrhœal infection_,
and with _rheumatism_, especially that following scarlet fever, and are
apt to be persistent or to relapse after apparent cure. In the _gouty_
form, urate of soda is deposited in the wall of the bursa, and may
result in the formation of chalky tumours, sometimes of considerable
size (Fig. 114).

[Illustration: FIG. 114.--Section through Bursa over external malleolus,
showing deposit of urate of soda. (Cf. Fig. 117.)]

_Tuberculous disease_ of bursæ closely resembles that of tendon sheaths.
It may occur as an independent affection, or may be associated with
disease in an adjacent bone or joint. It is met with chiefly in the
prepatellar and subdeltoid bursæ, or in one of the bursæ over the great
trochanter. The clinical features are those of an indolent hydrops, with
or without melon-seed bodies, or of uniform thickening of the wall of
the bursa; the tuberculous granulation tissue may break down into a cold
abscess, and give rise to sinuses. The best treatment is to excise the
affected bursa, or, when this is impracticable, to lay it freely open,
remove the tuberculous tissue with the sharp spoon or knife, and treat
the cavity by the open method.

_Syphilitic disease_ is rarely recognised except in the form of bursal
and peri-bursal gummata in front of the knee-joint.

_New growths_ include the fibroma, the myxoma, the myeloma or
giant-celled tumour, and various forms of sarcoma.

#Diseases of Individual Bursæ.#--The _olecranon bursa_ is frequently
the seat of pyogenic infection and of traumatic or trade bursitis, the
latter being known as "miner's" or "student's elbow."

[Illustration: FIG. 115.--Tuberculous Disease of Sub-deltoid Bursa.

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

The _sub-deltoid_ or _sub-acromial bursa_, which usually presents a
single cavity and does not normally communicate with the shoulder-joint,
is indispensable in abduction and rotation of the humerus. When the arm
is abducted, the fixed lower part or floor of the bursa is carried under
the acromion, and the upper part or roof is rolled up in the same
direction, hence tenderness over the inflamed bursa may disappear when
the arm is abducted (Dawbarn's sign). It is liable to traumatic
affections from a fall on the shoulder, pressure, or over-use of the
limb. Pain, located commonly at the insertion of the deltoid, is a
constant symptom and is especially annoying at night, the patient being
unable to get into a comfortable position. Tenderness may be elicited
over the anatomical limits of the bursa, and is usually most marked over
the great tuberosity, just external to the inter-tubercular (bicipital)
groove. When adhesions are present, abduction beyond 10 degrees is
impossible. Demonstrable effusion is not uncommon, but is disguised by
the overlying tissues. If left to himself, the patient tends to maintain
the limb in the "sling position," and resists movements in the direction
of abduction and rotation. In the treatment of this affection the arm
should be maintained at a right angle to the body, the arm being rotated
medially (Codman). When pain does not prevent it, movements of the arm
and massage are persevered with. In neglected cases, when adhesions have
formed and the shoulder is fixed, it may be necessary to break down the
adhesions under an anæsthetic.

The bursa is also liable to infective conditions, such as acute
rheumatism, gonorrhœa, suppuration, or tubercle. In tuberculous disease
a large fluctuating swelling may form and acquire the characters of a
cold abscess (Fig. 115).

The bursa underneath the tendon of the _subscapularis_ muscle when
inflamed causes alteration in the attitude of the shoulder and
impairment of its movements.

An adventitious bursa forms over the _acromion_ process in porters and
others who carry weights on the shoulder, and may be the seat of
traumatic bursitis.

The bursa under the _tendon of insertion of the biceps_, when the seat
of disease, is attended with pain and swelling about a finger's breadth
below the bend of the elbow; there is pain and difficulty in effecting
the combined movement of flexion and supination, slight limitation of
extension, and restriction of pronation.

In the lower extremity, a large number of normal and adventitious bursæ
are met with and may be the seat of bursitis. That over the _tuberosity
of the ischium_, when enlarged as a trade disease, is known as
"weaver's" or "tailor's bottom." It may form a fluctuating swelling of
great size, projecting on the buttock and extending down the thigh, and
causing great inconvenience in sitting (Fig. 116). It sometimes contains
a number of loose bodies.

There are two bursæ over the _great trochanter_, one superficial to, the
other beneath the aponeurosis of the gluteus maximus; the latter is not
infrequently infected by tuberculous disease that has spread from the
trochanter.

The bursa _between the psoas muscle and the capsule of the hip-joint_
may be the seat of tuberculous disease, and give rise to clinical
features not unlike those of disease of the hip-joint. The limb is
flexed, abducted and rotated out; there is a swelling in the upper part
of Scarpa's triangle, but the movements are not restricted in directions
which do not entail putting the ilio-psoas muscle on the stretch.

Cartilaginous and partly ossified loose bodies may accumulate in the
ilio-psoas bursa and distend it, both in a downward direction towards
the hip-joint, with which it communicates, and upwards, projecting
towards the abdomen.

The bursa beneath the quadriceps extensor--_subcrural bursa_--usually
communicates with the knee-joint and shares in its diseases. When shut
off from the joint it may suffer independently, and when distended with
fluid forms a horse-shoe swelling above the patella.

In front of the patella and its ligament is the _prepatellar bursa_,
which may have one, two, or three compartments, usually communicating
with one another. It is the seat of the affection known as "housemaid's
knee," which is very common and is sometimes bilateral, and, less
frequently, of tuberculous disease which usually originates in the
patella.

[Illustration: FIG. 116.--Great Enlargement of the Ischial Bursa.

(Mr. Scot-Skirving's case.)]

The bursa _between the ligamentum patellæ and the tibia_ is rarely the
seat of disease. When it is, there is pain and tenderness referred to
the ligament, the patient is unable to extend the limb completely, the
tuberosity of the tibia is apparently enlarged, and there is a
fluctuating swelling on either side of the ligament, most marked in the
extended position of the limb.

Of the numerous bursæ in the popliteal space, that _between the
semi-membranosus and the medial head of the gastrocnemius_ is most
frequently the seat of disease, which is usually of the nature of a
simple hydrops, forming a fluctuating egg-or sausage-shaped swelling at
the medial side of the popliteal space. It is flaccid in the flexed, and
tense in the extended position. As a rule it causes little
inconvenience, and may be left alone. Otherwise it should be dissected
out, and if, as is frequently the case, there is a communication with
the knee-joint, this should be closed with sutures.

[Illustration: FIG. 117.--Gouty Disease of Bursæ in a tailor. The bursal
tumours were almost entirely composed of urate of soda. (Cf. Fig. 114.)]

An adventitious bursa may form over the _lateral malleolus_, especially
in tailors, giving rise to the condition known as "tailor's ankle"
(Fig. 117).

The bursa _between the tendo-calcaneus (Achillis) and the upper part of
the calcaneus_ may become inflamed--especially as a result of
post-scarlatinal rheumatism or gonorrhœa. The affection is known as
Achillo-bursitis. There is severe pain in the region of the insertion of
the tendo-calcaneus, the movements at the ankle-joint are restricted,
and the patient may be unable to walk. There is a tender swelling on
either side of the tendon. When, in spite of palliative treatment, the
affection persists or relapses, it is best to excise the bursa. The
tendo-calcaneus is detached from the calcaneus, the bursa dissected out,
and the tendon replaced. If there is a bony projection from the
calcaneus, it should be shaved off with the chisel.

The bursa that is sometimes met with on the under aspect of the
calcaneus--_the subcalcanean bursa_--when inflamed, gives rise to pain
and tenderness in the sole of the foot. This affection may be associated
with a spinous projection from the bone, which is capable of being
recognised in a skiagram. The soft parts of the heel are turned forwards
as a flap, the bursa is dissected out, and the projection of bone, if
present, is removed.

The enlargement of adventitious bursæ over the head of the first
metatarsal in hallux valgus; over the tarsus, metatarsus, and digits in
the different forms of club-foot; over the angular projection in Pott's
disease of the spine; over the end of the bone in amputation stumps, and
over hard tumours such as chondroma and osteoma, are described
elsewhere.



CHAPTER XX

DISEASES OF BONE


Anatomy and physiology--Regeneration of bone--Transplantation of bone.
    DISEASES OF BONE--Definition of terms--Pyogenic diseases:
    _Acute osteomyelitis and periostitis_; _Chronic and relapsing
    osteomyelitis_; _Abscess of bone_--Tuberculous disease--Syphilitic
    disease--Hydatids; Rickets; Osteomalacia--Ostitis deformans of
    Paget--Osteomyelitis fibrosa--Affections of bones in diseases of
    the nervous system--Fragilitas ossium--Tumours and cysts of bone.

#Surgical Anatomy.#--During the period of growth, a long bone such as
the tibia consists of a shaft or _diaphysis_, and two extremities or
_epiphyses_. So long as growth continues there intervenes between the
shaft and each of the epiphyses a disc of actively growing
cartilage--_the epiphysial cartilage_; and at the junction of this
cartilage with the shaft is a zone of young, vascular, spongy bone known
as the _metaphysis_ or _epiphysial junction_. The shaft is a cylinder of
compact bone enclosing the medullary canal, which is filled with yellow
marrow. The extremities, which include the ossifying junctions, consist
of spongy bone, the spaces of which are filled with red marrow. The
articular aspect of the epiphysis is invested with a thick layer of
hyaline cartilage, known as the _articular cartilage_, which would
appear to be mainly nourished from the synovia.

The external investment--the _periosteum_--is thick and vascular during
the period of growth, but becomes thin and less vascular when the
skeleton has attained maturity. Except where muscles are attached it is
easily separated from the bone; at the extremities it is intimately
connected with the epiphysial cartilage and with the epiphysis, and at
the margin of the latter it becomes continuous with the capsule of the
adjacent joint. It consists of two layers, an outer fibrous and an inner
cellular layer; the cells, which are called osteoblasts, are continuous
with those lining the Haversian canals and the medullary cavity.

The arrangement of the _blood vessels_ determines to some extent the
incidence of disease in bone. The nutrient artery, after entering the
medullary canal through a special foramen in the cortex, bifurcates, and
one main division runs towards each of the extremities, and terminates
at the ossifying junction in a series of capillary loops projected
against the epiphysial cartilage. This arrangement favours the lodgment
of any organisms that may be circulating in the blood, and partly
accounts for the frequency with which diseases of bacterial origin
develop in the region of the ossifying junction. The diaphysis is also
nourished by numerous blood vessels from the periosteum, which penetrate
the cortex through the Haversian canals and anastomose with those
derived from the nutrient artery. The epiphyses are nourished by a
separate system of blood vessels, derived from the arteries which supply
the adjacent joint. The veins of the marrow are of large calibre and are
devoid of valves.

The _nerves_ enter the marrow along with the arteries, and, being
derived from the sympathetic system, are probably chiefly concerned with
the innervation of the blood vessels, but they are also capable of
transmitting sensory impulses, as pain is a prominent feature of many
bone affections.

It has long been believed that _the function of the periosteum_ is to
form new bone, but this view has been questioned by Sir William Macewen,
who maintains that its chief function is to limit the formation of new
bone. His experimental observations appear to show that new bone is
exclusively formed by the cellular elements or osteoblasts: these are
found on the surface of the bone, lining the Haversian canals and in the
marrow. We believe that it will avoid confusion in the study of the
diseases of bone if the osteoblasts on the surface of the bone are still
regarded as forming the deeper layer of the periosteum.

The formation of new bone by the osteoblasts may be _defective_ as a
result of physiological conditions, such as old age and disease of a
part, and defective formation is often associated with atrophy, or more
strictly speaking, absorption, of the existing bone, as is well seen in
the edentulous jaw and in the neck of the femur of a person advanced in
years. Defective formation associated with atrophy is also illustrated
in the bones of the lower limbs of persons who are unable to stand or
walk, and in the distal portion of a bone which is the seat of an
ununited fracture. The same combination is seen in an exaggerated degree
in the bones of limbs that are paralysed; in the case of adults, atrophy
of bone predominates; in children and adolescents, defective formation
is the more prominent feature, and the affected bones are attenuated,
smooth on the surface, and abnormally light.

On the other hand, the formation of new bone may be _exaggerated_, the
osteoblasts being excited to abnormal activity by stimuli of different
kinds: for example, the secretion of certain glandular organs, such as
the pituitary and thyreoid; the diluted toxins of certain
micro-organisms, such as the staphylococcus aureus and the spirochæte of
syphilis; a condition of hyperæmia, such as that produced artificially
by the application of a Bier's bandage or that which accompanies a
chronic leg-ulcer.

The new bone is laid down on the surface, in the Haversian canals, or
in the cancellous spaces and medullary canal, or in all three
situations. The new bone on the surface sometimes takes the form of a
diffuse _encrustation_ of porous or spongy bone as in secondary
syphilis, sometimes as a uniform increase in the girth of the
bone--_hyperostosis_, sometimes as a localised heaping up of bone or
_node_, and sometimes in the form of spicules, spoken of as
_osteophytes_. When the new bone is laid down in the Haversian canals,
cancellous spaces and medulla, the bone becomes denser and heavier, and
is said to be _sclerosed_; in extreme instances this may result in
obliteration of the medullary canal. Hyperostosis and sclerosis are
frequently met with in combination, a condition that is well illustrated
in the femur and tibia in tertiary syphilis; if the subject of this
condition is confined to bed for several months before his death, the
sclerosis may be undone, and rarefaction may even proceed beyond the
normal, the bone becoming lighter and richer in fat, although retaining
its abnormal girth.

The _function of the epiphysial cartilage_ is to provide for the growth
of the shaft in length. While all epiphysial cartilages contribute to
this result, certain of them functionate more actively and for a longer
period than others. Those at the knee, for example, contribute more to
the length of limb than do those at the hip or ankle, and they are also
the last to unite. In the upper limb the more active epiphyses are at
the shoulder and wrist, and these also are the last to unite.

The activity of the epiphysial cartilage may be modified as a result of
disease. In rickets, for example, the formation of new bone may take
place unequally, and may go on more rapidly in one half of the disc than
in the other, with the result that the axis of the shaft comes to
deviate from the normal, giving rise to knock-knee or bow-knee. In
bacterial diseases originating in the marrow, if the epiphysial junction
is directly involved in the destructive process, its bone-forming
functions may be retarded or abolished, and the subsequent growth of the
bone be seriously interfered with. On the other hand, if it is not
directly involved but is merely influenced by the proximity of an
infective focus, its bone-forming functions may be stimulated by the
diluted toxins and the growth of the bone in length exaggerated. In
paralysed limbs the growth from the epiphyses is usually little short of
the normal. The result of interference with growth is more injurious in
the lower than in the upper limb, because, from the functional point of
view, it is essential that the lower extremities should be approximately
of equal length. In the forearm or leg, where there are two parallel
bones, if the growth of one is arrested the continued growth of the
other results in a deviation of the hand or foot to one side.

In certain diseases, such as rickets and inherited syphilis, and in
developmental anomalies such as achondroplasia, _dwarfing_ of the
skeleton results from defective growth of bone at the ossifying
junctions. Conversely, excessive growth of bone at the ossifying
junctions results in abnormal height of the skeleton or _giantism_ as a
result, for example, of increased activity of the pituitary in
adolescents, and in eunuchs who have been castrated in childhood or
adolescence; in the latter, union of the epiphyses at the ends of the
long bones is delayed beyond the usual period at which the skeleton
attains maturity.

#Regeneration of Bone.#--When bone has been lost or destroyed as a
result of injury or disease, it is capable of being reproduced, the
extent to which regeneration takes place varying under different
conditions. The chief part in the regeneration of bone is played by the
osteoblasts in the adjacent marrow and in the deeper layer of the
periosteum. The shaft of a long bone may be reproduced after having been
destroyed by disease or removed by operation. The flat bones of the
skull and the bones of the face, which are primarily developed in
membrane, have little capacity of regeneration; hence, when bone has
been lost or removed in these situations, there results a permanent
defect.

Wounds or defects in articular cartilage are repaired by fibrous or
osseous tissue derived from the subjacent cancellous spaces.

_Transplantation of Bone--Bone-grafting._--Clinical experience is
conclusive that a portion of bone which has been completely detached
from its surroundings--for example, a trephine circle, or a flap of bone
detached with the saw, or the loose fragments in a compound
fracture--may become, if replaced in position, firmly and permanently
incorporated with the surrounding bone. Embedded foreign bodies, on the
other hand, such as ivory pegs or decalcified bone, exhibit, on removal
after a sufficient interval, evidence of having been eroded, in the
shape of worm-eaten depressions and perforations, and do not become
united or fused to the surrounding bone. It follows from this that the
implanting of living bone is to be preferred to the implanting of dead
bone or of foreign material. We believe that transplanted living bone
when placed under favourable conditions survives and becomes
incorporated with the bone with which it is in contact, and does not
merely act as a scaffolding. We believe also that the retention of the
periosteum on the graft is not essential, but, by favouring the
establishment of vascular connections, it contributes to the survival of
the graft and the success of the transplantation. Macewen maintains that
bone grafts "take" better if broken up into small fragments; we regard
this as unnecessary. Bone grafts yield better functional results when
they are immovably fixed to the adjacent bone by suture, pegs, or
plates. As in all grafting procedures, asepsis is essential.

Transplanted bone retains its vitality when embedded in the soft parts,
but is gradually absorbed and replaced by fibrous tissue.


DISEASES OF BONE

The morbid processes met with in bone originate in the same way and lead
to the same results as do similar processes in other tissues. The
structural peculiarities of bone, however, and the important changes
which take place in the skeleton during the period of growth, modify
certain of the clinical and pathological features.

_Definition of Terms._--Any diseased process that affects the periosteum
is spoken of as _periostitis_; the term _osteomyelitis_ is employed when
it is located in the marrow. The term _epiphysitis_ has been applied to
an inflammatory process in two distinct situations--namely, the
ossifying nucleus in the epiphysis, and the ossifying junction or
metaphysis between the epiphysial cartilage and the diaphysis. We shall
restrict the term to inflammation in the first of these situations.
Inflammation at the ossifying junction is included under the term
osteomyelitis.

The term _rarefying ostitis_ is applied to any process that is attended
with excessive absorption of the framework of a bone, whereby it becomes
more porous or spongy than it was before, a condition known as
_osteoporosis_.

The term _caries_ is employed to indicate any diseased process
associated with crumbling away of the trabecular framework of a bone. It
may be considered as the equivalent of ulceration or molecular
destruction in the soft parts. The carious process is preceded by the
formation of granulation tissue in the marrow or periosteum, which eats
away and replaces the bone in contact with it. The subsequent
degeneration and death of the granulation tissue under the necrotic
influence of bacterial toxins results in disintegration and crumbling
away of the trabecular framework of the portion of bone affected.
Clinically, carious bone yields a soft grating sensation under the
pressure of the probe. The macerated bone presents a rough, eroded
surface.

The term _dry caries_ (_caries sicca_) is applied to that variety which
is unattended with suppuration.

_Necrosis_ is the term applied to the death of a tangible portion of
bone, and the dead portion when separated is called a _sequestrum_. The
term _exfoliation_ is sometimes employed to indicate the separation or
throwing off of a superficial sequestrum. The edges and deep surface of
the sequestrum present a serrated or worm-eaten appearance due to the
process of erosion by which the dead bone has been separated from the
living.


BACTERIAL DISEASES

The most important diseases in this group are the pyogenic, the
tuberculous, and the syphilitic.

PYOGENIC DISEASES OF BONE.--These diseases result from
infection with pyogenic organisms, and two varieties or types are
recognised according to whether the organisms concerned reach their seat
of action by way of the blood-stream, or through an infection of the
soft parts in contact with the bone.


INFECTIONS THROUGH THE BLOOD-STREAM

#Diseases caused by the Staphylococcus Aureus.#--As the majority of
pyogenic diseases are due to infection with the staphylococcus aureus,
these will be described first.

#Acute osteomyelitis# is a suppurative process beginning in the marrow
and tending to spread to the periosteum. The disease is common in
children, but is rare after the skeleton has attained maturity. Boys are
affected more often than girls, in the proportion of three to one,
probably because they are more liable to exposure, to injury, and to
violent exertion.

_Etiology._--Staphylococci gain access to the blood-stream in various
ways, it may be through the skin or through a mucous surface.

Such conditions as, for example, a blow, some extra exertion such as a
long walk, or exposure to cold, as in wading, may act as localising
factors.

The long bones are chiefly affected, and the commonest sites are: either
end of the tibia and the lower end of the femur; the other bones of the
skeleton are affected in rare instances.

_Pathology._--The disease commences and is most intense in the marrow of
the ossifying junction at one end of the diaphysis; it may commence at
both ends simultaneously--_bipolar osteomyelitis_; or, commencing at one
end, may spread to the other.

The changes observed are those of intense engorgement of the marrow,
going on to greenish-yellow purulent infiltration. Where the process is
most advanced--that is, at the ossifying junction--there are evidences
of absorption of the framework of the bone; the marrow spaces and
Haversian canals undergo enlargement and become filled with
greenish-yellow pus. This rarefaction of the spongy bone is the earliest
change seen with the X-rays.

The process may remain localised to the ossifying junction, but usually
spreads along the medullary canal for a varying distance, and also
extends to the periosteum by way of the enlarged Haversian canals. The
pus accumulates under the periosteum and lifts it up from the bone. The
extent of spread in the medullary canal and beneath the periosteum is in
close correspondence. The periosteum of the diaphysis is easily
separated--hence the facility with which the pus spreads along the
shaft; but in the region of the ossifying junction it is raised with
difficulty because of its intimate connection with the epiphysial
cartilage. Less frequently there is more than one collection of pus
under the periosteum, each being derived from a focus of suppuration in
the subjacent marrow. The pus perforates the periosteum, and makes its
way to the surface by the easiest anatomical route, and discharges
externally, forming one or more sinuses through which fresh infection
may take place. The infection may spread to the adjacent joint, either
directly through the epiphysis and articular cartilage, or along the
deep layer of the periosteum and its continuation--the capsular
ligament. When the epiphysis is intra-articular, as, for example, in the
head of the femur, the pus when it reaches the surface of the bone
necessarily erupts directly into the joint.

While the occurrence of purely periosteal suppuration is regarded as
possible, we are of opinion that the embolic form of staphylococcal
osteomyelitis always originates in the marrow.

The portion of the diaphysis which has sustained the action of the
concentrated toxins has its vitality further impaired as a result of the
stripping of the periosteum and thrombosis of the blood vessels of the
marrow, so that _necrosis_ of bone is one of the most striking results
of the disease, and as this takes place rapidly, that is, in a day or
two, the term _acute necrosis_, formerly applied to the disease, was
amply justified.

When there is marked rarefaction of the bone at the ossifying junction,
the epiphysis is liable to be separated--_epiphysiolysis_. The
separation usually takes place through the young bone of the ossifying
junction, and the surfaces of the diaphysis and epiphysis are opposed to
each other by irregular eroded surfaces bathed in pus. The separated
epiphysis may be kept in place by the periosteum, but when this has been
detached by the formation of pus beneath it, the epiphysis is liable to
be displaced by muscular action or by some movement of the limb, or it
is the diaphysis that is displaced, for example, the lower end of the
diaphysis of the femur may be projected into the popliteal space.

The epiphysial cartilage usually continues its bone-forming functions,
but when it has been seriously damaged or displaced, the further growth
of the bone in length may be interfered with. Sometimes the separated
and displaced epiphysis dies and constitutes a sequestrum.

The adjacent joint may become filled at an early stage with a serous
effusion, which may be sterile. When the cocci gain access to the joint,
the lesion assumes the characters of a purulent arthritis, which, from
its frequency during the earlier years of life, has been called _the
acute arthritis of infants_.

Separation of an epiphysis nearly always results in infection and
destruction of the adjacent joint.

Osteomyelitis is rare in the bones of the carpus and tarsus, and the
associated joints are usually infected from the outset. In flat bones,
such as the skull, the scapula, or the ilium, suppuration usually occurs
on both aspects of the bone as well as in the marrow.

_Clinical Features._--The constitutional symptoms, which are due to the
associated toxæmia, vary considerably in different cases. In mild cases
they may be so slight as to escape recognition. In exceptionally severe
cases the patient may succumb before there are obvious signs of the
localisation of the staphylococci in the bone marrow. In average cases
the temperature rises rapidly with a rigor and runs an irregular course
with morning remissions, there is marked general illness accompanied by
headache, vomiting, and sometimes delirium.

The local manifestations are pain and tenderness in relation to one of
the long bones; the pain may be so severe as to prevent sleep and to
cause the child to cry out. Tenderness on pressure over the bone is the
most valuable diagnostic sign. At a later stage there is an ill-defined
swelling in the region of the ossifying junction, with œdema of the
overlying skin and dilatation of the superficial veins.

The swelling appears earlier and is more definite in superficial bones
such as the tibia, than in those more deeply placed such as the upper
end of the femur. It may be less evident to the eye than to the fingers,
and is best appreciated by gently stroking the bone from the middle of
its shaft towards the end. The maximum thickening and tenderness usually
correspond to the junction of the diaphysis with the epiphysis, and the
swelling tails off gradually along the shaft. As time goes on there is
redness of the skin, especially over a superficial bone, such as the
tibia, the swelling becomes softer, and gives evidence of fluctuation.
This stage may be reached at the end of twenty-four hours, or not for
some days.

Suppuration spreads towards the surface, until, some days later, the
skin sloughs and pus escapes, after which the fever usually remits and
the pain and other symptoms are relieved. The pus may contain blood and
droplets of fat derived from the marrow, and in some cases minute
particles of bone are present also. The presence of fat and bony
particles in the pus confirms the medullary origin of the suppuration.

If an incision is made, the periosteum is found to be raised from the
bone; the extent of the bare bone will be found to correspond fairly
accurately with the extent of the lesion in the marrow.

_Local Complications._--The adjacent joint may exhibit symptoms which
vary from those of a simple effusion to those of a purulent _arthritis_.
The joint symptoms may count for little in the clinical picture, or, as
in the case of the hip, may so predominate as to overshadow those of the
bone lesion from which they originated.

_Separation and displacement of the epiphysis_ usually reveals itself by
an alteration in the attitude of the limb; it is nearly always
associated with suppuration in the adjacent joint.

When _pathological fracture_ of the shaft occurs, as it may do, from
some muscular effort or strain, it is attended with the usual signs of
fracture.

_Dislocation_ of the adjacent joint has been chiefly observed at the
hip; it may result from effusion into the joint and stretching of the
ligaments, or may be the sequel of a purulent arthritis; the signs of
dislocation are not so obvious as might be expected, but it is attended
with an alteration in the attitude of the limb, and the displacement of
the head of the bone is readily shown in a skiagram.

_General Complications._--In some cases a _multiplicity of lesions_ in
the bones and joints imparts to the disease the features of pyæmia. The
occurrence of endocarditis, as indicated by alterations in the heart
sounds and the development of murmurs, may cause widespread infective
embolism, and metastatic suppurations in the kidneys, heart-wall, and
lungs, as well as in other bones and joints than those primarily
affected. The secondary suppurations are liable to be overlooked unless
sought for, as they are rarely attended with much pain.

In these multiple forms of osteomyelitis the toxæmic symptoms
predominate; the patient is dull and listless, or he may be restless and
talkative, or actually delirious. The tongue is dry and coated, the lips
and teeth are covered with sordes, the motions are loose and offensive,
and may be passed involuntarily. The temperature is remittent and
irregular, the pulse small and rapid, and the urine may contain blood
and albumen. Sometimes the skin shows erythematous and purpuric rashes,
and the patient may cry out as in meningitis. The post-mortem
appearances are those of pyæmia.

_Differential Diagnosis._--Acute osteomyelitis is to be diagnosed from
infections of the soft parts, such as erysipelas and cellulitis, and, in
the case of the tibia, from erythema nodosum. Tenderness localised to
the ossifying junction is the most valuable diagnostic sign of
osteomyelitis.

When there is early and pronounced general intoxication, there is likely
to be confusion with other acute febrile illnesses, such as scarlet
fever. In all febrile conditions in children and adolescents, the
ossifying junctions of the long bones should be examined for areas of
pain and tenderness.

Osteomyelitis has many features in common with acute articular
rheumatism, and some authorities believe them to be different forms of
the same disease (Kocher). In acute rheumatism, however, the joint
symptoms predominate, there is an absence of suppuration, and the pains
and temperature yield to salicylates.

The _prognosis_ varies with the type of the disease, with its
location--the vertebræ, skull, pelvis, and lower jaw being specially
unfavourable--with the multiplicity of the lesions, and with the
development of endocarditis and internal metastases.

_Treatment._--This is carried out on the same lines as in other pyogenic
infections.

In the earliest stages of the disease, the induction of hyperæmia is
indicated, and should be employed until the diagnosis is definitely
established, and in the meantime preparations for operation should be
made. An incision is made down to and through the periosteum, and
whether pus is found or not, the bone should be opened in the vicinity
of the ossifying junction by means of a drill, gouge, or trephine. If
pus is found, the opening in the bone is extended along the shaft as far
as the periosteum has been separated, and the infected marrow is removed
with the spoon. The cavity is then lightly packed with rubber dam, or,
as recommended by Bier, the skin edges are brought together by sutures
which are loosely tied to afford sufficient space between them for the
exit of discharge, and the hyperæmic treatment is continued.

When there is widespread suppuration in the marrow, and the shaft is
extensively bared of periosteum and appears likely to die, it may be
resected straight away or after an interval of a day or two. Early
resection of the shaft is also indicated if the opening of the medullary
canal is not followed by relief of symptoms. In the leg and forearm, the
unaffected bone maintains the length and contour of the limb; in the
case of the femur and humerus, extension with weight and pulley along
with some form of moulded gutter splint is employed with a similar
object.

Amputation of the limb is reserved for grave cases, in which life is
endangered by toxæmia, which is attributed to the primary lesion. It may
be called for later if the limb is likely to be useless, as, for
example, when the whole shaft of the bone is dead without the formation
of a new case, when the epiphyses are separated and displaced, and the
joints are disorganised.

Flat bones, such as the skull or ilium, must be trephined and the pus
cleared out from both aspects of the bone. In the vertebræ, operative
interference is usually restricted to opening and draining the
associated abscess.

#Nature's Effort at Repair.#--_In cases which are left to nature_, and
in which necrosis of bone has occurred, those portions of the periosteum
and marrow which have retained their vitality resume their osteogenetic
functions, often to an exaggerated degree. Where the periosteum has been
lifted up by an accumulation of pus, or is in contact with bone that is
dead, it proceeds to form new bone with great activity, so that the dead
shaft becomes surrounded by a sheath or case of new bone, known as the
_involucrum_ (Fig. 118). Where the periosteum has been perforated by pus
making its way to the surface, there are defects or holes in the
involucrum, called _cloacæ_. As these correspond more or less in
position to the sinuses in the skin, in passing a probe down one of the
sinuses it usually passes through a cloaca and strikes the dead bone
lying in the interior. If the periosteum has been extensively
destroyed, new bone may only be formed in patches, or not at all. The
dead bone is separated from the living by the agency of granulation
tissue with its usual complements of phagocytes and osteoclasts, so that
the sequestrum presents along its margins and on its deep surface a
pitted, grooved, and worm-eaten appearance, except on the periosteal
aspect, which is unaltered. Ultimately the dead bone becomes loose and
lies in a cavity a little larger than itself; the wall of the cavity is
formed by the new case, lined with granulation tissue. The separation of
the sequestrum takes place more rapidly in the spongy bone of the
ossifying junction than in the compact bone of the shaft.

When foci of suppuration have been scattered up and down the medullary
cavity, and the bone has died in patches, several sequestra may be
included by the new case; each portion of dead bone is slowly separated,
and comes to lie in a cavity lined by granulations.

Even at a distance from the actual necrosis there is formation of new
bone by the marrow; the medullary canal is often obliterated, and the
bone becomes heavier and denser--sclerosis; and the new bone which is
deposited on the original shaft results in an increase in the girth of
the bone--hyperostosis.

[Illustration: FIG. 118.--Shaft of Femur after Acute Osteomyelitis. The
shaft has undergone extensive necrosis, and a shell of new bone has been
formed by the periosteum.]

_Pathological fracture_ of the shaft may occur at the site of necrosis,
when the new case is incapable of resisting the strain put upon it, and
is most frequently met with in the shaft of the femur. Short of
fracture, there may be bending or curving of the new case, and this
results in deformity and shortening of the limb (Fig. 119).

The _extrusion of a sequestrum_ may occur, provided there is a cloaca
large enough to allow of its escape, but the surgeon has usually to
interfere by performing the operation of sequestrectomy. Displacement or
partial extrusion of the dead bone may cause complications, as when a
sequestrum derived from the trigone of the femur perforates the
popliteal artery or the cavity of the knee-joint, or a sequestrum of the
pelvis perforates the wall of the urinary bladder.

The extent to which bone which has been lost is reproduced varies in
different parts of the skeleton: while the long bones, the scapula, the
mandible, and other bones which are developed in cartilage are almost
completely re-formed, bones which are entirely developed in membrane,
such as the flat bones of the skull and the maxilla, are not reproduced.

[Illustration: FIG. 119.--Femur and Tibia showing results of Acute
Osteomyelitis affecting Trigone of Femur; sequestrum partly surrounded
by new case; backward displacement of lower epiphysis and implication of
knee-joint.]

It may be instructive to describe _the X-ray appearances of a long bone
that has passed through an attack of acute osteomyelitis_ severe enough
to have caused necrosis of part of the diaphysis. The shadow of the dead
bone is seen in the position of the original shaft which it represents;
it is of the same shape and density as the original shaft, while its
margins present an irregular contour from the erosion concerned in its
separation. The sequestrum is separated from the living bone by a clear
zone which corresponds to the layer of granulations lining the cavity in
which it lies. This clear zone separating the shadow of the dead bone
from that of the living bone by which it is surrounded is conclusive
evidence of a sequestrum. The medullary canal in the vicinity of the
sequestrum being obliterated, is represented by a shadow of varying
density, continuous with that of the surrounding bone. The shadow of the
new case or involucrum with its wavy contour is also in evidence, with
its openings or cloacæ, and is mainly responsible for the increase in
the diameter of the bone.

The skiagram may also show separation and displacement of the adjacent
epiphysis and destruction of the articular surfaces or dislocation of
the joint.

_Sequelæ of Acute Suppurative Osteomyelitis._--The commonest sequel is
the presence of a sequestrum with one or more discharging sinuses; owing
to the abundant formation of scar tissue these sinuses have rigid edges
which are usually depressed and adherent to the bone.

_The Recognition and Removal of Sequestra._--So long as there is dead
bone there will be suppuration from the granulations lining the cavity
in which it lies, and a discharge of pus from the sinuses, so that the
mere persistence of discharge after an attack of osteomyelitis, is
presumptive evidence of the occurrence of necrosis. Where there are one
or more sinuses, the passage of a probe which strikes bare bone affords
corroboration of the view that the bone has perished. When the dead bone
has been separated from the living, the X-rays yield the most exact
information.

The traditional practice is to wait until the dead bone is entirely
separated before undertaking an operation for its removal, from fear, on
the one hand, of leaving portions behind which may keep up the
discharge, and, on the other, of removing more bone than is necessary.
This practice need not be adhered to, as by operating at an earlier
stage healing is greatly hastened. If it is decided to wait for
separation of the dead bone, drainage should be improved, and the
infective element combated by the induction of hyperæmia.

_The operation_ for the removal of the dead bone (_sequestrectomy_)
consists in opening up the periosteum and the new case sufficiently to
allow of the removal of all the dead bone, including the most minute
sequestra. The limb having been rendered bloodless, existing sinuses are
enlarged, but if these are inconveniently situated--for example, in the
centre of the popliteal space in necrosis of the femoral trigone--it is
better to make a fresh wound down to the bone on that aspect of the
limb which affords best access, and which entails the least injury of
the soft parts. The periosteum, which is thick and easily separable, is
raised from the new case with an elevator, and with the chisel or gouge
enough of the new bone is taken away to allow of the removal of the
sequestrum. Care must be taken not to leave behind any fragment of dead
bone, as this will interfere with healing, and may determine a relapse
of suppuration.

The dead bone having been removed, the lining granulations are scraped
away with a spoon, and the cavity is disinfected.

There are different ways of dealing with a _bone cavity_. It may be
packed with gauze (impregnated with "bipp" or with iodoform), which is
changed at intervals until healing takes place from the bottom; it may
be filled with a flap of bone and periosteum raised from the vicinity,
or with bone grafts; or the wall of bone on one side of the cavity may
be chiselled through at its base, so that it can be brought into contact
with the opposite wall. The method of filling bone cavities devised by
Mosetig-Moorhof, consists in disinfecting and drying the cavity by a
current of hot air, and filling it with a mixture of powdered iodoform
(60 parts) and oil of sesame and spermaceti (each 40 parts), which is
fluid at a temperature of 112° F.; the soft parts are then brought
together without drainage. As the cavity fills up with new bone the
iodoform is gradually absorbed. Iodoform gives a dark shadow with the
X-rays, so that the process of its absorption can be followed in
skiagrams taken at intervals.

These procedures may be carried out at the same time as the sequestrum
is removed, or after an interval. In all of them, asepsis is essential
for success.

The _deformities_ resulting from osteomyelitis are more marked the
earlier in life the disease occurs. Even under favourable conditions,
and with the continuous effort at reconstruction of the bone by Nature's
method, the return to normal is often far from perfect, and there
usually remains a variable amount of hyperostosis and sclerosis and
sometimes curving of the bone. Under less favourable conditions, the
late results of osteomyelitis may be more serious. _Shortening_ is not
uncommon from interference with growth at the ossifying junction.
_Exaggerated growth_ in the length of a bone is rare, and has been
observed chiefly in the bones of the leg. Where there are two parallel
bones--as in the leg, for example--the growth of the diseased bone may
be impaired, and the other continuing its normal growth becomes
disproportionately long; less frequently the growth of the diseased
bone is exaggerated, and it becomes the longer of the two. In either
case, the longer bone becomes curved. An _obliquity_ of the bone may
result when one half of the epiphysial cartilage is destroyed and the
other half continues to form bone, giving rise to such deformities as
knock-knee and club-hand.

Deformity may also result from vicious union of a pathological fracture,
permanent displacement of an epiphysis, contracture, ankylosis, or
dislocation of the adjacent joint.

#Relapsing Osteomyelitis.#--As the term indicates, the various forms of
relapsing osteomyelitis date back to an antecedent attack, and their
occurrence depends on the capacity of staphylococci to lie latent in the
marrow.

Relapse may take place within a few months of the original attack, or
not for many years. Cases are sometimes met with in which relapses recur
at regular intervals for several years, the tendency, however, being for
the attacks to become milder as the virulence of the organisms becomes
more and more attenuated.

_Clinical Features._--Osteomyelitis in a patient over twenty-five is
nearly always of the relapsing variety. In some cases the bone becomes
enlarged, with pain and tenderness on pressure; in others there are the
usual phenomena which attend suppuration, but the pus is slow in coming
to the surface, and the constitutional symptoms are slight. The pus may
escape by new channels, or one of the old sinuses may re-open.
Radiograms usually furnish useful information as to the condition of the
bone, both as it is altered by the original attack and by the changes
that attend the relapse of the infective process.

_Treatment._--In cases of thickening of the bone with persistent and
severe pain, if relief is not afforded by the repeated application of
blisters, the thickened periosteum should be incised, and the bone
opened up with the chisel or trephine. In cases attended with
suppuration, the swelling is incised and drained, and if there is a
sequestrum, it must be removed.

#Circumscribed Abscess of Bone--"Brodie's Abscess."#--The most important
form of relapsing osteomyelitis is the circumscribed abscess of bone
first described by Benjamin Brodie. It is usually met with in young
adults, but we have met with it in patients over fifty. Several years
may intervene between the original attack of osteomyelitis and the onset
of symptoms of abscess.

_Morbid Anatomy._[7]--The abscess is nearly always situated in the
central axis of the bone in the region of the ossifying junction,
although cases are occasionally met with in which it lies nearer the
middle of the shaft. In exceptional cases there is more than one abscess
(Fig. 120). The tibia is the bone most commonly affected, but the lower
end of the femur, or either end of the humerus, may be the seat of the
abscess. In the quiescent stage the lesion is represented by a small
cavity in the bone, filled with clear serum, and lined by a fibrous
membrane which is engaged in forming bone. Around the cavity the bone is
sclerosed, and the medullary canal is obliterated. When the infection
becomes active, the contents of the cavity are transformed into a
greenish-yellow pus from which the staphylococcus can be isolated, and
the cavity is lined by a thin film of granulation tissue which erodes
the surrounding bone and so causes the abscess to increase in size. If
the erosion proceeds uniformly, the cavity is spherical or oval; if it
is more active at some points than others, diverticula or tunnels are
formed, and one of these may finally erupt through the shell of the bone
or into an adjacent joint. Small irregular sequestra are occasionally
found within the abscess cavity. In long-standing cases it is common to
find extensive obliteration of the medullary canal, and a considerable
increase in the girth of the bone.

[7] Alexis Thomson, _Edin. Med. Journ._, 1906.

[Illustration: FIG. 120.--Segment of Tibia resected for Brodie's
Abscess. The specimen shows two separate abscesses in the centre of the
shaft, the lower one quiescent, the upper one active and increasing in
size.]

The size of the abscess ranges from that of a cherry to that of a
walnut, but specimens in museums show that, if left to Nature, the
abscess may attain much greater dimensions.

The affected bone is not only thicker and heavier than normal, but may
also be curved or otherwise deformed as a result of the original attack
of osteomyelitis.

The _clinical features_ are almost exclusively local. Pain, due to
tension within the abscess, is the dominant symptom. At first it is
vague and difficult to localise, later it is referred to the interior of
the bone, and is described as "boring." It is aggravated by use of the
limb, and there are often, especially during the night, exacerbations in
which the pain becomes excruciating. In the early stages there are
periods of days or weeks during which the symptoms abate, but as the
abscess increases these become shorter, until the patient is hardly ever
free from pain. Localised tenderness can almost always be elicited by
percussion, or by compressing the bone between the fingers and thumb.
The pain induced by the traction of muscles attached to the bone, or by
the weight of the body, may interfere with the function of the limb, and
in the lower extremity cause a limp in walking. The limb may be disabled
from _involvement of the adjacent joint_, in which there may be an
intermittent hydrops which comes and goes coincidently with
exacerbations of pain; or the abscess may perforate the joint and set up
an acute arthritis.

The _diagnosis_ of Brodie's abscess from other affections met with at
the ends of long bones, and particularly from tuberculosis, syphilis,
and new growths, is made by a consideration of the previous history,
especially with reference to an antecedent attack of osteomyelitis. When
the adjacent joint is implicated, the surgeon may be misled by the
patient referring all the symptoms to the joint.

The X-ray picture is usually diagnostic chiefly because all the lesions
which are liable to be confused with Brodie's abscess--gumma, tubercle,
myeloma, chondroma, and sarcoma--give a well-marked central clear area;
the sclerosis around Brodie's abscess gives a dense shadow in which the
central clear area is either not seen at all or only faintly (Fig. 121).

_Treatment._--If an abscess is suspected, there should be no hesitation
in exploring the interior of the bone. It is exposed by a suitable
incision; the periosteum is reflected and the bone is opened up by a
trephine or chisel, and the presence of an abscess may be at once
indicated by the escape of pus. If, owing to the small size of the
abscess or the density of the bone surrounding it, the pus is not
reached by this procedure, the bone should be drilled in different
directions.

[Illustration: FIG. 121.--Radiogram of Brodie's Abscess in Lower End of
Tibia.]

#Other Forms of Acute Osteomyelitis.#--Among the less severe forms of
osteomyelitis resulting from the action of attenuated organisms are the
_serous_ variety, in which an effusion of serous fluid forms under the
periosteum; and _growth fever_, in which the child complains of vague
evanescent pains (growing pains), and of feeling tired and disinclined
to play; there may be some rise of temperature in the evening.

Infection with the _staphylococcus albus_, the _streptococcus_, or the
_pneumococcus_ also causes a mild form of osteomyelitis which may go on
to suppuration.

_Necrosis without suppuration_, described by Paget under the name "quiet
necrosis," is a rare disease, and would appear to be associated with an
attenuated form of staphylococcal infection (Tavel). It occurs in
adults, being met with up to the age of fifty or sixty, and is
characterised by the insidious development of a swelling which involves
a considerable extent of a long bone. The pain varies in intensity, and
may be continuous or intermittent, and there is tenderness on pressure.
The shaft is increased in girth as a result of its being surrounded by a
new case of bone. The resemblance to sarcoma may be very close, but the
swelling is not as defined as in sarcoma, nor does it ever assume the
characteristic "leg of mutton" shape. In both diseases there is a
tendency to pathological fracture. It is difficult also in the absence
of skiagrams to differentiate the condition from syphilitic and from
tuberculous disease. If the diagnosis is not established after
examination with the X-rays, an exploratory incision should be made; if
dead bone is found, it is removed.

In typhoid fever the bone marrow is liable to be invaded by _the typhoid
bacillus_, which may set up osteomyelitis soon after its lodgment, or it
may lie latent for a considerable period before doing so. The lesions
may be single or multiple, they involve the marrow or the periosteum or
both, and they may or may not be attended with suppuration. They are
most commonly met with in the tibia and in the ribs at the
costo-chondral junctions.

The bone lesions usually occur during the seventh or eighth week of the
fever, but have been known to occur much later. The chief complaint is
of vague pains, at first referred to several bones, later becoming
localised in one; they are aggravated by movement, or by handling the
bone, and are worst at night. There is redness and œdema of the
overlying soft parts, and swelling with vague fluctuation, and on
incision there escapes a yellow creamy pus, or a brown syrupy fluid
containing the typhoid bacillus in pure culture. Necrosis is
exceptional.

When the abscess develops slowly, the condition resembles tuberculous
disease, from which it may be diagnosed by the history of typhoid fever,
and by obtaining a positive Widal reaction.

The prognosis is favourable, but recovery is apt to be slow, and relapse
is not uncommon.

It is usually sufficient to incise the periosteum, but when the disease
occurs in a rib it may be necessary to resect a portion of bone.

#Pyogenic Osteomyelitis due to Spread of Infection from the Soft
Parts.#--There still remain those forms of osteomyelitis which result
from infection through a wound involving the bone--for example, compound
fractures, gun-shot injuries, osteotomies, amputations, resections, or
operations for un-united fracture. In all of these the marrow is exposed
to infection by such organisms as are present in the wound. A similar
form of osteomyelitis may occur apart from a wound--for example,
infection may spread to the jaws from lesions of the mouth; to the
skull, from lesions of the scalp or of the cranial bones
themselves--such as a syphilitic gumma or a sarcoma which has fungated
externally; or to the petrous temporal, from suppuration in the middle
ear.

The most common is an osteomyelitis commencing in the marrow exposed in
a wound infected with pyogenic organisms. In amputation stumps,
fungating granulations protrude from the sawn end of the bone, and if
necrosis takes place, the sequestrum is annular, affecting the
cross-section of the bone at the saw-line; or tubular, extending up the
shaft, and tapering off above. The periosteum is more easily detached,
is thicker than normal, and is actively engaged in forming bone. In the
macerated specimen, the new bone presents a characteristic coral-like
appearance, and may be perforated by cloacæ (Fig. 122).

[Illustration: FIG. 122.--Tubular Sequestrum resulting from Septic
Osteomyelitis in Amputation Stump.]

Like other pyogenic infections, it may terminate in pyæmia, as a result
of septic phlebitis in the marrow.

The _clinical features_ of osteomyelitis in _an amputation stump_ are
those of ordinary pyogenic infection; the involvement of the bone may be
suspected from the clinical course, the absence of improvement from
measures directed towards overcoming the sepsis in the soft parts, and
the persistence of suppuration in spite of free drainage, but it is not
recognised unless the bone is exposed by opening up the stump or the
changes in the bone are shown by the X-rays. The first change is due to
the deposit of new bone on the periosteal surface; later, there is the
shadow of the sequestrum.

Healing does not take place until the sequestrum is extruded or removed
by operation.

_In compound fractures_, if a fragment dies and forms a sequestrum, it
is apt to be walled in by new bone; the sinuses continue to discharge
until the sequestrum is removed. Even after healing has taken place,
relapse is liable to occur, especially in gun-shot injuries. Months or
years afterwards, the bone may become painful and tender. The symptoms
may subside under rest and elevation of the limb and the application of
a compress, or an abscess forms and bursts with comparatively little
suffering. The contents may be clear yellow serum or watery pus;
sometimes a small spicule of bone is discharged. Valuable information,
both for diagnosis and treatment, is afforded by skiagrams.

[Illustration: FIG. 123.--New Periosteal Bone on surface of Femur from
Amputation Stump. Osteomyelitis supervened on the amputation, and
resulted in necrosis at the sawn section of the bone. (Anatomical
Museum, University of Edinburgh.)]


TUBERCULOUS DISEASE

The tuberculous diseases of bone result from infection of the marrow or
periosteum by tubercle bacilli conveyed through the arteries; it is
exceedingly rare for tubercle to appear in bone as a primary infection,
the bacilli being usually derived from some pre-existing focus in the
bronchial glands or elsewhere. According to the observations of John
Fraser, 60 per cent. of the cases of bone and joint tubercle in children
are due to the bovine bacillus, 37 per cent. to the human variety, and
in 3 per cent. both types are present.

Tuberculous disease in bone is characterised by its insidious onset and
slow progress, and by the frequency with which it is associated with
disease of the adjacent joint.

#Periosteal tuberculosis# is met with in the ribs, sternum, vertebral
column, skull, and less frequently in the long bones of the limbs. It
may originate in the periosteum, or may spread thence from the marrow,
or from synovial membrane.

_In superficial bones_, such as the sternum, the formation of
tuberculous granulation tissue in the deeper layer of the periosteum,
and its subsequent caseation and liquefaction, is attended by the
insidious development of a doughy swelling, which is not as a rule
painful, although tender on pressure. While the swelling often remains
quiescent for some time, it tends to increase in size, to become boggy
or fluctuating, and to assume the characters of a cold abscess. The pus
perforates the fibrous layer of the periosteum, invading and infecting
the overlying soft parts, its spread being influenced by the anatomical
arrangement of the tissues. The size of the abscess affords no
indication of the extent of the bone lesion from which it originates. As
the abscess reaches the surface, the skin becomes of a dusky red or
livid colour, is gradually thinned out, and finally sloughs, forming a
sinus. A probe passed into the sinus strikes carious bone. Small
sequestra may be found embedded in the granulation tissue. The sinus
persists as long as any active tubercle remains in the tissues, and is
apt to form an avenue for pyogenic infection.

_In deeply seated bones_, such as the upper end of the femur, the
formation of a cold abscess in the soft parts is often the first
evidence of the disease.

_Diagnosis._--Before the stage of cold abscess is reached, the localised
swelling is to be differentiated from a gumma, from chronic forms of
staphylococcal osteomyelitis, from enlarged bursa or ganglion, from
sub-periosteal lipoma, and from sarcoma. Most difficulty is met with in
relation to periosteal sarcoma, which must be differentiated either by
the X-ray appearances or by an exploratory incision.

_X-ray appearances in periosteal tubercle_: the surface of the cortical
bone in the area of disease is roughened and irregular by erosion, and
in the vicinity there may be a deposit of new bone on the surface,
particularly if a sinus is present and mixed infection has occurred; in
_syphilis_ the shadow of the bone is denser as a result of sclerosis,
and there is usually more new bone on the surface--hyperostosis; in
_periosteal sarcoma_ there is greater erosion and consequently greater
irregularity in the contour of the cortical bone, and frequently there
is evidence of formation of bone in the form of characteristic spicules
projecting from the surface at a right angle.

The early recognition of periosteal lesions in the articular ends of
bones is of importance, as the disease, if left to itself, is liable to
spread to the adjacent joint.

The _treatment_ is that of tuberculous lesions in general; if
conservative measures fail, the choice lies between the injection of
iodoform, and removal of the infected tissues with the sharp spoon. In
the ribs it is more satisfactory to remove the diseased portion of bone
along with the wall of the associated abscess or sinus. If all the
tubercle has been removed and there is no pyogenic infection, the wound
is stitched up with the object of obtaining primary union; otherwise it
is treated by the open method.

#Tuberculous Osteomyelitis.#--Tuberculous lesions in the marrow occur as
isolated or as multiple foci of granulation tissue, which replace the
marrow and erode the trabeculæ of bone in the vicinity (Fig. 124). The
individual focus varies in size from a pea to a walnut. The changes that
ensue resemble in character those in other tissues, and the extent of
the destruction varies according to the way in which the tubercle
bacillus and the marrow interact upon one another. The granulation
tissue may undergo caseation and liquefaction, or may become
encapsulated by fibrous tissue--"encysted tubercle."

[Illustration: FIG. 124.--Tuberculous Osteomyelitis of Os Magnum,
excised from a boy æt. 8. Note well-defined caseous focus, with several
minute foci in surrounding marrow.]

Sometimes the tuberculous granulation tissue spreads in the marrow,
assuming the characters of a diffuse infiltration--diffuse tuberculous
osteomyelitis. The trabecular framework of the bone undergoes erosion
and absorption--rarefying ostitis--and either disappears altogether or
only irregular fragments or sequestra of microscopic dimensions remain
in the area affected. Less frequently the trabecular framework is added
to by the formation of new bone, resulting in a remarkable degree of
sclerosis, and if, following upon this, there is caseation of the
tubercle and death of the affected portion of bone, there results a
sequestrum often of considerable size and characteristic shape, which,
because of the sclerosis and surrounding endarteritis, is exceedingly
slow in separating. When the sequestrum involves an articular surface it
is often wedge-shaped; in other situations it is rounded or truncated
and lies in the long axis of the medullary canal (Fig. 125). Finally,
the sequestrum lies loose in a cavity lined by tuberculous granulation
tissue, and is readily identified in a radiogram. This type of sclerosis
preceding death of the bone is highly characteristic of tuberculosis.

[Illustration: FIG. 125.--Tuberculous Disease of Child's Tibia,
showing sequestrum in medullary cavity, and increase in girth from
excess of new bone.]

_Clinical Features._--As a rule, it is only in superficially placed
bones, such as the tibia, ulna, clavicle, mandible, or phalanges, that
tuberculous disease in the marrow gives rise to signs sufficiently
definite to allow of its clinical recognition. In the vertebræ, or in
the bones of deeply seated joints, such as the hip or shoulder, the
existence of tuberculous lesions in the marrow can only be inferred from
indirect signs--such, for example, as rigidity and curvature in the case
of the spine, or from the symptoms of grave and persistent joint-disease
in the case of the hip or shoulder.

With few exceptions, tuberculous disease in the interior of a bone does
not reveal its presence until by extension it reaches one or other of
the surfaces of the bone. In the shaft of a long bone its eruption on
the periosteal surface is usually followed by the formation of a cold
abscess in the overlying soft parts. When situated in the articular ends
of bones, the disease more often erupts in relation to the reflection of
the synovial membrane or directly on the articular surface--in either
case giving rise to disease of the joint (Fig. 156).

[Illustration: Fig. 126.--Diffuse Tuberculous Osteomyelitis of Right
Tibia.

(Photograph lent by Sir H. J. Stiles.)]

#Diffuse Tuberculous Osteomyelitis in the shaft of a long bone# is
comparatively rare, and has been observed chiefly in the tibia and the
ulna in children (Fig. 126). It commences at the growing extremity of
the diaphysis, and spreads along the medulla to a variable extent; it is
attended by the formation of vascular and porous bone on the surface,
which causes thickening of the diaphysis; this is most marked at the
ossifying junction and tapers off along the shaft. The infection not
only spreads along the medulla, but it invades the spongy bone
surrounding this, and then the cortical bone, and is only prevented from
reaching the soft parts by the new bone formed by the periosteum. The
bone is replaced by granulation tissue, and disappears, or part of it
may become sclerosed and in time form a sequestrum. In the macerated
specimen, the sequestrum appears small in proportion to the large cavity
in which it lies. All these changes are revealed in a good skiagram,
which not only confirms the diagnosis, but, in many instances,
demonstrates the extent of the disease, the presence or absence of a
sequestrum, and the amount of new bone on the surface. Finally the
periosteum gives way, and an abscess forms in the soft parts; and if
left to itself ruptures externally, leaving a sinus. The most
satisfactory _treatment_ is to resect sub-periosteally the diseased
portion of the diaphysis.

_In cancellous bones, such as those of the tarsus_, there is a similar
caseous infiltration in the marrow, and this may be attended with the
formation of a sequestrum either in the interior of the bone or
involving its outer shell, as shown in Fig. 127. The situation and
extent of the disease are shown in X-ray photographs. After the
tuberculous granulation tissue erupts through the cortex of the bone, it
gives rise to a cold abscess or infects adjacent joints or tendon
sheaths.

[Illustration: FIG. 127.--Advanced Tuberculous Disease in region of
Ankle. The ankle-joint is ankylosed, and there is a large sequestrum in
the calcaneus.

(Specimen in Anatomical Museum, University of Edinburgh.)]

If an exact diagnosis is made at an early stage of the disease--and this
is often possible with the aid of X-rays--the affected bone is excised
sub-periosteally or its interior is cleared out with the sharp spoon and
gouge, the latter procedure being preferred in the case of the
_calcaneus_ to conserve the stability of the heel. When several bones
and joints are simultaneously affected, and there are sinuses with
mixed infection, amputation is usually indicated, especially in adults.

#Tuberculous dactylitis# is the name applied to a diffuse form of the
disease as it affects the phalanges, metacarpal or metatarsal bones. The
lesion presents, on a small scale, all the anatomical changes that have
been described as occurring in the medulla of the tibia or ulna, and
they are easily followed in skiagrams. A periosteal type of dactylitis
is also met with.

The _clinical features_ are those of a spindle-shaped swelling of a
finger or toe, indolent, painless, and interfering but little with the
function of the digit. Recovery may eventually occur without
suppuration, but it is common to have the formation of a cold abscess,
which bursts and forms one or more sinuses. It may be difficult to
differentiate tuberculous dactylitis from the enlargement of the
phalanges in inherited syphilis (syphilitic dactylitis), especially when
the tuberculous lesion occurs in a child who is the subject of inherited
syphilis.

[Illustration: FIG. 128.--Tuberculous Dactylitis.]

In the syphilitic lesion, skiagrams usually show a more abundant
formation of new bone, but in many cases the doubt is only cleared up by
observing the results of the tuberculin test or the effects of
anti-syphilitic treatment.

Sarcoma of a phalanx or metacarpal bone may closely resemble a
dactylitis both clinically and in skiagrams, but it is rare.

_Treatment._--Recovery under conservative measures is not uncommon, and
the functional results are usually better than those following upon
operative treatment, although in either case the affected finger is
liable to be dwarfed (Fig. 129). The finger should be immobilised in a
splint, and a Bier's bandage applied to the upper arm. Operative
interference is indicated if a cold abscess develops, if there is a
persistent sinus, or if a sequestrum has formed, a point upon which
information is obtained by examination with the X-rays. When a toe is
affected, amputation is the best treatment, but in the case of a finger
it is rarely called for. In the case of a metacarpal or metatarsal bone,
sub-periosteal resection is the procedure of choice, saving the
articular ends if possible.

[Illustration: FIG. 129.--Shortening of Middle Finger of Adult, the
result of Tuberculous Dactylitis in childhood.]


SYPHILITIC DISEASE

Syphilitic affections of bone may be met with at any period of the
disease, but the graver forms occur in the tertiary stage of acquired
and inherited syphilis. The virus is carried by the blood-stream to all
parts of the skeleton, but the local development of the disease appears
to be influenced by a predisposition on the part of individual bones.

Syphilitic diseases of bone are much less common in practice than those
due to pyogenic and tuberculous infectious, and they show a marked
predilection for the tibia, sternum, and skull. They differ from
tuberculous affections in the frequency with which they attack the
shafts of bones rather than the articular ends, and in the comparative
rarity of joint complications.

_Evanescent periostitis_ is met with in acquired syphilis during the
period of the early skin eruptions. The patient complains, especially at
night, of pains over the frontal bone, ribs, sternum, tibiæ, or ulnæ.
Localised tenderness is elicited on pressure, and there is slight
swelling, which, however, rarely amounts to what may be described as a
_periosteal node_.

In the later stages of acquired syphilis, _gummatous periostitis and
osteomyelitis_ occur, and are characterised by the formation in the
periosteum and marrow of circumscribed gummata or of a diffuse gummatous
infiltration. The framework of the bone is rarefied in the area
immediately involved, and sclerosed in the parts beyond. If the
gummatous tissue degenerates and breaks down, and especially if the
overlying skin is perforated and septic infection is superadded, the
bone disintegrates and exhibits the condition known as _syphilitic
caries_; sometimes a portion of bone has its blood supply so far
interfered with that it dies--_syphilitic necrosis_. Syphilitic
sequestra are heavier and denser than normal bone, because sclerosis
usually precedes death of the bone. The bones especially affected by
gummatous disease are: the skull, the septum of the nose, the nasal
bones, palate, sternum, femur, tibia, and the bones of the forearm.

_In the bones of the skull_, gummata may form in the peri-cranium,
diploë, or dura mater. An isolated gumma forms a firm elastic swelling,
shading off into the surroundings. In the macerated bone there is a
depression or an actual perforation of the calvaria; multiple gummata
tend to fuse with one another at their margins, giving the appearance of
a combination of circles: these sometimes surround an area of bone and
cut it off from its blood supply (Fig. 130). If the overlying skin is
destroyed and septic infection superadded, such an isolated area of bone
is apt to die and furnish a sequestrum; the separation of the dead bone
is extremely slow, partly from the want of vascularity in the sclerosed
bone round about, and partly from the density of the sequestrum. In
exceptional cases the necrosis involves the entire vertical plate of the
frontal bone. Pus is formed between the bone and the dura (suppurative
pachymeningitis), and this may be followed by cerebral abscess or by
pyæmia. Gummatous disease in the wall of the orbit may cause
displacement of the eye and paralysis of the ocular muscles.

[Illustration: FIG. 130.--Syphilitic Disease of Skull, showing a
sequestrum in process of separation.]

On the inner surface of the skull, the formation of gummatous tissue may
cause pressure on the brain and give rise to intense pain in the head,
Jacksonian epilepsy, or paralysis, the symptoms varying with the seat
and extent of the disease. The cranial nerves may be pressed upon at the
base, especially at their points of exit, and this gives rise to
symptoms of irritation or paralysis in the area of distribution of the
nerves affected.

_In the septum of the nose, the nasal bones, and the hard palate_,
gummatous disease causes ulceration, which, beginning in the mucous
membrane, spreads to the bones, and being complicated with septic
infection leads to caries and necrosis. In the nose, the disease is
attended with stinking discharge (ozœna), the extrusion of portions of
dead bone, and subsequently with deformity characterised by loss of the
bridge of the nose; in the palate, it is common to have a perforation,
so that the air escapes through the nose in speaking, giving to the
voice a characteristic nasal tone.

_Syphilitic disease of the tibia_ may be taken as the type of the
affection as it occurs _in the long bones_. Gummatous disease in the
periosteum may be localised and result in the formation of a
well-defined node, or the whole shaft may become the seat of an
irregular nodular enlargement (Fig. 132). If the bone is macerated, it
is found to be heavier and bulkier than normal; there is diffuse
sclerosis with obliteration of the medullary canal, and the surface is
uneven from heaping up of new bone--hyperostosis (Fig. 131). If a
periosteal gumma breaks down and invades the skin, a syphilitic ulcer is
formed with carious bone at the bottom. A central gumma may eat away the
surrounding bone to such an extent that the shaft undergoes pathological
fracture. In the rare cases in which it attacks the articular end of a
long bone, gummatous disease may implicate the adjacent joint and give
rise to syphilitic arthritis.

[Illustration: FIG. 131.--Syphilitic Hyperostosis and Sclerosis of
Tibia, on section and on surface view.]

_Clinical Features._--There is severe boring pain--as if a gimlet were
being driven into the bone. It is worst at night, preventing sleep, and
has been ascribed to compression of the nerves in the narrowed Haversian
canals.

The _periosteal gumma_ appears as a smooth, circumscribed swelling which
is soft and elastic in the centre and firm at the margins, and shades
off into the surrounding bone. The gumma may be completely absorbed or
it may give place to a hard node. In some cases the gumma softens in the
centre, the skin becomes adherent, thin, and red, and finally gives way.
The opening in the skin persists as a sinus, or develops into a typical
ulcer with irregular, crescentic margins; in either case a probe reveals
the presence of carious bone or of a sequestrum. The health may be
impaired as a result of mixed infection, and the absorption of toxins
and waxy degeneration in the viscera may ultimately be induced.

A _central gumma_ in a long bone may not reveal its presence until it
erupts through the shell and reaches the periosteal surface or invades
an adjacent joint. Sometimes the first manifestation is a fracture of
the bone produced by slight violence.

In radiograms the appearance of syphilitic bones is usually
characteristic. When there is hyperostosis and sclerosis, the shaft
appears denser and broader than normal, and the contour is uneven or
wavy. When there is a central gumma, the shadow is interrupted by a
rounded clear area, like that of a chondroma or myeloma, but there is
sclerosis round about.

_Diagnosis._--The conditions most liable to be mistaken for syphilitic
disease of bone are chronic staphylococcal osteomyelitis, tuberculosis,
and sarcoma; and the diagnosis is to be made by the history and progress
of the disease, the result of examination with the X-rays, and the
results of specific tests and treatment.

_Treatment._--The general health is to be improved by open air, by
nourishing food, and by the administration of cod-liver oil, iron, and
arsenic. Anti-syphilitic remedies should be given, and if they are
administered before there is any destruction of tissue, the benefit
derived from them is usually marked.

Radiograms show the rapid absorption of the new bone both on the surface
and in the marrow, and are of value in establishing the therapeutic
diagnosis.

In certain cases, and particularly when there are destructive changes in
the bone complicated with pyogenic infection, specific remedies have
little effect. In cases of persistent or relapsing gummatous disease
with ulceration of skin, it is often necessary to remove the diseased
soft parts with the sharp spoon and scissors, and to gouge or chisel
away the unhealthy bone, on the same lines as in tuberculous disease.
When hyperostosis and sclerosis of the bone is attended with severe pain
which does not yield to blistering, the periosteum may be incised and
the sclerosed bone perforated with a drill or trephine.

#Lesions of Bone in Inherited Syphilis.#--_Craniotabes_, in which the
flat bones of the skull undergo absorption in patches, was formerly
regarded as syphilitic, but it is now known to result from prolonged
malnutrition from any cause. _Bossing of the skull_ resulting in the
formation of Parrot's nodes is also being withdrawn from the category of
syphilitic affections. The lesions in infancy--epiphysitis, bossin