Digitized by the Internet Archive in 2010 with funding from Columbia University Libraries, http://www.archive.org/details/principlesofsurgOOsenn Principles of Surgery, N. SKNN, M.E)., Ph.D., Professor Pki.nciples of Scrgery axd Surgical Pathology in the Risk ilEuiCAL College, Chicago, III. Professor of Surgery in the Chicago Polyclinic; Atte.vding Surgeo.v to the Milwaukee Hospital; Consulting Surgeon to the Milwaukee County Hospital and to the Milwaukee County Insane Asylum; Honorary Fellow College of Physicians in Philadelphia, Pa.: Member of the American Surgical Association, of the American Medical Association, of the British Medical Association, of the Wisconsin State Medical Society, etc. ILLUSTRATED WITH 109 WOOD-ENGRAVINGS. PHILADELPHIA AND LONDON : F. A. DAVIS, PUBLISHER, 1890. 3/ 60S' Entered according to Act of Congress, in the vear 1890, by * F. A. DAVIS, In the Office of tlie Librarian of Congress, at Washington, D. C, U. S. A. Philadelphia, Pa., XT. S. A. The Medical Bulletin Printing House, 1231 Filbert Street. I ^ . PREFACE A iMODERN work on the principles of surgen^ in the English language has become a generally and well-recognized necessity. The recent great discoveries relating to the etiology and pathology of surgical diseases have made the text-books of only a few years ago old and almost worthless. The many treatises on surgery, by American and English authors, which have made tlieir appearance in rapid succession during the last ten years or more, are replete with valuable practical information, but most of them are defective in those parts relating to the matter treating of the fundamental principles of the art and science of surgery. It has been my aim to write a book for the student and general practitioner which should, at least in part, fill this gap in surgical literature, and which should serve the purpose of a systematic treatise on the causation, pathology, diagnosis, prog- nosis, and treatment of the injuries and affections which the surgeon is most frequently called upon to treat. The successful study and practice of any branch of the healing art require a thorough knowledge of the principles upon which it is based. The student who has mastered the principles of surgery will have no difficulty in applying his knowledge in practice, while the one who has burdened his memory with numerous details to meet special indications is always at a loss in making prompt and judicious use of his therapeutic resources when confronted by rare lesions or unexpected emergencies. (iii) IV PREFACE. In writing this book it has been my intention to keep in constant view the difference between the cellular processes, as we observe them in regeneration and inflammation, and to connect the modern science of bacteriology more intimately with the etiology and pathology of surgical affections than has here- tofore been done by most authors who have written on the same subjects. In showing the direct etiological relationship which exists between certain pathogenic micro-organisms and definite pathological processes, I have frequently made liberal use of the experimental and clinical material contained in my work on " Surgical Bacteriology." When the subject of tumors was reached it was found that the manuscript had become so voluminous that it was deemed advisable to publish the volume without this part of the intended scope of the work, — an arrangement to which the publisher kindly gave his consent. It is the author's intention to make good this defect by the preparation, in the near future, of a special work on " The Pathology and Surgical Treatment of Tumors." With few exceptions the sources from which my informa- tion was taken are not given, as a copious bibliography would have required considerable valuable space. At the same time the author hopes that he has presented the views and opinions of the authorities quoted with sufficient clearness and thorough- ness to render a resort to the original articles, in most instances, unnecessary. Among the text-books which I have consulted I desire to mention the following : Histology : Klein, Schafer, Heitzmann, and Satterthwaite. Pathology: Klebs, Hamilton, Birch-Hirschfeld, Paget, Virchow, Coates, Lebert, Rindfleisch, Delafield, and Prudden. The Principles of Surgery: Konig, Hueter-Lossen, Landerer, Billroth- Winiwarter, and Van Buren. Bacteriology : Fluegge, Baumgarten, and Cruikshank. The PREFACE. V illustrations were selected from modern text-books not readily accessible to the average student. A prolonged absence from home made it impossible for the author to attend to the proof-reading, and he asks the indulg- ence of the reader for any imperfections which may appear in the book from any sources for which he cannot be held person- ally responsible. Should this volume become the means of lightening and facilitating the student's work in acquiring a thorough knowl- edge of the fundamental principles of surgery, and of serving as a useful source of information for the busy general practitioner, the author will feel abundantly rewarded for the many sleepless nights which were required in its preparation. N. Senn. MiLWACKKB, October, 1890. TABLE OF CONTENTS. PAGE Preface, iii Table of Contents. vii List of Illustrations, xi CHAPTER I. Regeneration, 1 CHAPTER II. Regeneration of Different Tissues, 31 CHAPTER III. Inflammation, 67 CHAPTER IV. Inflammation {continued), 93 CHAPTER V. Pathogenic Bacteria .127 CHAPTER VI. Necrosis, . . . . . . . . . . . .157 CHAPTER VII. Necrosis (continued), . . . . . . . . .17;') (vii) VI 11 TABLE OF COiN TENTS. CHAPTER VIII. PAGK Suppuration, 191 CHAPTER IX. Suppuration {continued), . . . . . . . .20'.' CHAPTER X. Suppurative Osteomyelitis, . . 231 CHAPTER XI. SuppuRATiuiN IN Large Cavities; Abscess of Internal Organs, 259 CHAPTER XII. SEPTICiEMIA, 30o CHAPTER XIII. Pyemia, 333 CHAPTER XIV. Erysipelas, 359 CHAPTER XV. Tetanus, 383 CHAPTER XVI Hydrophobia, . . . • 403 CHAPTER XVII. Surgical Tuberculosis 419 CHAPTER XVIII. Clinical Forms of Surgical Tuberculosis, . . . .447 TABLE Oi' (UNTENTS. ix CHAPTER XIX. PASE Tuberculosis of Lymphatic Glands and Peritoneum, . . . 469 CHAPTER XX. Tuberculosis of Bones and Joints, 489 CHAPTER XXI. Tuberculosis of Tendon-Sheaths, etc., 525 CHAPTER XXII. Actinomycosis Ho.minis, 549 CHAPTER XXIII. Anthrax, 571 CHAPTER XXIV. Gj.anders, 589 Index, 603 LIST OF ILLUSTRATIONS. FIG. PAGE 1. A wound twenty-six hours old (Thiersch), 4 2. " " " " 5 3. Quiescent nucleus (Fleming), . 8 4. Living cell of salamander (Fleming), 8 5. Endothelial cells (Fleming), 9 6. Epithelial cell of salamander (Fleming), 10 7. " " " 10 8. " " " 11 9. Cell division (McKendrick), 13 10. Granulating wound (Billroth- Winiwarter), 14 11. Granulation tissue from wound (Hamilton), 15 13. Superficial capillaries of a wound beginning to granulate (Hamilton), . . 17 13. Formation of new blood-vessels by budding (Arnold), 18 14. Development of blood-corpuscles in connective-tissue cells, and transformation of the latter into capillary blood-vessels (Fluegge), 19 15. Granulating wound undergoing cicatrization (Landerer), 20 16. Embryonal connective-tissue cell undergoing transformation into mature state (Ziegler), 21 17. Wandering epithelial cells from frog (Klebs), 22 18. Corneal corpuscles in a state of proliferation (Senftleben), 33 19. Wound of cornea (vou Wyss), 34 20. Rhinoplasty and transplantation of large skin-grafts (Thiersch), .... 40 21. Microscopical appearances of the interior of artery of dog, 43 22. Microscopical appearances of the interior of vein of dog, 44 23. Femoral artery of dog, 45 24. Muscular fibres near a wound in a state of proliferation (0. Weber), ... 48 25. Section through callus (Bajardi), 51 26. Transverse section through callus (Maas), .52 27. Nerve-fibre in state of regeneration (Gluck), 61 28. Longitudinal section through nerve (Gluck), 62 29. Nerve suture, showing application of direct and paraneurotic sutures, . . 63 30. Capillary vessels of the frog's mesentery (Klein), 69 31. Leucocyte, showing reticulum of protoplasmic strings (Klein), .... 70 32. Change of forms of a moving leucocyte by amoeboid movements (Klein), . . 71 33. Third corpuscle (Eberth and Schimmelbusch), . . ..... 72 34. Normal circulation in frog's web (Landerer), . 78 35. Capillaries of frog's web in a state of hypersemia (Landerer), .... 79 36. Leucocyte passing through capillary wall (Landerer), 86 37. Inflammation of frog's web at stage where capillary stream is impeded by com- mencing emigration (Landerer), 88 88. Germinating endothelium (Hamilton), 97 (Xi) XI 1 LIST OF ILLFSTRATTONS. KlU. PAGE 39. Omentum of young dog, experimentally Inflamed (Hamilton), . . . .98 40. Aeute pleurisy (Hamilton), 99 41. Artificial keratitis (Hamilton), 106 42. Phagocytosis, Ill 43. Different forms of bacteria (Baumgarten), 128 44. Endogenous spore production in bacillus anthracis (Baumgarten), . . . 130 45. Spore of bacillus of anthrax (De Bary), 131 4fi. Gelatin cultures following surface inoculation (Fluegge), 132 47. Cultures in gelatin growing in tlie track made by the needle (Fluegge), . . 133 4S. Experimentally-produced growth of streptococci in centre of cornea of rabbit (Baumgarten), 161 49. Microscopic pictures of staphylococcus (Rosenbach), 301 .50. Micrococcus pyogenes tenuis, cultivated from pus in a case of empyema (Rosen- bach), 203 .51. Microscopic picture of streptococcus pyogenes (Rosenbach), .... 203 .52. Bacillus pyogenes foetidus (Fluegge), 204 .53. Bacillus pj'ocyaneus (Fluegge), 204 54. White corpuscles and pus-corpuscles (Koch), 206 55. Fragmentation of nucleus in leucocytes undergoing transformation into pus- corpuscles (Landerer), 207 .56. Pus with staphylococcus (Fluegge), 208 .57. Pus with streptococcus (Fluegge), 208 58. Pus-corpuscles (Billroth-Winiwarter), 208 .59. Infiltration of connective tissue of cutis, with beginning suppuration in the centre (Billroth- Winiwarter), 213 60. Vessels (artificially injected) from walls of an abscess artificially produced in the tongue of a dog (Billroth-Winiwarter), 214 61. Gonococcus (Bumm), 260 62. Motor areas (London Lancet), 274 63. Wilson's cyrtometer (Loudon Lancet), 276 64. Wilson's cyrtometer applied (London ianceO) 276 65. Head, skull, and cerebral fissures (adapted from Marshall), 277 66. Vein of the diaphragm of a septicaemic mouse (Koch), 305 67. Glomerulus of a septicsemic rabbit (Koch), 807 68. Capillary vessels surrounding the Intestinal glands of a septicsemlc rabbit (Koch), 308 69. Bacillus of malignant oedema (Koch), 309 70. Spore formation in bacillus of malignant cedema(Fluegge), 309 71. Cultures of bacillus of malignant oedema in gelatin (Fluegge), . . . .310 72. Bacillus saprogenes 1 (Rosenbach), 315 73. Bacillus saprogenes 2 (Rosenbach), 315 74. Bacillus saprogenes 3 (Rosenbach), • • • 315 75. Proteus vulgaris (Hauser), 316 76. Proteus mirabilis (Hauser), 317 77. Involution forms of proteus mirabilis (Hauser), . . • ■ • • .318 78. Vessel from the cortex of the kidney of a pysemic rabbit (Koch), . . .336 79. Laminated thrombus in a vein (Birch-Hirschfeld), 342 80. Thrombo-phlebltis (Billroth), 343 81. Embolus of branch of pulmonary artery (Birch-Hlrechfeld), . . . .345 82. Pysemic abscess of lung (Hamilton), 346 83. Coagulation necrosis from a kidney infarct (Birch-Hirschfeld), . . . .347 84. Pysemic pus, showing complete nuclear destruction in corpuscles and an abundance of pus-microbes within and between pus-corpuscles (Landerer), . 351 LIST OF ILLUSTRATIONS. XUl FIQ. I'AGK 85. Section of ear of rabbit parallel to surface of cartilage. The morbid process resembled erj'sipelas (Koch), 360 86. Streptococcus erysipelatosus (Baumgarten), 361 87. Stale culture of streptococcus of erysipelas in gelatin (Baumgarten), . . . 362 88. Section through skin near the margin of the erysipelatous zone (Koch), . . 36.^ 89. Tetanus bacilli (Frankel-Pfeift'er), 384 90. A blood-vessel from medulla oblongata in a case of hydrophobia (Coates), . . 411 91. From the salivary gland in a case of hydrophobia (Coates), 412 93. Tubercle bacilli containing spores (Koch), 423 93. Giant cell with one tubercle bacillus (Fluegge), 424 94. Giant cell. Miliary tuberculosis (Fluegge), 424 9.5. Cover-glass preparation from phthisical sputum (Baumgarten), .... 425 96. Giant cell from centre of tubercle of lung (Hamilton), 438 97. Section from mucous membrane of pharynx, showing epithelioid cells with a few small giant cells (Birch-Hirschfeld), 440 98. Fully-developed reticular tubercle of lung (Hamilton), 441 99. Ray-fungus, with one of the rays more projecting and branching (Ponflck), . 550 100. Actinomyces. Section from actinomycotic swelling (Fluegge), .... 554 101. Actinomyces from lung of cow (Marchand), 563 102. Anthrax bacilli. Spore formation and spore germination (Koch), . . . 572 103. Stab culture of anthrax bacilli in gelatin (Baumgarten), 573 104. Anthrax colony upon gelatin (Fluegge), 574 105. Intestinal villus of anthracic rabbit (Koch), 575 106. Anthrax (Fluegge), 582 107. Bacilli of glanders from a j'oung potato culture (Baumgarten), .... 590 108. Glanderous nodule from the liver of a field-mouse (Baum-garten), . . . 592 109. Acute glanders, involving nose and face, showing extent of local lesions (Birch- Hirschfeld), 598 PRINCIPLES OF SURGERY. CHAPTER I. Regeneration. Regeneration includes a multitude of processes which are intended to repair the normal phj'siological waste of the tissues in the living body or to restore tissues lost b}- injur}- or disease. In the human body normal regeneration or repair of tissues is a physiological process,.which is essential for the maintenance of the anatomical perfection and func- tional activity of the different tissues and organs. In a condition of perfect health, in the full-grown bod}', the normal waste incident to the increasing activity of the tissues is balanced I)}' this reparative process, while during the development of the bod}- an excess of material is added upon which depends the increase of tissue which constitutes growth. If cell-destruction is in excess of cell-reproduction atropln' is the inevi- table result, and if the function of regeneration is comi^letel}- suspended death must necessaril}- ensue, the blood being the first tissue the seat of extreme atrophic changes, soon to be followed b}' similar changes in all the tissues, resulting in diminution of function proportionate to the de- gree of atrophy, and, finally, death from marasmus. Studied from a surgical aspect, regeneration includes the process observed in the healing of wounds produced by a trauma and the com- plete or partial restoration of parts damaged or destro^'ed by the action of chemical substances, extremes of cold or heat, and the various de- structive inflammatory processes caused b}- the presence of specific pathogenic micro-organisms. Regeneration and inflammation are dis- tinct conditions, which should no longer be confounded or considered from the same etiological and pathological stand-point. An ideal regen- eration takes place without inflammation provided the seat of injury or tissue-destruction remains aseptic ; that is, free from pathogenic microbes. On the other hand, a regenerative process within or around an inflamma- tory focus can only be established in tissues in which the cause which has produced the inflammation has not been sufficientl}' intense to destro}^ the proto|)lasm of the cells. Under these circumstances the reparative process is initiated at a time when the cause which has given rise to the (1) 2 PRINCIPLES OP SUPOKKV. inflammation lias ceased to be active, or in tissues not deprived of theil* vegetative power by its action. In a circumscribed suppurative inflam- mation the cells exposed to the direct action of the pus-microbes and their ptomaines are destroyed, and the process of repair starts from th( abscess-walls and their immediate vicinity, from tissues which have re- tained their power of cell-i)rol iteration. An^'^ organ the seat of a tuber- cular infection, in which the parasitic cause is not sulficientl}' intense to destroy the vitality of the cells, retains its normal structure and function b}^ virtue of this intrinsic power of regeneiation of its cells. All repara- tive processes consist of homologous cell-development, and the new tissue resembles, anatomically and phj'siologicall}-, the fixed cells from which it is produced. The legitimate succession of cells is now a well- established law in pathology as well as embryology, and, according to this tissue, is never produced b}' substitution of function. According to this histogenetic law, each cell-element possesses an intrinsic vegeta- tive power from the earliest embr3'onal elevelopment throughout life, which, in case of loss of tissue b^^ injury or disease, enables it to produce its owni kind and never any other materially different histological struc- ture. In conformity with this general law of tissue-production, an injur}- or defect of a nerve-fibre is repaired by proliferation from pre-existing cells which compose this structure, epithelial cells are produced only by epithelial cells, new vessels are formed from cells which exist in a normal vessel-wall, etc. From this stand-point will be considered — I. HEALING OF WOUNDS. A wound may be defined as a sudden solution of continuit}- of any of the tissues of the body caused by the application of mechanical force. A wound is open or subcutaneous according as the surface covering the skin or mucous membrane has been cut or torn or has remained intact. Since the introduction of the antiseptic treatment of wounds, the classi- fication into open and subcutaneous wounds is no longer of the same practical importance, as an open wound, under careful antiseptic treat- ment, is at once placed under the same favorable conditions for a satis- factory and rapid healing as a subcutaneous wound. All wounds, irre- spective of the anatomical structure of the tissues involved, heal by the production of new material from pre-existing fixed tissue-cells. The fixed tissue-cells at the site of injury being endowed from earliest embryonal life with a peculiar power of adaptation to existing conditions surround- ing them, assume active tissue proliferation, and the embrj'onal cells thus produced constitute the granulation-tissue, whicii, toward the completion of the healing process, is transformed into mature cells, representing the tissue or tissues which have undergone the reparative process. IMMEDIATE OR DIRECT UNION. 3 IMMEDIATE OR DIRECT UNION. Since the time of Jolin Hunter a great deal lias been said and written on immediate or direct union of Avounds, Hunter believed that this method of healing would be accomplished within a few hours, and without the interposition of new material between the accurately coapted surfaces. Macartney was a supporter of this view, as will be seen fiom the following: "The circumstances under Avhich immediate union is effected are the cases of incised wounds that admit of being, with safety and propriety, closely and immediately bound up. The blood, if any be shed on the surface of the wouiid, is thus pressed out, and the divided blood-vessels and nerves are brought into perfect contact, and union ma^' take place in a few hours ; and, as no intermediate substance exists in a wound so healed, no mark or cicatrix is left behind." Paget applies this method of healing to large wounds where rapid union is accomplished, and where, on examination, no interposed tissue is found between their edges. Such a case came under his own observation. A patient on whom he had performed an operation for the removal of a carcinomatous breast died from an attack of erysipelas a few da3-s later. Examination showed that firm union had taken place apparently without an}- inter- mediate material. He also made three experiments on raljbits for the purpose of studying this rapid method of repair. The hair was removed, the skin incised, and the wound accurateh' sutured. Three days later he examined the parts, and found the wound quite firmly united, without an}- macroscopical evidences of inflammation. On microscopical examina- tion, he found some exudation material in the immediate vicinit}' of the Avound. Among the more modern investigators, we find Thiersch still up- holding the possibility of immediate union b}- direct cohesion of similar parts. He studied the repair of wounds in the tongue of guinea-pigs. The tongue was incised in a longitudinal direction, and the parts were examined a few hours to several days after the injury had been in- flicted. Before sections were made for microscopical examination the lingual vessels were injected with liquid glue stained with carmine. In specimens where the wound was only a few hours old lie found, at least, parts of the wound firmly adherent, and on microscopical examination he satisfied himself that the connective tissue, saturated with blood and plasma, had formed an immediate and permanent union. He described also a plasmatic circulation in the wound which he considered of great importance for the nutrition of the tissues. He believed that these new cliaiinels, by becoming paved with the adjacent connective cells, could be transformed into permanent blood-vessels. The same section examined under a higher power furnishes a good PRINCIPLES OF SURGERY. .S'.' \ illiistnition of the part taken by the fixed tissue-cell in the repair of the wound. Some surgeons still believe in immediate union in the repair of wounds of nerves, as many cases have been reported where complete restora- tion of function was claimed to have been establislied within a few hours after nerve suture. Such observations are not free from criticism, because functional results after nerve suture maj' lead to wrong conclusions, as restoration of function in distal pa,rts may be owing to tlie presence of other nerves which reach such parts, and partly it may be due to physical con- ^ ductio)! of irritation. The occurrence ^ ^^ iiW^ A.'itU'lSli'ffi^.s. '■'■i^ Fig. 1.— a Wound Twenty-six Hours Old. (Thiersch.) A. Coaptated parts apparently united. Tissues only slightly stained with coloring material of blood ; few leucocytes. B. B. Spaces hctween wound-surfaces filled with red and white blood-corpuscles, some of the former well preserved, others showing various degrees of disintegration ; between them, oedema^ tons connective-tissue fibres. C, C show that these fibres are continuous with the connective tissue of the wound-surfaces. Surface of wound coaptation imperfect ; the epithelial cells dip down into the wound. D. A separated cone of new tissue. B. Infiltration of fatty tissue with blood and leucocytes. G. Divided muscular fibres, with escaped pieces which have partly undergone colloid degeneration. (Hartnack, Obj. 4, Oc. 2.) of immediate union was doubted by O'Halleran, a distinguished contem- l)orary of Bell, as may be learned from the following quotation: " I would ask the most ignorant tNro in our profession whether he ever saw, or heard even, of a wound, though no more than one inch long, IMMEDIATE OR DIRECT UNION. united in so short a time," adding, " These tales are told with more confidence than veracity ; healing by inosculation, by the first intention, by immediate coalescence without suppuration is merel}' chimerical and opposite to the rules of nature." Gussenbauer repeated the experiments of Thiersch and Wywodzoff on the healing of wounds in the tongue of guinea-pigs, and came to entirely different conclusions. In wounds eight to twelve hours old he found that the margins formed an elliptical space, the separation being widest in the middle. The divided muscular fibres had retracted, Fig. 2. (Thiersch.) A, embryonal cells showing karyokinetic figures; B, lymph-spaces; C, striped masses infiltrated with red blood-corpuscles in various stages of disintegration ; D, blood-vessel ; F, fat-tissue. (Hartnack, Obj. 8, Oe. 4.) imparting to the wound an uneven surface, which was covered with a layer of reddish, gelatinous material. In recent wounds the space is filled with blood-corpuscles which are often much changed in color, size, and shape. In wounds twenty-four to forty -eight hours old the material between the surfaces of the wound presented a reticulated appearance, each one of the s[)aces corresponding to a blood-vessel. Contrary to Thiersch, he asserts that in this substance no connective tissue can be found ; the reticulated structure he attributed to the presence of fibrin, the coagulum infiltrating at the same time the adjacent tissues. He believes that the 6 PRINCIPLES OF SURGERY. p.ireneliymn fluid tnkes part in tlie formation of tho coagulum. He was unable to verify, by his own observations, the existence of the i)lasma channels described by Thiersch. When the wound-surfaces were kept accuratel}' approximated he found few blood-corpuscles, but the net-work of fibrin was never found absent. In hare-lip oi)erations and incised wounds of the face and scalj), if uninterru[)ted apposition is maintained I'or a day or two, the i)arts are found so firmly glued together that the belief that immediate union had taken place might still be maintained i'rom a superficial examination, but a microscopical examination will always reveal the conditions described by Gussenbauer, and the union is therefore only apparent, and nc^t real. The surfaces of the wound have become adhei'ent by the interposition of an adhesive material. A certain amount of coagulation necrosis takes place in every wound, and the material thus formed serves as a cement-substance which temporarily glues the parts together. This mechanical union, the result of destruc- tive chemical changes in tlie extravasated blood, is the form of union which has been wrongly interpreted and described as immediate union. This primar}' adhesion occurs most readily in wounds of dense vascular tissue and where approximation and fixation of the edges of the wound are most thoroughly secured, — conditions which favor the subsequent definitive healing of the wound by the interposition of new tissue. UNION BY PRIMARY INTENTION. Organic union, the union aimed at in the treatment of all wounds, is only obtained by tissue-proliferation from the fixed cells of the injured parts, and is completed only after restoration of the continuity of the divided structures, and the return, partial or complete, of the functions suspended ])y the injury or disease. Return of structure and function to an at least approximately normal standard implies a return of the interrupted circulation by the formation of new blood-vessels; in other words, organic union cannot be said to have taken place without an adequate supply of new blood-vessels in the new tissue which form a capillary net-work between the divided blood-vessels. Such a union, even under the most favorable circumstances, cannot be established in less than six to eight days, and its attainment may require weeks and months. The next method of repair described by John Hunter was union by adhesive inflammation. Absence of sui)puration and rapid union liave alwaj^s been considered as essential features of this mode of healing, and corresponds to the healing of wounds per primam inten- tionem, an expression which, for obvious reasons, has been retained in modern literature to distinguish it from the method of healing per secundem infentionem, where the reparative process is often indefinitel}'' UNIOJS BY PRIMARY INTENTION. 7 delaj-ed by suppuration. All wounds which heal witliout suppuration heal by primary union, either without or with visible granulation tissue. An ideal result is obtained if the divided surface unites throughout and the repair in the depth of the wound is accomplished during the same time underneath the united skin or mucous membrane. If there has been a considerable loss of surface tissue and the superficial portion of the wound cannot be approximated, or, if rapid healing at the surface of the wound fails to take place, the wound heals slowly by the formation of a larger amount of granulation tissue, and 3-et, if suppuration does not complicate the process it must be said that the wound has healed by primary union. This method of healiug was exceedingly rare before antiseptic surgery was practiced, but since that time it is of frequent occurrence. All wounds which heal icithout siqjpuration heal without inflammation. All inflamed wounds suppurate; the rejjai-ative process is delayed until the inflammation has subsided. The proper modern classification of wouuds in reference to the method of repair consists in a distinction between (1) aseptic wounds and (2) infected wounds. Aseptic wounds — that zs, wounds not contaminated icith pathogenic micro- organisms — heal without inflammation. An aseptic wound, as a rule, is painless, and does not px'esent ixwy of the other witnesses of inflammation. The slight swelling and, perhaps, redness are the result of mechanical disturbances of the circulation, and subside with the formation of an adequate collateral circulation ; hence, from an etiological and pathological point of view, we have no legitimate right to apply the term inflanmiation to such a method of repair. Koenig makes the statement that the product of tissue-proliferation in the healing of an aseptic wound is not in excess of the local demand ; hence, the process is purel}' one of regen- eration, and not inflammation. Hueter was one of the first who insisted on limiting the meaning of the term inflammation, which he wished to have applied onl^' to destructive processes caused by the action of specific microbes. In an aseptic wound the fixed tissue-cells assume tissue-proliferation, by virtue of their intrinsic vegetative power, within a few hours after the injury has been inflicted, and all the permanent material utilized in the process of repair is derived from this source. The leucocytes serve a useful purpose in the temporary closure of divided capillary vessels and in the formation of the temporary' cement- substance by which the surfaces of the wound are mechauicall}* glued together, and, lastly, as food for the embryonal cells, but they take no active part in the production of neiv tissue. In studying the process of healing in wounds as well as in the con- sideration of regeneration in genei'al, it is of the greatest importance to become familiar with the histological changes which precede and attend 8 PRINCIPLES OF SUlUiERY. the formation of new tissue; hence, in this connection should be given a description of KARYOKINESIS. Karyolvinesis, or karyomitosis, as described by Flemming, is the in- direct reproduction of cells as compared with direct cell-division by segmentation. It is a process by which the net-work of chromatin tlireads within the nucleus undergoes great development, and is snbject to certain transformations of form, which are instrumental in ertecting division of nucleus and cell. The term karyokinesi.s was first used by Schleicher, and the first accurate description of the process, as seen in the cells of a number of animals, simple in form and structure, was given by Biitschli in 18Y6. The motlern definition of a cell is much more com- plicated than that given b}^ Schleiden and Schwann, as recent researches have shown that it is not such a simple structure as it was formerly Fig. .3.— Quiescent Nucleus. Epithelial Cell of Salamander Entering upon THE "Glomerular" Phase. {Flem- ming. ) Fig. 4.— Living Cell of Salamander. (Flemniinff.) A, granules aggreg.^ted round a pole of the cell ; B, coils of "glomerular" net-work; C, cell-body. believed to be. When we speak of a cell now we mean a mass of cir- cumscribed living substance, with or without an envelope, which con- tains as an essential element in its interior a nucleus, with the property of forming new compounds out of substances taken into it, and is capable of reproduction by division. Both the nucleus and cell are composed of threads and intermediate substance. The cell-body consists of threads somewhat irregularly distributed, seldom forming a net-work, embedded in a homogeneous substance. The nuclear threads stain with liaima- toxylon and safranin, and hence are called chromatin threads, Aviiich are arranged in a net-like figure, the meshes of which are filled with a sub- stance which cannot be stained, and hence is named by Flemming achromatwe. The nucleus is surrounded bj^ a membrane composed of two la3'ers ; the inner can be stained, but not the outer. The nucleoli, usually multi])le, are made up of a substance more refractile than the structures described in the nucleus. They are round and smooth, and KARTOKINESIS. 9 either suspended in the not-work or between tlie tlireads. The nucleus in a cell that is not in a condition ol" functional activit}' is said to be in a quiescent or resting state. At this time the chromatin threads become transformed into a sort of skein, formed apparently of one long, convoluted thread ; the inner layer of the nuclear membrane and nucleoli disappear, or are incorporated into the achromatine substance of the nucleus. The development of the net-work of the chromatin substance in the nucleus undergoes five phases until complete division of the nucleus and cell has been eflected. Phase I, The first change indicative of beginning karyokinesis, according to Flemming, is the formation within the cell-protoplasm of two poles opposite to each other and near the nucleus. The next change noticed is that in the nucleus : the chromatin Fig. 5.— Endothelial CEiii-S; Abdomen of Salamander. (Flemming.) 1. Surface view of nuclear net-work: A, cell-body; B. threads of net-work; C, one of the poles with the achromatine threads radiating from it. 2. Equatorial view of a corresponding cell; A, one of the poles; B, the nuclear net-work seen on edge; C, the achromatine threads forming a spindle beween the poles. threads become plainer, thicker, and more convoluted. This increase of chromatin substance is the result of longitudinal splitting of its threads. The achromatine layer of the nuclear envelope increases in thickness, while the inner layer has become a part of the chromatin net-work. Phase II. During tiiis stage the chromatin threads are drawn out into loops with long limbs. This arrangement imi)arts to tlie hxijied net-work the figure of an aster, or star. In the middle of the star is a clear space, which does not stain and is occupied by achromatine substance. In animal cells the greater portion of the space within the nuclear membrane is tilled with cliromatin threads, while in vegetable cells the achromatine substance predominates. The nuclear spindle in the centre of the achromatine substance (Fig. 4, C), according to Strassburger and Biitschli, consists of fine, colorless fibres, 10 PRINCIPLES OF SURGERY. which do not stain at all, or only slightly, l)y using special nucleus- staining reagents, and on this account the achromatine threads probably contain no nuclein. Phase III. The star-shaped mass of nuclear threads divides into two equal portions, with the angles of the loops to the poles, and their limbs partly obliquely, partly perpendicularlj- to the equator of the nucleus. The equatorial disk is formed in this manner, and indicates the completion of this phase. Phase IV. This phase begins with a separation of the threads at the equator, and ends with concentration of the threads in each polar segment of the cell. As the number of loops in each segment is the same as in the old Fig. 6.— Epithelial Cell of Salamander. (Flemming.) A, pole and achromatine threads; B, cell-body ; C, disk- like arrangement of chromatin threads at equator of nucleus. Fig. 7.— Epithelial Cell of Sala- mander. (Flemming.) A, A', chromatin threads of daughter-stars; B, achromatine threads and pole. nucleus, it may be conjectured that the halves of each thread separate into the two daughter-stars. Phase V. The threads in the daughter-nucleus form a wreath, after which they contract more and more until the undivided convolutions can hardly be recognized. A nuclear membrane again appears, after which the net-work returns to its quiescent state. There is a strong tendency at the present time to refer all karyo- i^inetic changes to the agency of the nucleus, and to ascribe to the proto- plasm of the cell the passive role of a nutritive substance. In the imiiregnated ovum the influence of nuclear changes has been described, but at the same time it was shown that the protoplasm of the cell is callable of automatic as well as responsive action. Pfliiger asserted that gravitation is the sole guiding agency in the process of cleavage of protoplasm. According to Born, Herturg, Weismann. and Kolliker, the KARTOKINESIS. 11 protoplasm alone is isotropic, but Whitman thinks that this is far from the truth. Others, lilve Pfliiger, believe that the protoplasm contains physiological molecules from which organs are developed. Polaritv of cell-protoplasm and in nucleus exists independenth', and is not recip- rocal. Contractions in nn fertilized ova have been observed. M. Xuss- baum was the first to prove that enucleate fragments of an infusorium are incapable of reproduction, while parts of an infusorium containing a nucleus possessed this power. This would tend to establish the fact that the nucleus is indispensable to the preservation of the vegetative energy of the cell. On the other hand, Gruber, in one of his experiments, divided a stentor before fission had taken place in such a mnnner that the sections contained no nuclenr substance, and 3'et the next day each one of these parts represented a complete stentor. Against the con- clusions drawn from this experiment it might be urged that some of the nuclear chromatin threads might have found their way into the cell- protoplasm , and that from them the process of reproduction started. Nussbaum regards a combination of nuclear structure and eell-proto- li/:^ plasm as essential for cell-produc- tion. According to Flemming, the cell-body begins to divide toward the end of the fourth phase of karyo- kinesis. Cell-division commences with a constriction at the equator, which becomes deeper and deeper as the daughter-cells assume cell form, until complete regeneration takes place. Toward the completion of the separation onl}' a few achromatine threads (Fig. 8, B) connect the two. To Flemming belongs the credit of having first discovered karyokinetic changes in cells undergoing division, but our knowledge of this subject has been greatly advanced by the combined labors of Strassburger, Arnold, Klebs, and Whitman. Arnold studied this method of cell- division in giant cells of the medulla and in the blood-corpuscles of leuksemic blood. He preserved the blood-corpuscles in a 6-per-cent. methyl-green salt-solution, which preserves cells in a good condition if Fig. 8.— Epithelial Cell of Salaman- der. (Flemming.) A, A', daiighter-glomeruH ; B, achromatine threads still uniting tlie two daughter-cells. \2 PRINCIPLES OF SURGF:riV. the solution is kept at a iJiopcr tcniperature in the moist chaml)er on the o])ject-u,hiss. If to tills solution a 25-per-cent. solution of chloride of U'old is added, the karyokinetic figures are made clearer. In studying the process of karyokinesis in fixed tissue-cells in a state of infiltration, it is necessary to resort to the fixation and staining methods described by Flemming. The modern observers who have studied regeneration of epithelial cells have come to the conclusion that cell-division takes place almost exclusively by karyokinesis. Podwyssozki has studied this method of cell-reproduction with special reference to regeneration of liver-cells, and has come to some ver}' important conclusions. In cats and young guinea-pigs he observed, after injurj' of the liver, extra-nuclear chromatin substance before he could detect any karyokinetic figures in the nucleus. The chromatin in the cell-body appeared in two forms,- — either as fine granules scattered diffusely through the protoplasm of the cell, or a,s lumps of chromatin, and he designated these larger masses as procliromatin ; but he also noticed that the granular form, at a later stage, aggregated and formed masses which united with the nuclear chromatin. Klebs explains the presence of chromatin in the cell-protoplasm to an extra-cellular origin, — the leucocytes. He believes that the chromatin contained in leucocytes is liberated after fragmentation has taken place and enters the 3'oung cells, where they serve as food and become a part of the nuclear net-work. This view is strengthened by the statement of Podwyssozki tiiat he found numerous leucoC3'tes in the immediate vicinity of the new cells. Ziegler and Obolensk}' produced arsenical intoxication in animals l)y administering in daily doses subcutaneously, and when they examined the liver they found well-marked karyokinetic figures in the endothelial cells of the intra-acinous capillaries, the epithelia of the bile-ducts, and, less frequently, in the secreting cells. Karyokinetic figures were first visible in the nuclei of the capilhuy endothelia, and Avere undoubtedl3' caused by the direct action of the arsenic upon the cells. These experiments show that karyokinesis will follow the applica- tion of chemical as well as traumatic irritants. FRAGMENTATION OF NUCLEUS Arnold and Pfitzner have described, in giant and other cells under- going pathological changes, direct fragmentary division of the nucleus, by which it may break up into many parts, often of unequal size, without contemporaneous division of the cell. Arnold and others have also de- scribed incomplete fragmentation of the nucleus where the nuclear masses remain connected with each other, and can be seen as lobulated and reticulated structures. Arnold saw fragmentation of the nucleus in the cells of the marrow of bone and in leucocytes undergoing transformation DIRECT CEI.L-DlVrSTOX. 13 into piis-corpuscles. A nucleus which undergoes fragmentation contains but little chromatin substance, and is therefore incapable of multiplica- tion by kar^'okinesis ; and such cells, according to the investigations of Klebs, never take an active part in the regeneration of tissue. DIRECT CELL-DIVISION. In 1841 Martin Barry first made the observation that the division of cells was accompanied with division of the nucleus, and for a long- time it was believed that tiiis process is simply a segmentation of the nucleus, followed bv division of the whole cell. Remak taught that direct division commenced in the nucleolus, extended to the nucleus, and finally resulted in fission of the cell-body, each of the new cells contain- ing a daughter-nucleus. According to Pfitzner, direct cell-division is a more frequent method of cell-multiplication than the indirect in 3'oung animals where cell- proliferation is rapid. In the embryo the nucleus contains but little chromatin, and therefore the karyokinetic figures are less abundant. D Fig. 9. (McKendrick.) A, mature cell : B, commencing division of nucle>is and contraction of cell-protoplasm in the centre ; C, complete division of nucleus and cell; D, formation of two new cells. In most of the regenerntive processes in mature tissue-cells repro- duction takes place by karvokinesis, and only in exceptional instances by direct division. The new cellular elements present karyokinetic figures in all stages, and u-herever these are seen it is a positive evidence that the fi.red tissue-cells are the seat of tissue-proliferation^ and that wounds are healed and defects repaired exclusively hy this method of cell-formation . GRANULATION TISSUE. The new cells formed by indirect or direct cell-division in a wounded or injured part, the seat of regenerative processes, constitute the granu- lation tissue as long as they remain in their embryonal state. As imme- diate union never takes place in an}' part or tissue of the body, we are forced to admit that every wound heals onlj^b^- the interposition between the divided parts of a greater or less amount of granulation tissue. If the wound remain aseptic, and the surfaces of the wound are kept in accunite coaptation, the healing is accomplished in a short time, and b\- 14 I'KINCIPLES OF SURGERY. tlie prodiietioii of a miiiiinuin :iiiioiiiit of lu'W tissue. A similar wound, witii grt'ut loss of tissue prec-luding the possibility of bringing the parts in api)osition by mechanical resources, nuist necessarily heal by the pro- duction of a large quantity of granulation tissue, the process of repair in both instances J)eing the same, the difference being mainly the length of time required to comj)lete the healing process and the amount of new material necessary for this purpose. In the first c.ise the wound heals witliout visible granulation tissue ; in the latf er the defect becomes cov- ered with granulations before the wound can heal. The macroscopical and microscopical ni)pearances of granulating surfaces nre nearly iden- -^ vr "% i;^-^! ^ 1 f^m n£' v^- Fig. 10.— Granulating Wound. Capillary Loops Surrounded by Embryonal Cells, x 300-400. (Billroth- Winiwarter.) tical in all the tissues. A bone covered with granulations looks the same as a granulating surface of any of the soft tissues. Even the embryonal cells of which tlie granulations are covered, so long as they remain in this state, furnish, from their microscopical appearances, only remote or no indications as to their histogenetic source and ultimate destination. Differentiation takes place during their further development toward the completion of the healing process. The l)ulk of all granulation tissue is derived from the connective tissue as this mesoblastic structure is dif- fused throughout the entire bod}^ and, with the exception of the nervous system, is found in almost every organ. In the nervous sjstem it is GRANULATION TISSUE. 15 represented In- an almost similar tissne, — the neuroglia, — which performs the same role in the repair of injuries and defects of the brain, spinal cord, and nerves. A ■wound or defect covered with granulations presents a velvet}' appearance, each tuft or papilla representing a separate loop or net-work of new capillar}' vessels. The new capillary vessels are paved with endothelial cells contain- FiG. 11.— Gra>'Ulation Tissue fiuim Wound. Blood-vessels Injected. X 400. (IIamiUo7i.) A, A, capillary loops with several branches ; B. ordinary granulation cells ; C, fibroblasts; D, stroma. ing a very large nucleus. Sometimes a single capillary vessel enters a papilla and gives off a number of branches, which form a net-work of convoluted vessels, rendering the granulations exceedingl}' vascular and liable to bleed on the slightest provocation. The blood in the tuft is collected and returned usually through one vein. Emigi'ation of leucocytes through the walls of the new capillary vessels is a common occurrence, and, when they reach the surface, form 16 PRINCIPLES OF SURGERY. one of the elements of secretion of the wound. Wlien the cap''lary vessels are imperfectly developed, or when they are in a state of in- flammation, the exudation becomes profuse, and the granulation surface becomes covered with a membrane consisting of the products of coagula- tion necrosis. Wounds presenting such an appearance have frequently been mistaken as an evidence of diphtheritic infection. The so-called healthy granulations are small, firm, and of a pinkish-red color, and such a surface is only moistened with colorless, viscid fluid. Wounds covered with such granulations heal rapidly and leave a small, pliable cicatrix. Profuse flabby and pale granulations indicate a want of general vitality, or more frequently the presence of specific microbes, wliich act injuriously upon the process of transition of embryonal cells into tissue of a higher tj'pe. Such granulations are frecjuently met with in wounds after im[)erfect operations for tubercular lesions, in suppurating wounds, and in ulcers of the lower extremities, where the vascular conditions are unfavorable for the growth and development of new tissue. Histologi- call}^ granulation tissue is composed of a delicate, oedematous reticulum, and upon its fibres can be seen numerous connective-tissue corpuscles. The reticulum is intimately connected with the blood-vessels, and in its meshes are contained the embryonal cells and leucocytes, the latter serving as food for the former. The embryonal connective-tissue cells are about two or three times larger than the leucocytes. The giant cells which are occasionally found are fibroblasts wliich have grown to such enormous proportions by inclusion of nutritive material derived from disintegrating leucocytes. VASCULARIZATION OF GRANULATION TISSUE. The vessels which furnish the blood supph' to the granulation tissue are new structures, and are usually formed from pre-existing vessels in injured vascular tissue, and from the nearest blood-vessels in non-vascular tissue. Vessel formation and tissue proliferation are initiated simultaneously, and keep pace with each other until the neces- sary amount of granulation tissue has been produced, when, during the transformation of the embryonal cells into pernument tissue, the vascular supply is gradually diminished by the obliteration and disappearance of all of the superfluous vessels. As the layer of granulation tissue seldom exceeds more than ^ inch in thickness, the new A^essels always remain short, and retain their communication with the pre-existing vessels from which they started. TraA^ers, in his experiments on injuries of the frog's web, has observed that the blood in the divided vessels becomes stagnant some little distance from the wound. During this time material oozes from the cut vessels, which constitutes the primary-wound secretion. VASCULARIZATION OF GRANULATION TISSUE. 17 Befc^e granulations can be established the circulation must become restored by enlargement and multiplication of preformed vessels. The capillar}' vessels which have been cut or otherwise injured are closed with nature's htemostatic — a minute thrombus. The intra-vascular pressure on the proximal side of the obstruction results in dilatation of the vessel, which produces an increased blood-supply to the part com- mensurate with the increased demand for nutritive material. The new blood-vessels are formed by angioblasts, which are proliferated from pre- existing vascular structures. Arnold has studied the formation of new blood-vessels in the stump of the tail of tadpoles after amputation, and Fig. 12.— Superficial Capillaries op a Wound Beginning to Granulate, about Forty-eight Holrs after its Infliction. X 350. {Hamilton.) ^, free surface ; B, tlie capillary loops all distended with blood, and being driven outward in tortuous festoons ; C, embryonal cells. in keratitis vasculosa artificiall}^ produced in the cornea of rabbits. To the researches of this author we owe most of the knowledge we possess on this subject. The new vessels are produced by the budding process from capillaries near the surface of the wound. The bud appears first as a circumscribed thickening of the capillary wall, which soon projects outward in the form of a triangular cellular mass composed of angio- blasts. The bud is then transformed into a long string, terminating in a delicate granular thread. The base of such a projection becomes excavated, and blood enters from the vessel to which it is attached. When the terminal ends of two 2 18 PRINCIPLES OF SURGERY. of such projections meet they unite and form an arch, which, after they have become permeal)le to the blood-current, constitute a capillary loop from which branches again may develop in the same manner. The new channels contain, upon their inner surfaces, nuclei at variable distances, which subsequently undergo transformation into endothelial cells. The adventitia is formed b}' roimd cells, which arrange themselves along the outer surface of the new channels. Hunter maintained that blood- vessels are formed in granulations independently^ of pre-existing vessels, in the same manner as in the embryo, and that they enter into commu- nication with the vascular s^-stem subsequently. Such a method of vascularization during post-embryonie life is not jjroved. A number of pathologists, and among them Billroth, still believe that blood-corpuscles and blood-vessels can be produced from connective tissue. Thej' claim that connective-tissue cells in the intercapillarj'^ spaces enlarge, become branched, and that by union between similar projections between two or Fig. 13.— Formation of New Blood-vessels by Budding. {Arnold.) A, after three hours ; B, after six hours. more cells hollow spaces are created which serve as blood-vessels, while the nucleus assumes the role of a hgemapoietic organ, — a process which is well illustrated by Fig. 14. Still another method of vessel formation in granulations has been observed and described by Travers. He noticed that, when one of the new capillary vessels ruptures and blood is poured out into the granula- tion tissue, among the embr3'onal cells a vascular space without walls is formed. The extravasated blood, under these circumstances, did not disintegrate, and as soon as the space came in contact with another capillary loop the wall gave way and a communication was established between the two capillary vessels, and later the channel became lined with endothelial cells. Tliis method of vessel formation is termed canalization. While the possibility of the development of new vessels independently of preformed blood-vessels cannot be denied, such an origin is, to say the least, exceedingly rare, and for all practical purposes, CICATRIZATION. 19 b when we speak of vascularization of granulation tissue or the formation of new blood-vessels in general, we mean the formation of new channels b}' tissue proliferation from the walls of pre-existijig blood-vessels. Dr. J. Hamilton, author of the excellent " Text-Book of Pathology," asserts that the blood-vessels in granulation tissue are not new, but dilated, tortuous, preformed vessels. In wounds that heal rapidly the existence of most of the new blood- vessels is a short one. With the beginning of cicatrization they disappear rapidly', and comparatively onl}"^ a few of them remain as per- manent structures as a system of collateral vessels which restore indi- rectly the loss of continuit}' between the divided vessels. A failure of the vessels to disappear after cicatrization has been completed usuall}' is an indi- cation that some pathogenic micro- organisms have become embedded in the scar-tissue, which interfere with the proper and prompt transformation of embryonal into permanent tissue. Such scars are often met with after operations for tubercular lesions and after the healing of extensive burns, being caused in the first instance by the bacillus of tuberculosis and in the latter by pus-microbes. The vascular conditions in granulating surfaces should be carefully studied, and in the treatment due attention should be given to this important point, as compression and position are potent measures in improving a fault}^ circulation, which maj'^ have indefinitely retarded the healing process. Fig. 14.— Development of Blood- corpuscles IN Connective-tissue Cells, and Transformation of the Latter into Capillary Blood-ves- sels. (Fluegge.) A, an elongated cell with a cavity in its protoplasm occupied by fluid and by blood-corpuscles; B, a hollow cell, the nucleus of which has been multiplied: the new nuclei are arranged around the wall of the cavity, the corpuscles in which have now become discoid ; C, shows the mode of union of a " liannapoietic " cell, which, in this instance, contains only one corpuscle, with the prolongation (BL) of a previously existing vessel. A, and C, from the newborn rat ; B, from foetal sheep. CICATRIZATION. The process of transformation of the embrj'onal cells in granulation tissue into permanent, fixed tissue-cells is called cicatrization. Sir James Paget has well said that during the stage of the healing process a life of eminence is changed into one of longevity. In tissues endowed with great vegetative powers and a high degree of adaptation, even large defects are replaced by tissue which resembles to perfection, anatomi- •20 PRINCIPLES OF SURGERY. cally, histologically, and physiologically, the injured pre-existing tissue. This is the cLe in injuries involving considerable loss of substance m ■g'C |1 fQ"'S. § 2a o ^5 J3 . "a a . a > §•2 J2 - •3Q ill q 9 ^ o m .d-s c ^-5 8 bone tendons, and peripl.eral nerves. Complete restoration of a p:riV.a> ne"ve frejntly takes place after resection of more than an CICATRIZATION. 21 inch of its contiuuity. In subcutaneous tenotom}' the tendon-ends may be kept separated for two or more inches, and yet after a few months it would be difficult to ascertain, even after the most careful examination, the site of operation. The fractured ends of a broken bone may be complete!}' separated by lateral displacement during the entire time required in the healing process, and 3et they are firml}^ united b}' the interposition of a connecting bridge of new bone. In other tissues endowed with less reparative energy, as for instance the muscular fibre, a slight separation results in the formation of cicatricial tissue between the anatomical structure Avhich it is the intention to unite. By cicatri- zation is therefore understood tlie completion of the reparative process, and the term does not necessarily imply the formation of a permanent cicatrix. An ideal healing culminates in the formation of tissue which effects a plu'siologicnl restitution of a defect caused by injury or disease. As a rule, it can be stated that the result will be satisfactory in proportion to the amount of granulation tissue produced or required in the process of repair. In an aseptic wound the reparative material will not be in excess of tlie local demand, and the demand will depend on the degree of accurac}^ of approximation of the surfaces of the wound. Cicatrization begins in the ganulation tissue nearest the pre- formed vessels ; that is, the margins and surface of the wound. The embryonal connective-tissue cells, or fibroblasts, as they are cnlled, at first round, become elongated with thread-like prolongations from the extremities. The new connective tissue contracts, thus bringing the margins of the wound or granulating surface in closer apposition, and by its constricting effect assisting in the obliteration of superfluous vessels. The cicatrix or scar will be large if the process of granulation has been in excess of the demand, or if a large defect had to be healed by the deposition or interposition of a large quantit}' of cicatricial material. Large scnrs should be prevented, if possible, b}' appropriate treatment, as from the contraction they give rise to distressing deformities, and from tlieir low vitality they furnish a permanent predisposition to ulcer- ative processes and not infrequently become the seat of malignant Fig. 16.— Embryonal Connkctive- TissuE Cell Undergoing Transfor- mation INTO r^lATURE State. (Ziegler.) A, the cell-body : still contains a considerable amount of protoplasm, which, however, gradually di- minishes toward D. where it represents a mature connective-tissue cell with a very small amount of protoplasm surrounded by connective-tissue fibres. 22 PRINCIPLES or SURGERY. disease. After the healing of any ulcer of considerable size upon the mucous surface of any of the hollow viscera the cicatricial contraction often gives rise to the formation of strictures. Nerves appear to form in granulations, as these are often exceedingly tender to the touch. Their existence, however, has not been demonstrated. The pain and tenderness ma}' be caused b}' force being transmitted to subjacent nerves. According to Vanderkolk, no I3 mphatic vessels are present in granula- tion tissue. During the process of cicatrization all the embrjonal cell- elements undergo transformation into mature tissue, the fibroblasts are converted into connective tissue, the angioblasts into vessels, the mj'oblasts into muscle-fibres, the osteoblasts into bone, etc., each histo- logical element represented in the wound or defect furnishing the material for its own repair. EPIDERMIZATION. A wound of the external sur- face of the body can be said to have healed after the completion of epi- dermization. In accordance with the general law of succession of cells, epidermization takes place ex- clusively by proliferation of pre- formed epithelial cells. The new epithelial cells have a more or less rounded shape, and cover the granu- lations from the margins of the wound, where the new skin appears ^'''•''■-^'''^^^ff^^a''7KilbI:l'"'' ''"''''''' as a bluish-pink pellicle. At first A, old epithelial cells upon edge of wound of skin, with thcV do UOt readily adhere tO tllC proliferation of nucleus. '' ^ granulations, but appear to cover them (Fig. 15, E') ; later, however, the}' throw down long processes which penetrate the granulations, and in this way obtain a permanent foothold. New epithelial cells possess amoeboid movements, may become detached from the epithelial matrix, and wander some distance and form perma- nent attachments, and in such an event an independent centre of epider- mization is established. Migration of epithelial cells was first observed and described by Klebs in superficial wounds in the skin of tlie frog. The irregular projections of the new skin over the granulations, so frequently observed during the healing of wounds by granulation, is undoubtedly often due to such a displacement of embryonal epithelial cells. In granulating surfaces following destruction of the skin by burns, caustics, or ulceration, independent centres of epidermization are often POSITIVE INDICATIONS IN THE TREATMENT OF WOUNDS. 2o seen in the midst of the field of granulations. In sucli cases the entire thickness of the skin at some points has not been destroyed, and epi- thelial proliferation takes place from remaining remnants of glands, as is well shown at F and G in Fig. 15. The granulations in the immediate vicinity of the zone of epidermization become reduced in size, the blood- vessels are diminished in number, and the subjacent fibroblasts are rapidly converted into connective tissue. In wounds of the skin which ileal without visible granulations the i)apillae are absent from the cicatrix, even although it be broad from subsequent yielding to traction. In wounds healing b}^ open granulations new papillae are formed in the new skin, because the capillary loops atrophy downward and become the papillar}^ vessels. Epidermization and cicatrization are favorablj^ influ- enced b}- measures which secure for the wound an aseptic condition throughout, and by keeping the delicate granulations covered with pro- tective silk until the wound is completelj' healed. POSITIVE INDICATIONS IN THE TREATMENT OF WOUNDS, WITH SPECIAL REFERENCE TO SECURE UNION BY FIRST INTENTION. Absolute Asepsis. — AhsoUde asepsis can only be secured by strictest antiseptic measures. Surgical cleanliness is more than ordinary clean- liness. Antiseptic precautions are employed for the purpose of securing for the wound and everything that is brought in contact with it an aseptic condition. The mechanical removal of microbes from the field of opera- tion by shaving and washing with warm water and potash-soap should be as thorough as possible, but cannot be relied upon in securing asepsis. The surface must be disinfected with a reliable germicidal solution, either a 1-to-lOOO solution of corrosive sublimate or a 4-per-cent. solution of carbolic acid. Accidental wounds must always be considered as infected wounds, and a faithful ertort must be made to render them aseptic by exposing, if possible, the entire wounded surface to the direct action of one of these solutions, while the surface for a considerable distance around it is also disinfected. Recentl}^ a weak solution of the double cyanide of mercury and zinc has been recommended by Sir Joseph Lister as an antiseptic, and, from his experimental investigations and clinical experience, it appears that this substance possesses an advantage over carbolic acid, corrosive sublimate, and other antiseptics, as it exerts an inhibitory etleet u{)on microbes which still may remain in the wound or its immediate vicinity, which prevents them from multiplying in tin; tissues or in the dressing. The hands of the operator and his assistants are to be cleansed by washing in warm water and potasii-soap. and then disinfected in a 1-to-lOOO sublimate solution, and, lastly, washing in abso- 24: PRINCIPLES OF SURGERT. lute iilcoliol. Special care is to be exercised in cleansing and disinfecting the space under the finger-nails. On each side of the wound or field of operation a towel wrung out of an antiseptic solution is spread smoothly, in order that, during the operation, instruments and sponges will not be contaminated by being brought in contact with non-aseptic clothing or surface. None but sterilized sponges are to be used, and, in the absence of such, pieces of aseptic gauze, folded into convenient shape, shoukl be used as substitutes. The cheapest and most reliable method of disinfection of instruments is to boil them for five minutes and then plnce them upon an aseptic towel, ready for use. If these anti- septic precautions have been faithfully carried out, sterilized water can 1)6 used for irrigation during the operation, or the dry method of operat- ing recently introduced into practice b}' Landerer can be followed in operating upon aseptic tissues or in the treatment of aseptic wounds. In the operative treatment of suppurative affections, irrigation with a l-to-5000 solution of sublimate must be frequently resorted to during tlie operation, and, in the removal of tubercular products, irrigation with an aqueous solution of the tincture of iodine, made by adding enough of the tincture to sterilized water to impart to the solution a sherry color, should be used. CAREFUL H^MOSTASIS. Tlie presence of a blood-clot between the surfaces of the wound is objectionable for the following reasons : 1. It separates mechanicallj'' the surfaces which it is intended to unite. 2. It serves as a culture medium for micro-organisms, which, if in contact with living tissue, might remain harmless. 3. It gives rise to tension, and consequently becomes pro- ductive of pain and an undue degree of reflex irritation. For years, von Bergmann has insisted that careful arrest of haemorrhage is one of the most urgent and important indications in the treatment of wounds, and his teachings merit the attention of every prudent surgeon. Bleeding points should be tied with sterilized catgut or silk. A number of sur- geons have discarded catgut, as it is more difficult to render it aseptic than silk. The latter can be readily sterilized by boiling. The haemor- rhage that so often interferes with an ideal healing of the wound is the capiihiry or parenchymatous oozing, and this should always be carefully arrested before the wound is sutured. The following measures should be resorted to in controlling this form of bleeding, and in the order named: 1. Position. 2. Surface compression. 3. Hot-water irrigation. 4. Anti- septic tampon. 1. In wounds of the extremities, capillar}^ oozing is usuall}' promptly arrested by holding the limb in a perpendicular position. In this position the intra-arterial pressure is diminished and the return of venous blood ACCURATE SUTURING. 25 favored, both of which are important elements in diminishing the amount of blood in the capillar}^ vessels. In order to produce the desired effect, this position should be maintained for fifteen to twent}' minutes, and the limb should be kept in this position for at least six hours after the operation. 2. Surface pressure with a flat sponge or a compress mechanically arrests the bleeding, and the capillary vessels, partl}^ or completely emptied of blood, are placed in a moi'e favorable condition for the forma- tion of a thrombus. After an amputation, for instance, the sponge or compress is applied to the surface of the cut muscles and the flaps are laid over it, and compression with two hands applied, with the limb in a perpendicular position before the elastic constrictor is removed. Com- pression, continued in this manner for ten or fifteen minutes, will usually be successful in completely arresting parench3'matous bleeding. 3. Irrigation with water at a temperature sutlicienth' high to coagu- late the albumen on the surface of the wound seals mechanically the cut vessels, and, at the same time, produces a localized anemia by contract- ing the terminal arterial branches. A temperature of 120° F. will answer for this purpose. 4. St^^ptics should never be emploj^ed in arresting bleeding from a recent wound. If the procedures mentioned fail in accomplishing the desired object, the wound should not be sutured until haemorrhage has been completely checked by the use of the antiseptic tampon. The wound is packed with iodoform gauze, and the customarj' dressing is applied in such a manner as to exercise uniform gentle pressure. After twenty-four hours the dressing and tampon are removed, and the wound closed with sutures. In such cases secondarj' suturing is of great value in securing a speed}' and satisfactory healing of the wound. ACCURATE SUTURING. Brilliant operators are not alioays the best surgeons. The best results in surgery follow the one who is most jjainstaking in following out the minutest details. This assertion applies most forcibl}' in the treatment of wounds. The surgeon here occupies the position of handmaid to the vis medicatrix naturee. and in the exercise of his duties must do all in his power to tax oid}- to a minimum extent the regenerative resources of the wounded tissues. In the treatment of wounds it becomes his imperative duty, not only to unite the surfaces of the wound accurately and neatly, but to unite, whenever it becomes necessary, tissues of the same anatomical structure and physiological function. Divided nerves, tendons, muscles, fascia, must be separately united with buried sutures before the wound is closed by the ordinary interrupted or continuous 26 PRINCIPLES OF SURGERY. suture. When several nerves or tendons have been divided in the same wound, great care must be exercised to unite the ends of the same nerve or tendon. Accurate approximation of a deep wound is impossible without the buried suture. Several, rows of these sutures may be re- quired. Reliable catgut should be preierred for the deep sutures, but if this material is not at liand fine silk can be used. The best materials for the ordinary interrupted sutures are silk or silk-worm gut. Separate sutures for the skin are usually required in order to approximate the superficial margins of the wound accurately. If the surgeon has reason to believe that the wound is aseptic, drainage should be dispensed witli, because the manuer of suturing, as just described, guards against the occurrence of " dead spaces." An absorbent antiseptic compress, com- posed of a few layers of iodoform gauze and a thick layer of salicylated cotton, or sublimated moss or wood-wool, is the most appropriate dress- ing for such cases. The bandage to retain this dressing is applied in such manner as to exercise uniform equable compression, — an important element in affording support to the injured vessels and in securing rest for the parts involved in the injur3^ PHYSIOLOGICAL REST. In the after-treatment of a wound nothing is more important than to secure for the parts which have been mechanically united, as far as possible, physiological rest. The importance of rest in the prevention and treatment of inflammation has been prominently brought forward by Hilton, and his teachings have resulted in a great deal of good in the treatment of inflammatory surgical affections. If one of the extremities is the seat of the wound, immobilization upon a splint or with a plaster- of-P'im (■'cssing, in such a position as to relax the muscles involved in the n . ' of paramount importance. The injured part must be kept in a position wliich will favor a normal blood-supply and prevent passive liyperifimia. A wound properly dressed should not be disturbed until union has taken place. If any one of the three most important indica- tions for a change of dressing — pain, rise in temperature, and saturation of the dressing with wound-secretions — do not arise, the first dressing is allowed to remain for eight days to six weeks, according to the location, character, or size of the wound. In wounds of the gastro-intestinal canal, physiological rest is secured by abstinence from food, and, if necessary, peristalsis is diminished by a few doses of opium. In wounds of the bladder distention of the organ is prevented by the introduction and retention of a catheter. In Avounds of the brain or its envelopes, rest is secured by exclusion of light and by enforcing quietude in the patient's room. UNION BY SECONDARY INTENTION. 27 UNION BY SECONDARY INTENTION. In an aseptic wound all the new material resulting from proliferation of the fixed tissue-cells is used in the process of repair, and the time for healing of the wound will depend on the anatomical structure of the part injured and the amount of material required to form a bridge of living tissue between the divided parts. As long as the wound heals without destruction of any of the new tissue-elements by specific microbic causes, it is proper to speak of a union by primary intention, whether the healing is completed in three or four days, or whether it is protracted for months until the ultimate object of wound treatment has been reached. From a pathological, and even from a practical, stand- point, it is not correct to include, under the head of healing by the second intention, aseptic wounds that, on account of want of proper approximation, or on account of loss of tissue, have of necessity to heal by granulation, with infected wounds in which the regenerative processes are disturbed by suppuration. In a suppurating wound the embryonal cells which are destined to become transformed into new tissue are exposed to tlie destructive action of pus-microbes and their ptomaines, their protoplasm is destroyed, and the}' become one of the histological sources of pus-corpuscles. The cells on the surface of the Avound, being most distant from the vascular suppl}', possess tlie least power of resist- ance to the action of pus-microbes, and on this account, as well as from the greater number of pus-microbes on the surface of the wound than in the deeper tissues, they are converted into pus-corpuscles. As long as suppuration remains active the superficial layer of granulation cells are destroyed, and as soon as other embryonal cells take their place the process is repeated, and thus the healing of the wound is indefinitely delayed. Wlien a favorable change takes place in the wound, either spon- taneousl}' or from the employment of antiseptic measures, suppura- tion is diminished, the granulations become firmer and more vascular, and cicatrization and epidermization now progress in a satisfactory manner. Such a favorable change in the condition of the wound can be readil}' explained after the use of such agents as are known to destroy the microbic cause of the suppuration when brought in contact witli the wound. In such a case we would naturall}- expect that, with the removal, destruction, or rendering inert of the pus-microbes, the embryonal cells would remain attached to the point wliere the}' were produced, and would soon be converted into tissue resembling the matrix which produced them. Spontaneous cessation of suppuration, and with it the conversion of a surface covered with dead material into a healtii}' granulating sur- face, would indicate either that the virulence of the pus-microbes had 28 PRINCIPLES OF SURGERY. become attenuated, that the soil was no longer congenial for their multi- jilioation, or finally that the resistance on the part of the tissues to their pathogenic action had become increased. That tissue resistance has a potent influence in neutralizing and modifjnng the action of pathogenic micro-organisms has been observed clinically and demonstrated experi- mentally. Suppurating wounds are graver atfections, and are more difficult to manage in the aged and in badly-nourished persons, as well as in patients debilitated from excesses and other protracted diseases, A good circulation of tlie part is an important element in counteracting the cause of suppuration. A chronic varicose ulcer of the leg that suppurates freely, as long as the patient continues to use the limb, is often transformed into a healthy granulation surface after a few days of rest in bed, with the aftected limb in an elevated position. TREATMENT OF SUPPURATING WOUNDS, WITH SPECIAL REFERENCE TO HASTENING THE PROCESS OF REPAIR. In the treatment of an accidental Avound, which alwa3's must be regarded as a septic wound, or in the management of a wound where the antiseptic precautions have failed, no time should be lost in securing for the wound and its vicinity an aseptic condition by tliorough disinfection. The surroundings of the wound are disinfected in the same manner as for an operation. The wound is exposed as thorouglih^ as possiWe to direct treatment b^' enlarging it over recesses otlierwise inaccessible, after whicli it is thoroughly irrigated with a solution of sublimate (1 to 2000). If the granulations are copious and flabby they must be removed with Volkmaun's sharp spoon, and after the bleeding has ceased a 12 per-cent. solution of chloride of zinc is applied ; after a few minutes the surplus fluid is washed away by irrigation with the sublimate solu- tion. Tlie wound is now dried, sutured, and drained. Drainage in these cases is a necessary evil, as the surgeon can never feel certain that he has succeeded in obtaining perfect asepsis. If tlie wound is extensive, or if pus has been burrowing in different directions along the deep tissues, as in cases of compound fracture where a thorough disinfection of every part of the wound, as described above, is impossible or imprac- ticable, constant irrigation with a saturated solution of acetate of aluminum should be instituted and continued until the wound has been rendered aseptic. Acetate of aluminum is a reliable antiseptic, is non- toxic, and penetrates the tissues deeply. The treatment most appro- priate for a recent aseptic wound is to be adopted as soon as suppuration has ceased and the general symptoms at the same time point to an aseptic condition. SUTURING OF GRANULATrNG WOUNDS. 29 SUTURING OF GRANULATING AYOUNDS. If union by primary intention has failed to take place for any reason in wounds which can be closed by suturing, a second attempt can be made to approximate the surfaces with sutures with fair prospects of success as soon as the granulations are in an aseptic condition. Aseptic granulating surfaces when brought in contact unite rapidly, as vascular connections between the new capillary loops are established in a remark- ably short time, and the wound then heals in the same manner as after primary suturing. The cases best adapted for secondary suturing are those where suppuration has ceased, the granulations have become small and firm, — in short, wounds in which cicatrization has commenced. The technique in the treatment of such wounds is the same as in cases of aseptic recent wounds. The advantages of this method of dealing with wounds that have failed to unite are pronounced when the wound is deep and the margins can be coaptated without much tension. Buried sutures can be used for the same purpose and witli the same benefit as in the treatment of recent wounds. Before the surfaces are brought in contact with the svitures it is important to disinfect and dr}' the granulations thoroughly. As secondary suturing is applicable only in tlie treatment of such wounds where we have every reason to assume that an aseptic condition exists, or can be secured by disinfection, the whole wound should be carefully closed and drainage must be dispensed with, in order to obtain rapid healing of the entire wound. It has been recently suggested by Kahn that in extensive defects of the skin a covering for the wound can be obtained by sliding of the skin, after undermining it for some distance in a direction most suitable. That this procedure is applicable only under circumstances when the surgeon is sure of asepsis is to be taken for granted, as otherwise it might be followed by gangrene and still greater loss of tissue. CHAPTER II. Regeneration of Different Tissues. In connection with the subject of healing of wounds it is veiy important for the student to familiarize himself with the vegetative capacity of the different tissues of the body in order to estimate with some degree of acciirac}' the part taken b}' each tissue in the reparative processes which take place after an injur}- or disease. No positive proof has yet been furnished that the leucocytes or any other of the cellular elements of the blood take any active part in the restoration of lost jmrts. It does not appear to me reasonable or logical that such an indifferent cell as the leucoc3'te should ever become transformed directl}- into a fixed tissue-cell, and it is still more improbable that it should be possessed with such a diverse vegetative capacity as to undergo a transi- tion in one place into a connective-tissue cell, in another into bone, and still another into a muscle-fibre. It is much more rational to assume, in the repair of an injury and in the regeneration of a part destroj'ed b}' disease, that the universal law of legitimate succession of cells asserts itself, according to which the reparative process is initiated and completed b}' homologous cell proliferation. In the following pages experimental and clinical proofs will be advanced which will at least tend to establish the truth of this assertion. NON-VASCULAR TISSUE. The part taken by blood-vessels in regenerative processes is well shown in the healing of wounds of non-vascular tissue. Large wounds of the cornea and cartilage can onl}- heal after a blood-supply has been established through new vessels from the nearest vascular district. Rapid vascularization of the non-vascular tissues is alwaj's observed when the wound has become infected. Copnea. — Tlie normal cornea contains no blood-vessels, but vascular spaces, which form a system of channels for the circulation of the plasma- fluid. In 1863 Recklingliausen discovered in these spaces migrating corpuscles, resembling in size and shape the white blood-corpuscle, which be regarded as off'springs of the corneal corpuscles. Later, Cohnheim showed that these wandering cells were leucocytes which had escaped from the pericorneal capillary vessels and had found their Avny into these (31) 82 PRINCIPLES OF SURCERY. cluinnels. In traumatic keratitis these spaces become blocked with leucocytes, and they constitute largely' tlie primar}' product of inflam- matory exudation \ong before the fixed cells of the coruea could have yielded such an amount of cellular elements. Struhe niul His studied experimentally the healing of wounds of the cornea and traumatic kera- titis. They injured the cornea of rabbits by cutting and ca/uLerization. As the cornea is freel}^ supplied with nerves, thej^ observed as one of the earliest tissue changes a reflex paretic dilatation of the marginal 1)loo(l- vessels. The marginal hyperemia was followed by the formation of new blood-vessels in the direction of the seat of injury. The early opacity around the wound and the space between the wound and the advancing channels are caused by the presence of leucoc^ytes in the vascular spaces ; later, to proliferation of the corneal corpuscles. That leucoc3'tes enter the plasma-canals when the cornea is irritated has been definitely settled by Cohnheim by one of his most ingenious experiments. He injected finel^'-divided carmine suspended in an acid, or precipitated aniline into the dorsal lymph-sacs of frogs, with the result that when he irritated the cornea, a few days later, leucocytes stained with the pigment-material appeared at the margin of the cornea where cell-migration was known to appear first. He found a rai)id increase of corneal corpuscles in the animal subjected to experimentation ; thus, in one instance, eighteen hours after the injury, he found, in spaces normally occupied by one corpuscle, as many as 20 to 30 young cells closely packed together. Hamilton regards as the first change in an irritated cornea an in- crease of the plasma-current which may destroy the endothelial lining of the canals, and according to this observer cell-migration into the corneal spaces occurs later. Unimpaired innervation of the cornea is an important factor in the prompt healing of wounds of this structure, as it is well known that in patients suffering from glaucoma, and in the aged, wounds of the cornea heal often in a very unsatisfactory manner. An aseptic wound of a normal cornea heals without opacit}^ ; the new corneal corpuscles, after they attain maturit}'^, transmit light as perfectly as the cells from which they are produced. Imperfect restoration of tissue is to 1)e expected when the regenerative process is complicated by a suppurative inflammation with considerable destruction of tissue. Gussenbauer incised the cornea in rabbits half-way between the centre and its margin to the extent of half a line to a line, and found, in exam- ining the specimens after twenty-four hours, that no union had taken place. The wound-surfiices at this time were glued together by an inter- posed substance. The surfaces of the wound were in close contact at a point corresponding to the middle portion of the cornea, and the gap widened toward each of its surfaces so that the temporary cement- NON-VASCULAR TISSUE. 33 substance represented two cones with their apices directed toward each other and the bases toward the surfaces. On staining the specimens with chloride of gold it was found that this substance contained cells which were most numerous toward the surfaces of the cornea. The cor- neal corpuscles on the cut surfaces were seen to be enlarged and presenting different stages of cell-division. Instead of round the corpuscles were spindle-shaped, some containing one nucleus, others two nuclei ; intercellu- lar substance granular. In specimens eight days old the space between the cut surfaces was occupied almost exclusively by new corneal corpuscles, and the edges of the wound could no longer be clearly defined. During cicatrization of the wound the number of cells is diminished, while in form and size the}' resemble more and more the mature corneal corpuscles from which they were derived. In a non-penetrating incised wound of the cornea the gap is filled Fig. 18.— Corneal Corpuscles in a State of Proliferation. (Sen/tleben.) A, old corneal corpuscles with one or two nuclei and young o£fshoot3, B and C. up after a few daj-s with young cells derived from the C3'lindrical cells of the deepest la3'er of the corneal epithelia. If the w^ound has penetrated, the posterior third of the wound gaps toward the anterior chamber of the eye, and is first plugged with the products of coagulation necrosis, which is later replaced by epithelial cells from the niembrana Descemeti (Fig. 19, C), while the anterior por- tion is occupied by epithelial cells the same as in the non-penetrating wounds. At the end of the first week the corneal corpuscles begin to proliferate, and the cells from this source gradually displace the epithe- lial cells and bring nliout the definitive healing of the wound. As wounds of the cornea are not sutured, the surgeon should aim to secure approxi- mation by i-LMuoving coagulated blood if present, and by correcting any dis- placements wliich may be present by direct measures, and finally b}^ apply- ing a dressing which will exert uniform and equable elastic compression. 34 PRINCIPLES OF SURGERY. Although the antiseptic treatment cannot be carried out with the same precision in the treatment of wounds of tlie cornea as in other localities, it is at least the duty of the surgeon to use only sterilized instruments and aseptic sponges, and to employ such mild antiseptic solutions as will at least exercise an inhibitory influence upon pathogenic micro-organisms that may be present in the wound or upon the surface of the eye. Cartilage. — Cartilage is in every sense of the word a non- vascular struc- ture, as even the plasma-channels found in the cornea are absent here. Plasma diffusion must take place between or through the cells. It is un- FiG. 19.— Wound of Cornea, {von Wpss.) A-A', new corneal corpuscles ; B-A', temporary plug of fibrin ; C, epithelia from membrana Descemeti. doubtedly on account of thelimited provisions for nutritive supply that the vegetative capacity of this tissue is so exceedingly low. Normal cartilage when injured is unable to repair the defect. The process of healing of Avounds of cartilage was first studied experimentally by Redfern. In one experiment he found the wound almost unchanged after twenty-nine days. In one specimen, where the healing process had been completed, he found the defect repaired by connective tissue. The microscopical description of the healing process corresponded witli that given by Goodsir of inflammatory processes in this structure. Along the margins VASCULAR TISSUE. 35 of the, wound the cartilage-cells multiply and the cement-substance is dissolved. No new cartilage-cells are produced, and the space is occu- pied by connectiA'e tissue. Vascularization toward the seat of injur}'- from the marginal A^essels of the perichondrium takes place in the same manner as in the cornea. Reitz traced the formation of connective tissue from the cartilage-cells in tracheotomy^ wounds in rabbits. He observed, after the cement-substance had become dissolved, that the cartilage-cells were transformed into spindle-cells, and later into connective tissue. He found the gap between the divided cartilage-ring filled with such cells a few days after the wound had been inflicted, and explains the discrep- ancy between the results he obtained and those described by Redfern on the ground of the close proximity- of vascular suppl}^ in his case and the remoteness of vessels from the wound studied by Redfern, as the latter experimented on articular cartilage. Gussenbauer studied the repair of cartilage wounds after incising subcutaneousl}- costal cartilage. In wounds twenty-four hours old a triangular gap was found filled with fibrin and blood-corpuscles. No change was found at this time in the cartilage- cells and cement-substance. The cells of the perichondrium increased in volume and changed in form. Gussenbauer was unable to verify the observation made by Reitz in wounds of trachea, that cartilage-cells are transformed into connective-tissue cells, and believes that the ammonia used by Reitz to provoke croupous pneumonia, bv its introduction into the bronchial tubes through the tracheal wound, may liave modified the result. He traces tissue proliferation almost exclusivel}' to the peri- chondrium, the cells of which were found in all stages of division and development, while only a few of the cartilage-cells presented CAidences of segmentation. Corner studied not only the manner of repair of simple incised wounds of cartilage, but also produced more complicated injuries, and invariably found that the perichondrium took a more active part in the process of healing than the cartilage-cells. Wounds of fibro- and reticulated cartilage heal in the same manner as wounds of hyaline cartilage. The histological changes observed hy Redfern, Corner, and Gussenbauer during the repair of wounds of cartilage are descriptive of the changes which attend chondritis. VASCULAR TISSUE. The healing of wounds of vascular tissue is accomplished more rapidl}^ than of non-vascular tissue, as the primary wound-secretion, which is derived mostl}' from the wounded vessels, forms a temporary cement-substance which glues tlie parts together, — a condition which renders material assistance in maintaining coaptation, — wliile the direct blood-supply to the injured part cannot fail in increasing the vegetative 36 PRINCIPLES OF SURGERY. capacity of the cells, and, lastly, the leucocytes present in the recent wound serve as food for the cells which are undergoing karyokinetic changes. As a rule, to which there are few exceptions, it may be stated that the rapidity with which the healing process is completed is propor- tionate to the vascularity of the wounded part. For instance, wounds of the fingers heal much more rapidl}' than wounds of the arm or fore- arm, and wounds of the face more rapidly than wounds of the neck. Karyomitotic changes are first noticed in the nuclei of cells in close proximity to blood-vessels. In studying the healing of wounds of vascular tissue, Graser noticed that the connective-tissue cells a little distance from the surface of the wound were first to show evidences of karyokinetic changes ; hence, it is apparent that the reparative process is initiated in cells most favorably located in reference to an abundant blood-supply, which corresponds to the location of capillary vessels which are undergoing dilatation prior to the formation of new blood- vessels. Regeneration of tissue takes place most rapidly in parts where new blood-vessels are developed earh% rapid)}-, and abundantl}'. The healing process is retarded or completely suspended when the capillar}^ vessels, new and old, are seriously altered by inflammation. Surface Epithelia. — Epithelial cells in a normal condition receive no direct blood-supply, but their relations to the subjacent vascular tissue are so intimate, and their proliferation in the healing of surface wounds and in the repair of defects caused by pathological conditions is so largely dependent on the development of new blood-vessels, that the study of their regeneration among the vascular tissues appears appro- priate. In the consideration of this subject of epidermization, it has been shown that epithelial cells are derived exclusivel}^ from an epithelial matrix, either from the margin of the wound or an islet of the epiblast buried among the granulations. Regeneration of epithelial cells of the hypoblast takes place in a similar manner as has been described in epidermization of a wound of the cutaneous surface. Of special intei'est is the rapid regeneration of the gastro-intestinal mucous membrane. A recent gastric or intestinal ulcer presents elevated and swollen margins, and as long as this condition remains the healing process fails to become established until the swelling subsides, and paving of the granulations with epithelial cells is postponed until the surface of the ulcer is nearly on the same level with the surrounding border of the mucous membrane. Griffini and Vassale made gastric fistulfe in dogs for the purpose of studying directly, and during the life of the animals, the process of repair of wounds of tlie mucous membrane of the stomach. Through the fistula they made superficial wounds of the inner surface of the organ, and from their observations they satisfied themselves that VASCULAR TISSUE. 37 healing takes place rapidly, and that regeneration of epithelial cells occurs in the peptic glands, where even as early as the tliird day the epithelial cells showed evidences of active proliferation. The new epithelial cells spread over the interglandular spaces, while a part of the glandular structure is lost during the process of healing. In traumatic defects wliere the glands have been excised with the mucous membrane the epithelial covering of the granulating surface is derived from the preformed epithelial cells of the mucous membrane bordering the wound. At a later stage new glands are formed by karj'omitotic cellular changes after the normal type of development of glands in the embryo. Even the 3'oungest glands have an outlet, and the structure increases in depth by extension of mitotic changes in that direction. Pepsin-secreting cells are found onl}' after the glands have attained nearl}^ their normal depth. In one instance they were found onl^^ partly developed on the fortieth da3\ Connective-tissue proliferation takes no essential part in the growth and development of the new glands. Visceral wounds of the stomach heal kindl}- and rapidl}'. Even gunshot wounds of this organ, when made with a small bullet, ma}- heal without surgical interference, more especially if at the time the injnr\' has been inflicted the stomach is empty and all food is withheld for a few days. A strict diet is important in the treatment of wounds or ulcers of the stomach, as Leube has obtained excellent results from treatment of chronic ulcers of this organ by an exclusive milk diet. Grittiui also made the observation that the traumatic defects which he produced in the interior of the stomach of dogs healed most rapidly when food was withheld entirel}' for a few days, and later on nothing but milk was allowed. From these observa- tions and experiments it is evident that the j'oung cells are unfavorabl}' affected by the action of the gastric juice. Quincke has demonstrated experimentall3\ which has been a long- known and familiar clinical fact, that angeraia retards regeneration of the gastro-intestinal mucous membrane. In two dogs a gastric fistula was made, and through it a defect of the mucous lining was made of the same size in both animals. One of the animals was in perfect health, and healing was completed in eighteen days. The other dog was anaemic, and the healing process was prolonged thirty-one days. In the healing of an ulcer of the stomach or an}^ portion of the intestinal canal the epithelial cells are first to take an active part in establishing a process of repair, the connective-tissue cells entering later upon their part of tissue production. The heahng process terminates most satisfactorily when only a small amount of connective tissue is formed and the epithelial covering is completed in a short time, as such a scar represents almost to perfection the normal tissue it has replaced. If a large 38 PRINCIPLES OF SURGERY. quantity of granulation tissue is produced by the connective tissue, and the formation of the epithelial covering is delayed for a long time, or is imperfectl}' accomplished, there is great danger of subsequent cicatricial contraction of the new tissue producing a stricture. The best possible prophylactic means against the occurrence of strictures under such circumstances are suck dietetic and therapeutic measures as will secure for the ulcerated or wounded surface such favorable conditions as will expedite the paving of the surface with epithelial cells and limit the production of cicatricial tissue. TRANSPLANTATION OF SKIN. Epiderraization of a large granulation surface is a slow process, even under the most favorable circumstances, and the resulting cicatrix is often large, gives rise to contractions, and not infrequently becomes the seat of keloid or ulcerative processes subsequent!}'. Modern surgery offers means by which this tedious process can be materially shortened, and healing is accomplished by the formation of a moi'e satisfactory scar. Skin-grafting to Expedite the Healing of Granulating Surfaces. — In 1810 Reverdin discovered that small, thin pieces of superficial skin, transplanted upon a healthy, granulating surface, formed, in a short time, organic connections with the granulations, and that epidermization pro- ceeded independentlj' from such transplanted islets of skin. Later, Schwenninger demonstrated, by his experiments, that hairs could similarly be transferred to a granulating surface. An open, granulating wound or ulcer can be covered over with epidermis in a short time by resorting to Reverdin's method of transplantation of skin. The most essential condition for success is an aseptic condition of the granulations. In suppurating wounds this method of treatment is not applicable until suppuration has ceased and the granulations are small and firm. The part from which the skin is to be taken, in preference the thigh or arm, should be shaved and disinfected. The only instruments required for cutting and transferring the skin is an ordinary sewing-needle fixed in a needle-holder, or, what is still better, a pair of haemostatic forceps and a sharp razor. With the needle the skin is transfixed, and with a razor a thin section the size of the circumference of a split pea is removed and at once transferred to the granulating surface with the needle in such a manner that the cut surface is l)rouglit accurately in contact with the granulations. As the detached portion of skin always curls toward the raw surface at its margins, it must be cnrefully fiattened out with tlie point of one or two needles, care being taken to imbed it well among the granulations without causing any bleeding. The grafts are planted in rows, commencing near the border and leaving small spaces between TRANSPLANTATION OF SKIN. 39 the separate grafts. Each row of grafts is then separately protected with a narrow strip of protective silk, and a thick, antiseptic compress is applied and retained by a bandage, which should exercise uniform gentle compression. The dressing should not be removed in less than a week. At this time the grafts will not only have become firmly attached to the subjacent surface, but each of them has become surrounded Avith a zone of new epithelial cells. As each graft now constitutes an inde- pendent centre of epithelial proliferation, the remaining portion of the granulation surface soon becomes paved by new epithelial cells, and epidermization and cicatrization are rapidly completed. The results obtained by this method of treatment have not always been such as to satisf^-^ the earlier expectations. The new skin is but a poor substitute for the normal structure. Epidermization is hastened, and the results are better than after-healing without skin-grafting, but the ideal result, the formation of tissue resembling true skin, is not obtainable by this method of skin transplantation. Skin-grafting in the Treatment of Recent Wounds. — If after an operation or injur3^ it is found that a too extensive defect of the skin renders approximation b}' suturing impossible, the surgeon has it now in his power to supply the defect at once by taking large skin-grafts from another part of the bod}-, or from another person, and planting them in the form of a mosaic upon the raw surface. This method of skin-grafting in the treatment of extensive superficial wounds, as after the extirpation of a lupus, or a surface epithelioma, was devised by Thiersch. Experience has shown that grafts of the whole thickness of the skin, and an inch square, if planted smoothly' upon the raw surface and kept uninterruptedl}' in contact with the wound by an appropriate dressing, not only retain their vitalitj*, but enter rapidly into organic connections with the part with which tliey have been brought into con- tact, and, at the same time, their anatomical and physiological properties are maintained to perfection. Thiersch found that after eighteen hours they were supplied with new blood-vessels, which could be successfully injected from the vessels of the part to which the}" had become adherent. This method of transplantation of skin is now extensively practiced in connection with plastic operations about the face. For such purposes the skin is taken from the region of the trochanters, as the skin here is almost or entirely devoid of hair. All bleeding from the wound to be covered with the grafts is carefull}' arrested by surface pressure before the grafts are planted, as it is necessar}^ to secure accurate coaptation of the wound-surfaces in order to secure a favorable result. Tlie modern method of performing rhinoplast}- furnishes a good illustration of this method of skin transplantation. 40 PRINCIPLES OF SURGERY. As a matter of course, success by this method of skin transplanta- lion can only be expected when the wound and grafts are aseptic, and tlie parts are kept in this condition at least until vascularization of the grafts has taken place. After the grafts have been planted the treat- ment of the wound is the same as in Reverdin's method. During the after-treatment it is important to secure rest for the part, and to prevent, by appropriate means of fixation, even the slightest displacement of the grafts in any direction. A good plan is to apply a thin plaster-of-Paris Fig. 20.— Rhinoplasty and Transplantation of Large Skin-grafts. (Thiersch.) A, A, skin-flaps from face turned inward and covered with large flap from forehead, C after C, and B after B'. Defects covered with mosaic of large skin-grafts from troclian teric region. bandage over the dressing, Scliede has substituted Thiersch's for Re- verdin's method in the treatment of granulating surfaces by skin-graft- ing, and the results have been very gratifying. The granulating surface is transformed into a recent aseptic wound by removing the granulations with a sharp spoon. After all bleeding has ceased the wound is covered with large skin-grafts in the manner described. The skin obtained after this method of transplantation presents a normal appearance. I have repeatedly seen that, after excision of an epithelioma of the frontal or parietal region, a defect the size of the palm of the hand was healed CONNECTIVE TISSUE. 41 completel}- in less than three weeks b}- using Thiersch's grafts. This method of skin-grafting must be a welcome resource to the oculists in the operative removal of tuberculous lesions and malignant affections of the eyelids, as well as in the treatment of some forms of ectropion. Transplantation of Mucous Membrane. — In the treatment of traumatic or ulcerative defects of accessible mucous membranes, it would seem that restoration of the defect by transplantation of grafts of mucous membrane, if found feasible, would be the ideal treatment. Wolfler has recently shown that such a method of treatment is not only practicable, but has resorted to it successfully in the treatment of obstinate strictures of the urethra. After excision of the cicatrix at the seat of resection he sutured a circular graft of mucous membrane to each end of the resected urethra, and had the satisfaction to observe that the graft not only retained its vitality, but became adherent and constituted an essential part of the new portion of the urethra. Wolfe has also suc- ceeded in transplanting the whole of the tissues of the conjunctiva of the rabbit onto that of man in order to fill a defect caused by cicatricial contraction. This method of dealing with large defects of mucous surfaces accessible to direct treatment holds out many inducements for future imitation. The difficulties in the way of equal uniform success in the transplantation of grafts of mucous membrane, as in skin trans- plantation, are owing to the location of the seat of operation. In the former instance it must always be such as to preclude the possibility of securing perfect asepsis on the one hand, and the impossibility of apply- ing an efficient protective dressing ; at the same time, it is also more difficult to obtain the proper material for the grafting. CONNECTIVE TISSUE. The granulations seen upon a wound or ulcerating surface are formed almost exclusivel}^ by the transformation of mature connective tissue into embryonal tissue, the cellular elements of which they are I'omposed being embryonal connective-tissue cells. This transition of mature into embryonal cells is accomplished by karyokinesis. As con- nective tissue is found almost in every part and organ of the body, it takes an active part in the repair of all wounds, and when the more im- ])ortant tissues in the wound cannot be approximated for organic union to take place its greater vegetative capacity enables it to produce a large amount of new material, which later forms a connecting bridge of cica- tricial tissue. For instance, in a transverse wound of a muscle, where it is often difficult, if not impossible, to keep the divided ends sufficiently npproximated for the wound to heal by the interposition of new muscle- cells, the gap is spanned by a band of connective tissue, wliieli, if not 42 PRINCIPLES OF SURGERY. completel}^ at least partially, restores the function of the muscle by fur- nishing it with two additional fixed points of attachment. Graser has shown that the first karyokinetic changes are seen in connective-tissue cells some distance from tlie surface of the wound, and that the new cells reach the surface with the new blood-vessels, where they constitute the granulation tissue. In aseptic wounds, where cicatrization progresses rapidlj', the embryonal connective-tissue cells, or granulation cells, are short-lived, as they are rapidly- transformed into mature connective tissue, which here constitutes the cicatrix. In suppurating wounds, the super- ficial layer of embryonal cells are brought in contact with the pus- microbes and their ptomaines, which destroy the protoplasm of the cells, when they are transformed into pus-corpuscles ; while those nearer the blood-vessels retain their vitalit}' and capacity of undergoing cicatrization. BLOOD-VESSELS. Wounds of large blood-vessels, with few exceptions, require such measures in their treatment which completely arrest the circulation, and which .aim at permanent obliteration of the lumen by the usual method of cell proliferation and cicatrization. A wound of an arter}^ if accessi- ble to direct treatment, should be treated by cutting the vessel completely across and applying a ligature to each end. A small wound of a large vein can be treated successfull}^ under favorable conditions, b}^ closing it with a lateral ligature. With a tenaculum the margins of the wound are transfixed, and by making slight traction the vein-wall is raised, and around the base of the little cone thus formed a fine catgut ligature is applied. If the wound remains aseptic, the mural thrombosis at the seat of ligation is slight, and closure of the wound is effected without oblitera- tion of the lumen of the vessel. A wound of a blood-vessel usually terminates, spontaneously or through the intervention of art, in perma- nent interruption of the circulation b}' the formation of an intra-vascular cicatrix. For many years it has been maintained that obliteration of a vessel after injury, disease, or ligature resulted from what was termed " organization of the thrombus." It was believed that the thrombus be- came vascular eitlier from the lumen of the vessel or the vasa vasorum, and that the histological elements in the thrombus took an active part in the production of tlie intra-vascular cicatrix. Numerous experimental investigations by difterent authors, undertaken for the purpose of demon- strating that in wounds of blood-vessels healing takes place in the same manner as in the wounds of other tissues, have shown that the blood-clot always occupies only a passive role, and, if present, is only in tlie way of a speed}' definitive closure, which invariably is effected by prolifera- tion from the fixed cells of the vessel-wall. Eliminating the thrombus BLOOD-VESSELS. 43 as an active agent in the obliterating process, we can say that union be- tween the tissues which are brought in contact by the ligature takes place by tissue proliferation from the walls of the vessel itself. In the true sense of the word, direct or immediate union is as impossible here as in any other wound, and, hke everywhere else, the intra-vascular cica- trix is formed from tissue derived from the tissue of the injured vessel- wall. In case the inner tunics are severed by the ligature, the lacerated surfaces are brought in contact with the adventitia, and repair takes place as in other tissues which are largely composed of connective tissue, the process extending from both sides of the ligature, where endothelia Vasa vasorum. Intima. Partly-formed connective tissue from endothelia. Proliferated connective tissue in lumen. Endothelial ^_ ^ proliferation. ^-"^ , Fio. 21.— MiCROscopicAii Appkaraxofs of the Interiok of Aktery of Dog Forty-nine Days aftek Ligation. Transverse Section THROUGH Border of Artery, x 240. assist in the process of cicatrization. If, on the other hand, the con- tinuity of the vessel is not destroyed by the ligature, and the intima is simply brought in contact without being ruptured, the new cells from the connective tissue perforate the endothelial lining, and the new elements of the latter join in the reparative process by being converted fi'om their embryonal state into connective tissue. The histological changes in the interior of veins undergoing oV)literation are the same as in arteries, the new material of which the cicatrix is composed being derived exclusively from the endothelial and connective-tissue cells. 44 PRINCIPLES OF SURGERY. J. Collins Warren, who li:is done excellent work in studying experi- mentiilly the healing of arteries after ligature, niaiutains that he has seen sulfieieut evidence in his specimens tliat the muscle-cells in the tunica media take au active part in the process of rejjair. The same author compares tlie process of healing in arteries to the formation of callus after fracture, and hence calls tlie intra-vascular material the internal and the extra-vascular the external callus. The numerous experiments of the author on ligation of arteries and veins have demonstrated, to his own satisfaction, that the most speedy obliteration of a vessel is obtained if Proliferation of connective tissue. Fig. 22.— Microscopical Appearances op the Interior of Vein of Dog Forty-nine D.vys after Ligation. Transverse Section of Part of Vein in Ligateb Portion. X 240. the vessel is rendered bloodless by the application of two ligatures. The ligatures are applied with sufficient firmness to obliterate the lumen of the vessel without rupturing any of its coats. After ligation the walls of the vessel became thickened so that, a few weeks after the ligatures had been applied, the vessel presented a spindle shape, tapering toward each side, a condition entirely due to the formation of new material, — the external callus of Warren. The bloodless space between the ligatures is obliterated in a short time b3' cells which enter it from the vessel-wall. In the obliteration of A^eins nnd ligation of arteries in their con- tinuitj^ the double ligature, including a bloodless space about ^ inch in BLOOD-VESSELS. 45 length, places the tissues in the most ftivorablc conditions for speed}'- definitive closure by an intra-vascular cicatrix. When the vessel is ex- posed catgut should be used, but in the subcutaneous ligation of veins silk is preferable. Since the introduction of antiseptic surger}' and tlie aseptic ligature, seeoiulary haemorrhage has become an exceedingl}- rare accident, and, when it does occur, it is in wounds where the antiseptic measures have failed. A vessel in an aseptic wound, tied with an aseptic ligature, becomes in a few hours the seat of a regenerative process which eftectuall}' guards against the possibility of hnpuiorrhage, even if the mechanical obstruction caused by the ligature should be removed after a few daj's. The aseptic ligature, applied under strict antiseptic precau- tions, has been advantageous in other directions. The older surgeons alwa3'S expected, after ligating an arterj- in its continuit}', that the thrombus would extend on the proximal side to the nearest collateral branch, and on this account the}- were always anxious to secure a space of an inch or more between the ligature and the nearest large collateral Fig. 23.— FEMORAii Artery of Dog Fifty Days after Double Ligation WITH Silk. Below, Transverse Section showing Bloodless Space Filled with Cicatricial Material. (Xatural Size.) branch, in order to prevent secondarj- hferaorrhage. The aseptic ligature is never followed by such extensive thrombosis, and the intra-vascular cicatrix is often exceedingl}- narrow, — in fact, almost linear. The limited thrombosis and the prompt formation of an intra-vascular cicatrix place the surgeon now in a position that he can ligate a large arter^', close to a collateral branch or near a point of bifurcation, without a particle of fear of incurring secondary haemorrhage. In the ligation of veins the aseptic ligature has dispersed all fear of suppurative thrombo-phlebitis and pyaemia, — complications which were formerly so much feared, even after insignificant operations on veins. In the repair of wounds union between the divided ends of blood-vessels is probabl}' never effected. The vessel- ends are temporaril}- closed either b}^ t^ing with a ligature or by the formation of a thrombus, the former being the case when vessels of some size have been divided, the latter being accomplished usually spontane- ously in vessels which give rise to parenchjmatous haemorrhage. In either instance the ends of the vessel are, later, permanently sealed b}' the formation of a cicatrix by proliferation of fixed tissue-cells, the endo- 46 PRINCIPLES OF SURGERY. ihelia, and connective-tissue cells. The interrupted circulation between the two sides of the wound is restored indirectly through collateral branches, which are always new blood-vessels. The angioblasts in the injured capillary vessels assume active tissue proliferation within twenty- four hours after the injury has occurred, and through them, almost exclu- sively, the new blood-vessels are formed in the shape of loops, which, coming as they do from both sides, establish the vascular connection between the two surfaces of the wound. Man}' of these new blood-vessels disappear after the consummation of the reparative process, while others remain as permanent collateral vessels between the closed ends of the old blood-vessels permanently separated by the injur3\ MUSCLES. It is only quite recently that it has been ascertained that a divided muscle can unite, under favorable circumstances, by interposition of new muscular tissue between the divided ends. It was formerly believed that healing was alwaj's accomplished by the formation of connective tissue, and that the ends of the cut muscle remained permanently sepa- rated by a bridge of cicatricial tissue. The theory that connective tissue can be transformed into muscular tissue is untenable, since Pflueger has demonstrated the minute structure of muscular fibre. Kolliker has shown that the fibrillse in the muscle-fibre constitute the real ground- substance. Rabl ascertained, by his eml)ryological researches, that the muscular tissue is derived from a distinct portion of the mesoblast, and consequently proved that at a very early period of embryonal life an absolute difference takes place between muscular and connective tissue. Heterotopic muscular structures must, therefore, be looked upon, not as products of connective-tissue proliferation, but as a growth from a dis- placed embr^'onal matrix of muscular tissue. The vegetative capacity of muscle-cells, striped and unstriped, is quite limited, as compared with some of the other tissues, so that if the ends of a muscle that lias been cut transverselj' are separated for more than an inch complete restoration of the continuity of the muscle is not attaind, and the two ends are connected b}- a band of connective tissue. If, during the healing of the wound, the cut surfaces of the muscle are kept in accurate contact, and even if a gap of half an inch exist between them, restoration ad integrum takes place b}' proliferation of the muscle- elements near the seat of injury. Non-striated Muscular Fibre. — Stilling and Pfitzner, as well as Busachi, have shown that unstriped muscular fibres multiply b^y indirect division of their nuclei, and in the repair of wounds of this tissue new fibres are produced exclusivel}' b^' this method. These authors studied MtrscLES. 47 the karyokin»tic changes in the muscular fibres of the triton tseniatus. They observed, after the division of the nucleus in the usual manner by karyokinesis, that as the new nuclei separated and approached the poles of the cell the protoplasm of the cell-body at the transverse axis became narrower, showing a well-marked constriction, which would indicate that subsequently cell-division occurred. Herczel witnessed similar changes in the hypertrophic muscular coat of the intestines on the proximal side of strictures. In defects caused by the injury, removal, or destruction of unstriped muscular fibres, regeneration takes place only from the margins, wliile the centre at first is occupied by connective tissue. The new muscular fibres are at first irregularly arranged, and it is only toward the completion of the healing process that the new tissue repre- sents to perfection the mature muscular fibres. Klebs is of the opinion that the leucocytes serve as food for the cells which undergo karj-okinetic changes. Striated Muscular Fibre. — 0. Weber, as early as 1854, claimed that in the healing of wounds new muscular fibres are produced, but, in accord- ance with the views which then prevailed, believed they were derived from connective tissue. Wittich saw, in hibernating frogs, new fibres which he believed had developed from the cells of the internal peri- mysium. In 1865, after an examination of a genuine myoma strio- cellulare, Buhl expressed the opinion that new muscular fibres are produced from old fibres. In tlie same year Walde^'er discovered the muscle-cell sheath, and he regarded the cell inclosed by it as a derivative of the nucleus of the fibre, but, Avitli Zenker and others, he still regarded the perimysium as the source of new muscular fibres. In 1868 E. Neumann made the observation that after section or laceration of a muscle the ends of the fibres became the seat of active tissue changes, which resulted in the formation of what he termed muscle-buds. These muscle-buds were not only found at the ends of the fibres, but also on their sides; at first they were seen to be composed of numerous nuclei and protoplasm, while later they were transformed into striated fibres. The sarcolemma is such a delicate structure that new cells which form within it readily find their way through it, and appear upon its outer surface in the shape of buds, as described by Neumann. Tizzoni has recently investigated the karyokinetic changes in the nuclei or sarcoblasts in the perim^^sium during the repair of muscle wounds. The first evidences of cell proliferation were seen in the nuclei or myoblasts nearest tlie seat of injury, and proliferation took place in fibres which had undergone degeneration as well as in those which pre- sented a striated appearance. Leven found, during the first twenty-four hours after injury, an increase of nuclei of the sarcolemma sheath. These 48 PRINCIPLES OF SURGERY. new nuclei are arranu^ed in the form of rows and heaps, and by mutual pressure are flattened. Many of tliese new elements present karyokinetic figures, and around them i)rotoplasm is deposited, and tlie new cells become spindle-shaped. The new cells increase in number from the third to the fourth day, so that at this time from five to six can be seen under one field. Klebs studied regeneration of muscle in young guinea-pigs after puncturing subcutaueously the gastrocnemius muscle. He came to the following conclusions: A portion of the muscular fibres die and shrink, and in this condition the_y can be stained more deeply with hpematoxylin than the others. Such fibres are completely removed by absorption within the first four davs. In the fibres which remain striated Fig. 24.— Muscular Fibres Near a Wound in a State of Proliferation. (O. Weber). A, contused end of muscular fibre ; B, muscular fibre retracted within sarcolemma, the latter terminating in a sharp point; C, old fibre degenerated into a colloid mass; D, young nuclei between and upon fibres; E, nuclei surrounded by cell-protoplasm; F, new cell, showing scriations ; G, new muscular fibre. the fibrilloe become plainer, and in them the regenerative process can be distinctly seen. The nuclei increase in number, and are packed densely together, but at this stage he was unable to detect any evidences of karyokinesis. During this stage Steudel was also unable to detect any appearances which indicated indirect cell division. These 3''oung cells are called sarcoblasts by Klebs, and their transformation into muscle-fibres is effected by aggregation around them of a very thin layer of proto- plasm. The youngest cells are round, and the change into spindle form is o-radual. The new cells nre nrrano^ed in rows between the old muscular fibre (Fig. 24, between G and B). Some authors believe that the sarco- blasts unite end to end, and that the muscular fibre is formed in this BONE. 49 manner. Kraske and Klebs maintain that muscular fibres result from a single cell by gradual elongation of the cell-bodj'. In the regeneration of the muscular fibres of the heart after injur}', Martinti and Bonome witnessed karj'omitotic changes in the interior of the sheath of numerous fibres, while in others where degenerative changes had taken place no such changes could be seen. In wounds of the heart of old rats karj'o- mitosis commences five to six days after the injur}', and does not last longer than six to seven daj's, and results onl}^ in incomplete regener- ation. In myocarditis tlie formation of new muscular fibres has been observed by Virchow, Boettcher, and Waldeyer. Muscle Suture. — In the treatment of recent wounds special pains should be taken to secure accurate approximation between the ends of divided muscles. For this purpose special means must be employed when large muscles have been divided transversely. In sucli cases the retraction which follows gives rise to great separation, which can only be overcome by suturing respective ends separately with l)iiried animal sutures. Great care is necessary not to invert the margins, but to unite the cut surfaces throughout,usingfor this purpose, if necessary, as many as six sutures, which must include considerable tissue in order to prevent their tearing through. In muscles supplied with a well-marked sheath this should be sutured separatel3\ In the after-treatment it is necessary to place the limb in such a position that will relax the sutured muscles, and to secure immobility of the limb in this position b}^ a proper me- chanical support, which should not be removed until the healing process is completed, in order to prevent subsequent diastasis between the sutured ends. When it is desirable to elongate a contracted muscle in the correction of deformities, as in the treatment of torticollis, the con- tracted muscle should be exposed by incision, and after section a suture a distance is applied. A number of heavy catgut sutures will answer an excellent purpose, as they will maintain fixation of the separated ends in a desirable position, and will furnish an admirable scaffolding for the new connective-tissue cells, which, later on, are transformed into a tendon which permanently connects the retracted ends of the divided muscle. BONE. The granulation material by which the fractured bone unites is called callus. According to the location of this material around, within, or be- tween the fragments, we speak of an external, internal, or intermediate callus. The external or provisional callus is abundant, as a rule, where the broken bone is surrounded b3'a thick cushion of soft parts, and when the fragments are not well immobilized. It forms early and disappears gradually after the fracture has united. The internal or medullary callus, 50 PRINCIPLES OF SURGERY. which takes the place of the medunary tissue in fractures of the shaft of tlie long bones, serves a useful purpose as a means of fixation of the fragments, and is also removed in the course of time after union has taken place, and with its disappearance the medullary cavity is restored. The intermediate or definitive callus is the material interposed between the broken surfaces, and which is transformed into permanent tissue. Callus is the product of cell proliferation of those tissue-elements which are directly concerned in the growth and development of bone. Duhamel de Monceau attributed to the periosteum and endosteum the function of producing callus. Haller and his prosector, Detlef, be- lieved that the periosteum takes no part in the regeneration of bone, but that callus is derived from the fractured ends of the bone, more especially the myeloid tissue. Dupuytren maintained that the periosteum and the paraperiosteal connective tissue were bone-producing tissues. Cruveil- hier claimed that the lacerated soft tissues around the fractured bone- ends, the periosteum, connective tissue, muscles, tendons, etc., furnished the material for the callus. Flourens claimed that the periosteum alone could produce new bone. Rokitansky asserted that callus is developed directly from bone and its connective tissue, including the periosteum. From his own experimental work, R. Hein came to the conclusion that regeneration of bone takes place from connective tissue in and around bone and the periosteum. According to Virchow, callus is produced from connective tissue outside of the bone, as well as from the medullary tissue. Hofmokl con- sidered as sources of callus formation the periosteum, bone, and mar- row. Gegenbauer takes the ground that bone is produced directly from connective tissue. He asserts that Sharpey's fibres, if traced carefully, can be seen springing from a bony point between the Haversian canals, from which point they radiate toward both sides into the lamellar sys- tems. The fibres form net-works, and at points of intersection bone- cells are produced, and a deposit of lamellae takes place around the connective-tissue fibres. It is now generally conceded that the provisional callus is the prod- uct of tissue proliferation from the periosteum, while the definitive or permanent callus is produced directly from the medullary tissue. The provisional callus is nature's splint, its onl}' object being to immobilize the parts until the definitive callus firmly and permanently unites the fragments. The temporarj' callus is an accidental product, and appears earliest and most copiously where the paraperiosteal tissues are most abundant and motion between the fragments greatest ; the intermediate or permanent callus is produced later, and is transformed into permanent tissue. Oilier and Buchholtz, in their experiments on transplantation of BONE. 51 periosteum, found that the transplanted tissue first produced cartilage, which later was transformed into' bone ; but they also ascertained that such bone disappeared again unless it formed in a place where bone nor- mall}^ exists. Cohnheim and Maas came to the same conclusion from their experiments on intra-venous transplantation of periosteal grafts. It is possible that special cells (Mastzellen) are the active agents in the removal of tissue in places where it has no physiological existence. — A Fig. 25.— Section through Callus Fifty-two Hours after Fracture of Ulna FROM Rabbit. Beginning Formation of osteoid Tissue. (Bajardi.) A, cortical portion of bone; B, osteoid tissue; C, beginning of formation of a lamella, surrounded by osteoblasts; D, periosteum. (Hartnack, Obj. 8.) Macewen has maintained for years that bone grows only from bone, and the results obtained by applying this principle in practice speaks strongly in favor of this supposition. That medullary tissue alone can produce bone has been experimental!}' demonstrated by Burns. The osteoblasts from which bone production alone can take place are foimd in the periosteum, more especially its inner layer, the cambium, and in the interior of bone. Regeneration of bone from these cells takes place in two ways, — either the cells are transformed into an osteoid tissue, or 52 PRINCIPLES OF SURGERY. they are first changed into cartilage-cells, and the latter at a later stage undergo ossification. The osteoblasts in the periosteum, and, to a lesser extent, those in the central medullar}^ cavity, produce bone by this indi- rect method, while in other places ossification is effected in a more direct wa}' by the osteoblasts being transformed into an osteoid substance. In the normal regeneration of bone, cartilage pla3's an important part. As the bone-cells disappear, or at least lose their nuclei where cartilage- cells form, it is probable that the cartilage-cells represent structures in- termediate between osteoblasts and bone-colls. Cartilage is abundant R .R / / ^_ _i P Fig. 26.— Transverse Section through Callus of Tibia of Rabbit Forty Days AFTER Fracture, with External Resorption. (Muas.) P, periosteum, much thickenad ; R, giant cells or osteoklasts ; G, blood-vassels ; M, medullary resorption spaces ; K, compact portion of bone. where union is retarded, and especiall}^ in cases of pseudarthrosis. During ossification the h3-aline cement-substance between the cartilage- cells is dissolved, and the space gives way to lamellae, while the cells are transformed into bone-cells. According to Krafft, multiplication of the bone-producing cells of the periosteum can be seen twenty to thirty hours after fracture, in the shape of karyokinetic figures in the nuclei of the cells, while somewhat later the same figures are to be seen in the endothelia lining the blood-vessels. The new cartilage-cells also multiply by karyokinesis. Like in the healing of wounds in soft parts, the cells on the surface of the fracture take no part in the process of BONE. 53 regeneration, as their proliferation capacity has been destroyed by the trauma as well as the sudden diminution of the vascular supply. Osteo- porosis at the seat of regeneration is alwaj-s present, and results from the action of another kind of cells discovered by KoUiker, — the osteo- klasts. Robin described them as myeloplaques. The}^ are found in Howship's lacunae where resorption takes place. The osteoklasts appear to be nothing else but myeloid cells which have lost their bone-producing function ; they are in reality hyperplastic osteoblasts. Absorption of bone takes place because these cells do not produce bone. There is no reason to believe that these cells are altered bone-cells, as no intermediate forms have been found. Ziegler does not assign much influence to these cells in the resorption of bone. Wegner has shown that in pathological processes in bone where resorption takes place they are arranged along the sides of blood-vessels, and on this account he believed they were derived from the A'essel-wall. Klebs is of the opinion that the osteoklasts ma}- secrete a chemical substance which decalcifies the bone. Resorption of superfluous callus is accomplished undoubtedly bj^ the action of osteoklasts, an exceedingly useful function, as b}' it form and strength of the broken bone are restored. According to Mejer the architectural structure of the spongiosa, after the healing of a fracture, adapts itself to the new conditions, so that the new traction and pressure-curves are arranged in such a manner as will resist the greatest degree of force. This capacit}' of adaptation is present to a very high degree in bone. Abnormal and Defective Callus. — Callus may be formed in excess of local requirements after a fracture, and yet no union take place. The osteoblasts respond promptly to the stimulus created b}' the trauma, karyokinetic changes occur early, new cells are formed with great rapidity, and a large mass of new material is deposited at the seat of fracture, but bon}- consolidation does not occur because the new tissue does not undergo ossification. The normal development of cells is arrested at an early stage, and the chemical process upon which ossifica- tion depends are delayed or fail to appear altogether. Prompt bony union does not only imply that the osteoblasts at the seat of fracture should undergo karA^okinetic changes and multiply, but that the new tissue must be placed under the influence of favorable chemical conditions which will enable it to be transformed into bone. A few years ago B. von Langenbeck reported 2 cases of fracture of the femur, where he resorted to amputation of the thigh under the belief that tlie luxuriant callus, which formed in each case at the seat of fracture, was a sarcoma. Microscopical examination in both instances showed that the swelling was composed of cells which are found in callus 54 PRINCIPLES OF SURGERY. 5it nil early stage of its formation, witliout any evidences of ossification of tiie new material. The causes of delayed ossification are not known, but, as in a number of instances of profuse callus formation and delayed union a vigorous antisyphilitic course of treatment produced favorable results, it appears that the virus of syphilis may at least be one of them. We know that in gummata the same conditions prevail in the persistence of tissue in its embryonal state for an indefinite period of time, or until the syphilitic virus has been removed or neutralized by proper anti- syphilitic treatment. In cases where no such cause for the delay of the transition of callus into bone can be surmised, the internal administration of minute doses of phosphorus should be tried. Kassowitz produced osteoporosis in animals experimentally by large doses of phosphorus, while minute doses produced an opposite effect. He recommended the remedy in small doses in the treatment of rickets, and since then it has been ex- tensively used in the treatment of this disease, and with the best results. The action of this drug undoubtedly would produce a favorable effect upon the osteoid material, in hastening its transition from the embryonal into a mature state. Defective callus formation will necessarily follow a fracture if the osteoblasts fail to enter upon an active process of cell proliferation. These are the cases where the surgeon resorts to local measures, which are intended to stimulate the cells to increased activity. Fractures of the lower extremities which have failed to unite as long as the patient is kept in bed often unite promptly after he is allowed to walk around on crutches, the favorable change being brought about by an increased blood-supply to the seat of fracture. Dumreicher suggested that the local blood-supply could be increased by applying a compress and bandage above and below the seat of fracture, while Helferich more recently, and with the same object in view, advised moderate constriction with an elastic bandage applied in such a manner as not to interfere with the arterial circulation. Rubbing of the frag- ments forcibly against each other is an old method of treating delaj^ed union, and has often been sufficient to rouse the dormant osteoblasts into active cell proliferation. The distinguished Brainard made the treatment of delayed union a special study during many years of his useful life, and devised a new method of treatment, the subcutaneous drilling of the ends of the fragments, which has been extensively prac- ticed, and has yielded most excellent results. The drilling of the ends of the broken bone has a most decided effect in stimulating the sluggish separative process, as it produces osteoporosis and increases the vascu- larit}' of the parts, both of these conditions being well calculated to increase the local nutrition. Dieffenbach went one step farther, and BONE. 55 advised the use of ivory nails, which were allowed to remain until they became loose and dropped out. The term non-union is a relative one, as in some fractures this condition ma}' have been reached in three to four months, while others may unite after a 3-ear. In a fracture of the femur in a health}' man, who came under the author's observation, that had not united a year after the accident, bony consolidation took place after this time without any operative inter- ference. In another case bonj- union did not occur until nearly two 3'ears after the fracture had taken place. When a pseudarthrosis has once become established, all measures which have been found useful in the treatment of delayed union are useless, and the onlj^ rational treatment in such cases consists in transforming the old fracture into a recent one. Tlie ends of the fragments are exposed, the interposed ligamentous structures — muscles or tendons — or false joint excised, and the ends vivified in such a manner as to furnish large surfaces for apposition. The bone should never be cut transversely^ but alwa^'s obliquely, or, what is still better, Volkmann's step-operation should be done wherever the existing conditions make this possible. Direct fixation of the frag- ments with aseptic bone or ivory nails should always be practiced, as by this expedient we are able to secure greater immobilit}^ between the fragments, and at the same time the perforations and the presence of the foreign bodies cannot fail in imparting an additional stimulus to the tissues which will expedite the process of repair. The frequency with which non-union is met with after intra-capsular fracture of the neck of the femur has almost b}' universal consent been attributed to defective callus formation. It has been claimed that in such a fracture, occurring as it usually does in persons advanced in life, callus production is always defective, and, as the upper fragment is but scantily supplied with blood-vessels, it was asserted tliat it was not in a condition to take an active part in the reparative process. The author made numerous experiments on animals, fracturing the neck of the femur within the limits of the capsular ligament, and as long as the fracture was treated in the customary way bou}- union was never attained. He then resorted to direct means of fixation by transfixing both fragments with an absorbable nail, and with this treatment succeeded in obtain- ing bon}' union in the majority of cases. Since that time he has treated fractures of the neck of the femur by immediate reduction and permanent fixation with a plaster-of-Paris splint, with pressure over the trochanter major in the direction of the axis of the neck of the femur with a compress and set-screw, the latter passing through a splint which is incorporated in the plaster-of-Paris dressing. With this treatment he has obtained bony union in a number of instances, 56 PRINCIPLES OF SURGERY. where all the signs and sjanptoms pointed to a fracture within the capsular ligament. It is a well-established clinical fact that in the aged other fractures unite readily, and pseudarthrosis is exceedingly uncommon, excepting after this fracture; and the writer is satisfied that this undesirable result occurs more in consequence of improper treatment than defective callus production. If the fragments can be brought in accurate apposition soon after the accident has occurred, and coaptation can be maintained uninterruptedly for three months b}' an appropriate dressing, l)on3' union can be secured not only in exceptional, but in the majority of, cases. In the treatment of fractures, as in the treatment of wounds of the soft parts, accurate coaptation and effective fixation should be aimed at so as to place the parts in the most favorable conditions to unite by the smallest possible amount of new material. GLANDS. Griffini studied regeneration of testicle-substance in frogs, dogs, chickens, and guinea-pigs. He excised a wedge-shaped piece under strict antiseptic precautions, and killed the animals in from three to seventy- five days. Examination of the specimens showed that an increase of tubuli seminiferi had invariably taken place. They appeared to have originated as blind pouches from pre-existing tubules, T-izzoni has also observed, in his experiments on dogs, production of new gland-tissue during the healing of wounds of the liver and after partial excision of this organ. The same author studied experimentally regeneration of the spleen-tissue, and found that this occurred after partial and complete extirpation, the new tissue being made up of elements in connection with blood-vessels of the adjacent peritoneum. After complete extirpation of the organ the new spleens appear as nodules of a brownish color, which are attached to the vessels of the peritoneum, and develop around new buds of these vessels. The beginning of such a minute spleen appears as an accumulation of new loose connective tissue, in the meshes of which 13'niph-corpuscles are found ; later, follicles and pulp-substance appear, with a corresponding arrangement of blood-vessels. As these little organs always appear about the hilus of the spleen, they cannot be supernumerary spleens. After excision of wedge-shaped pieces of the spleen, formation of new spleen-tissue has also been observed upon the omentum at a point opposite the wound and independently from tissue proliferation in the wound. Reproduction of tissue therefore takes place in the same manner as in the regeneration of lymphatic tissue. After the removal of the entire spleen, tissue proliferation takes place in the adjacent blood-vessels, the product of which corresponds with normal CENTRAL NERVOUS SYSTEM. 57 splenic tissue, and doubtless possesses the same physiological functions. As the immediate result of such proliferation an altered condition of the vessels must be accepted, as the blood-vessels of the omentum and peri- toneum correspond with the fundus of the stomach. Mayer claimed regenerative capacity for the pulp of the spleen, but he may have been deceived b^^ the presence of lymphatic glands of the color of the spleen at the seat of extirpation. Picard and Malassez, Bizzozero and Salvioli, and finally Tizzoni and Fileti showed that after splenectomy a diminu- tion of the blood-corpuscles is observed first, but as the new spleen-tissue is produced their number again increases. Baier and Bacialli have showMi, b}- their experimental investigations, that new l^'mphatic tissue is rapidly produced after partial as well as after complete removal of a lymphatic gland. In the regeneration of this tissue the adjacent adipose tissue appeared to take an active part. According to Baier, the adipose tissue is first infiltrated with leucocytes, while Bacialli saw new endo- thelial cells and lymph-spaces develop from the connective-tissue cells, after having seen mitotic figures in the nuclei. After complete extirpa- tion of a lymphatic gland, reproduction of Ijanphoid structure in all probability does not take place from any other but lymphatic tissue, and the new gland-tissue is the product of tissue proliferation from the cut ends of 13'mphatic vessels. CENTRAL NERVOUS SYSTEM. The central nervous sj-stem is built up partly from the mesoblast and partly from the epiblast. The stellate and spider-shaped cells are derived from the mesoblast, while the neuroglia and the nerve-cells proper spring from the neuroblast, a part of the epiblast, which, in the embr3'o, is located nearest the middle axis. The neuroglia represent channels of nutrition, which are formed only at a time when the neuro- blastic tissues have reached the height of their development. The mesoblastic portion of the brain and spinal cord does not increase dur- ing the healing of a wound of these parts. In pathological conditions, however, as in cases of multiple sclerosis, the stellate and spider-shaped elements proliferate so active!}' that the nerve-cells are completely dis- placed b}' the new product. Man}^ authors have expressed their doubts as to the possibilit}' of regeneration of brain-tissue after injury or dis- ease, while others have gone to the opposite extreme, and claim that complete I'epair can take place in cases of extensive defects. Yoit claims that in pigeons he has observed complete restoration of both structure and function after extirpation of the entire cerebrum. While large de- fects are not repaired, the regenerative capacity of the nervous elements cannot be doubted, and such a doubt would come in conflict with a 58 PRINCIPLES OF SURGERY. general law. Regeneration of the cerebral nervous sj'stem comprises the production of new ganglia-cells and neuroglia, the latter consisting of a fine net-work, sometimes of nervous, at others of basis, substance. During the healing of every wound of the brain the observer can satisfy himself that the neuroglia possesses a high capacit}' of reproduction, as well-marked karyokinetic changes can be seen during the first twenty- four hours after the injury. The new cells are very abundant, and arrange themselves in groups. More difficult is the demonstration of the same changes in the ganglia-cells, but Mondino (1886) and Coen (1887) have given descriptions of these cells which leave no further doubt that they also multiply l\y karyokinesis. Klebs has also observed karyokinetic figures in the nuclei of ganglia-cells during the repair of injuries of the brain. In the embryo, increase of ganglia-cells by karyokinesis has been witnessed by Pfitzner, Uskoff, Rauber, Merk, and Cattani. It is true that brain wounds heal with some defects, but this applies to extensive injuries in which the regenerative capacit}'^ of the brain-substance is not equal to the emergency ; hence, only a part of the defect is repaired. Klebs gives an accurate account of his examination on the reparative process in two cases of brain injurj^ — one recent, the other of long stand- ing. Microscopical examination of the tissues from the seat of injury in both cases showed that new tissue had been produced. He found many new cells from the neuroglia which he is inclined to believe may func- tionally take the place of ganglia-cells. The same author made numerous experiments on young animals for the purpose of studying the process of healing in wounds of the brain. With an aseptic needle the brain was punctured. No s^'mptoms followed the injur}'. The brain was examined from two to four days after puncture ; only slight meningeal hoemorrhage. The needle-track in the brain not closed. Mitotic changes were found not in the cells in the immediate neighborhood of the punc- ture, but in the cells corresponding to from the second to the fifth row from it. In the same place were found an accumulation of resting nuclej. Mitotic cell proliferation of injured cells was found completed on the fourth day. Ganglia-cells undoubtedl}' increase in number in the same manner. He found no leucocvtes in the brain, and believes that those that must have been present had been appropriated as food bj' the cells which had undergone karyokinetic changes. The gray matter of the surface of the brain is composed of numerous but exceedingly small cells, and their numerous connections would indicate great reproductive capacitv. Peripheral Nerves. — When Cruikshank suggested the possibility of restoring physiological function in a divided nerve by suturing, his con- temporaries regarded the suggestion as an absurdity. Since that time CENTRAL NERVOUS SYSTEM. 59 the subject of nerve regeneration has engaged the attention of some of the best men in the profession, and from the knowledge which has thus accumulated it is safe to repeat the statement made b}^ Vanlair recently, that " the surgeon who neglects to suture a divided nerve commits the same mistake as he who neglects to reduce a fracture or fails to unite a divided tendon." Regeneration of a nerve takes place exclusively from pre-existing nerve-fibres. Schwann's sheath isolates the nerve-fibre so thoroughl}' from the mesoblast that it would be almost impossible for the latter to take an}- direct or active part in the regeneration of the former. The neuroblasts from which tissue proliferation takes place are found within the nerve-sheath. Confluenceof the new nerve-elements within the neurolemma does not take place, as, according to Cattani, they receive envelopes from the medulla. Section of a motor fibre is at once followed by degeneration of the motor terminal palate ; hence, degen- eration and regeneration in the divided nerve and the muscles supplied b}' it are parallel processes. Degeneration and regeneration have been studied in nerves that were stretched, lacerated, or completel}' cut across, and the histological processes were found almost identical in all of these conditions. The stud}' of degenerative and regenerative processes side by side in injured nerves has thrown much light upon their minute anatomj'. The medullated peripheral nerve-fibre is composed essentially of Schwann's sheath, the axis-cylinder, and a fluid which appears as a periaxial la3-er. Klebs looks upon this fluid as a sort of nervous endo- lymph, which, b}' virtue of its great mobility', takes part in the nutrition of the nerve. The space which contains the fluid, being between the axis-C3'linder and the sheath, serves not only the purpose of a channel for the fluid, but also for the dissemination of movable elements, as, for instance, migration corpuscles. Leucoc3^tes are only present in any considerable number in pathological conditions. Schwann's sheath is composed of connective tissue. The large oval nuclei, containing each one or two shining nucleoli, which are attached to its inner side, are the neuroblasts. It is as yet not definitely settled whether the portion of nerve between two of Ranvier's constrictions is composed of one or more cells. Klebs is inclined to accept the view that such a space is represented b}- one cell, and if several nuclei are present the}'^ are the product of nuclear segmentation. The nuclei must be regarded in the light of peripheral nerve-cells. The specific functional contents of a nerve-fibre are the axis-c3-linder, the endolymph, and medulla. The first two are continuous with the neighboring elements, but not so the medul- lar}- sheath. The medullary sheath is a ver}'" complicated structure. The masses of fat are. held together, and are inclosed by a frame-work of keratin. Finer keniiin threads unite both sheaths in the form of Golgi's 60 PRINCIPLES OF SURGERY. spirals, which are present in the funnels of Schmidt-Lautermann's med- ullar}^ spaces ; besides, numerous transverse threads are strung out in zigzag shape between the sheaths. The constituent parts of the medul- lary portion of the nerve-fibre can disappear separately ; if the medullary fat is removed by absorption, the keratin frame-work becomes visible, — a condition which is present during the early stages of neuritis parenchy- matosa ; if the keratin frame-work is dissolved, the fat appeal's in drops, as can be seen during the degeneration of a nerve after section. The axis-cylinder is a pre-existing structure, which, however, can be only distinctly outlined against the medullary sheath and endolymph by post-mortem influences. Its structure, in the larger medullated fibres at least, is not simple, but is composed of fine fibrillae, held together b}^ an amorphous, gelatinous substance. Physiologically, this part of the nerve must be regarded as a complex of different conductors, which only differ by the qualities of motility and sensibility. Regeneration of a periph- eral nerve-fibre is a regular typical process, as far as it serves as a substitute for lost elements of a nerve. The process resembles the physiological growth of a nerve which always occurs only in connection with the centi'al nervous system. If the separation between the nerve- ends exceeds an inch, restoration of its continuity without assistance cannot take place. In such an event the ends become bulbous, the medullary substance in the distal portion undergoes degeneration, and the axis-cylinder becomes more and more indistinct. The same changes take place in the nerve-ends after amputation. When a nerve is simply divided, and there is no loss of substance, the ends remaining in close contact, function is established in a remarkably short time. In two instances Gluck observed perfect function within twenty-four hours. He concludes that the granulation tissne must have been the means of con- duction in these cases. In his experiments on the sciatic nerve in fowls, where he divided the nerve and immediately sutured with catgut, func- tion was restored in from fifty to eighty-six hours. Waller and Vanlair are of the opinion that regeneration proceeds entirel}^ from the proximal end. Colasanti claims that degeneration of the peripheral end only extends as far as the next Ranvier's ring, while Tizzoni found that degeneration extends from the seat of injury in both directions, only that it is more marked on the distal side. Most of the recent writers on the subject assert that when a piece of the nerve is resected the entire nerve on the distal side undergoes degeneration, while, if the nerve is only divided, and the ends are immediately sutured, at least a number of the nerve-fibres retain their integrity. Eichhorst and others, who have made regeneration of the nerves a special study, are of the opinion that the nerve-fibres of both ends participate in the process of repair, CENTRAL NERVOUS SYSTEM. 61 and that regeneration commences with degeneration. Eichhorst believes that regeneration takes place exclusively by splitting of the axis-c} linder within Schwann's sheath, so that the latter in the course of time becomes distended with them. Continuity is restored by the central fibrils l^eing pushed outward through the cicatrix to meet the peripheral, and coales- cence follows. Beueke, on the other hand, traced the origin of the new fibres to protoplasm of the neuroblasts, which are transformed into delicate fibrils, which become surrounded b}- a coating of myeline,the future medulla. It is more probable that regeneration of a nerve takes place by the latter method. After a trauma, reproduc- tion of the axis-c3^1inder alwa^'s follows. Accord- ing to a number of investigators who have studied this subject, several axis-cylinders are formed within each Schwann's sheath, each of which is surrounded by a separate medullary sheath. It is difficult to ascertain whether these new fibres, growing out of one of the old fibres, again become united some distance toward the periphery, or whether they remain isolated to their point of peripheral distribution. After nerve section, the axis-cylinder swells at the cut end and becomes striated ; this swelling, however, is not an active process, but the result of imbibition of stagnant endolymph. The longitudinal striations and for- mation of vacuoles which have been described by Tizzoni are due to the same cause. The gran- ular appearance is brought about by disintegra- tion of the fibrillae. The old axis-cj'^linder breaks down into isolated fragments, which, in part at least, are removed b}^ leucocytes, which at this time have made their appearance. With such Fig. 27.— Nerve-fibre in A State op Regenera- tion Fifty to Seventy Hours after Injury. {Gluck.) A, proliferation of neuroblasts ; B, spindle-cell, which, becoming conflvient with similar cells from both sides, unites the nerve-fibres ; C, rows of spindle-cells, forming amyelinic nerve-fibres: D, young extensive destructive changes in the axis-cvlinder aniyeioid ceiis, formed from nuclei ~ "of neurolemma. it is difficult to conceive how regeneration of this structure could take place in the manner described b}' Eichhorst. The only histological elements within the fibre-sheath exempt from degeneration are the nuclei of the inner surface of the sheath, the neuro- blasts, and from these regeneration takes place. At the seat of regeneration the nerve is enlarged from the accumu- lation of the products of tissue proliferation within the neurolemma sheaths. The first stage of regeneration of a nerve is initiated by multiplica- 62 PRINCIPLES OF SURGERY. tion of the neuroblasts and increase of protoplasm. The nuclei increase to double their normal size and then divide into two or more. Division of nuclei probably takes place b}' karyokinesis. The protoplasm is gran- ular, and is stained a reddish color with neutral picrocarmine. The nerve-fibre originates from the protoplasm, and, according to Tizzoni, in the form of separate pieces, around which already can be distinguished a medullar}' sheath and transparent contents. In other cases there may be a direct connection between the old and new axis-cylinder. Longitudi- nal striation of the axis-cylinder prob- ably takes place at a time when the fibre has formed a direct connection with dis- tant parts, the seat of active physiologi- cal processes. Leucocytes have been found within the neurolemma by Tizzoni and Korybut-Daskiewicz, while Neumann de- nies their presence in this locality. Cattani believes that they are present within the fibre-sheath after nerve-stretching, and can be found as far as the motor ganglia of the cord. Nerves of difterent function, when united, will undergo repair and establish useful conductors for the transmission of nerve force. The late Professor Gunn estab- lished the correctness of this assertion by a series of interesting experiments on dogs. Early functional results after nerve suture are often fallacious, as the function at- tributed to sutured nerves may be per- formed by other nerves which reach over such areas ; and, again, the peripheral mani- festation may be the result of physical con- duction of the irritation, and apparent motor recoveries may be stimulated by the action of muscles other than those supplied by the sutured nerve. Fig. 28.— Lu.n(;itu]jixal Section THROUGH Nerve Twenty-one Days after Injury, show- ing Meduli.,ated and Non- MEDULLATED NeRVE-FIBRES with Round Cells between THEM. (Gluck.) NERVE SUTURE. Nerve suture was first performed by Baudens in 1836, with negative result. The procedure was revived b)^ Nelaton in 1863, and the follow- ing 3'ear by Langier. The first operations were made with fine silk sutures, which were not cut short, and subsequently came away by suppura- tion. O. Weber advised to unite the nerve-ends by passing the sutures, not through the nerve-substance, but only through the connective tissue NERVE SUTURE. 63 DireetSutaro Pe/TntwumZ Suiure surrounding the nerve, — the paraneurotic suture. Experience, however, has shown that transfixion of the nerve-ends by the sutures does not give rise to pain, and does not interfere with the normal reparative processes, and at the same time, by resorting to this direct method of suturing, more perfect coaptation is secured. In the case of large nerves, it is advisable to re-inforce the direct sutures with a number of para- neurotic sutures. The best material for the sutures is aseptic catgut. An ordinary sewing-needle with a dull point is preferable to a surgical needle, as it is more sure to pass through the nerve without injuring the fibres. From one to three direct sutures, according to the size of the nerve, are applied, and from three to six paraneurotic sutures. The needle is passed straight through the nerve on each side, one-eighth to one-fourth of an inch from the ends, and care must be exercised, in tying the sutures, to bring the cut surfaces in accurate apposition, and not to tie the sutures too tightly, as by doing so the nerve-ends are liable to become displaced by overlapping. In t3nng the paraneurotic sutures the necessary precautions must be taken to pre- vent tlie margins of the sheath from insinuating themselves between the nerve-ends. Primary Nerve Suture. — A primary nerve suture is one used to unite a nerve immediately or soon after the injury has occurred, and before any degenerative changes have taken place. It should always be resorted to in the treatment of accidental wounds where one or more nerves have been divided, also where in operations a nerve has been divided accidentally, and, finally, in cases where a neurectomy for pathological conditions cannot be avoided. The results after primary suture have been very satisfactory. Bruns has collected 71 cases from different sources, and in more than 33 per cent, of the number function was restored. As suppuration in a wound where a nerve has been sutured would, in all probability, cause tearing out of the sutures and displacement of the nerve-ends, it is of the greatest practical importance to secure for such wounds an aseptic condition and to obtain primary union throughout, and consequently no provision for drainage should be made. If the wound-surfaces cannot be approximated, and a greater or less space has to fill up by granulation, a bundle of catgut threads can be used for a capillar^' drain, in order to avoid tension from the accu- mulation of blood or the primary wound-secretion. Secondary Nerve Suture. — When a divided nerve fails to unite, the Viij. 29.— Nerve Suture, SHOWING Applica- tion OF Direct and Pakaneurotic Su- tures. 64 PRINCIPLES OF SURGERY. ends become bulbous, are usually- found imbedded in a mass of cica- tricial tissue, and sei)arated from each otlier from 1 to 2 or more inches. Function below the point of division is completely lost; the distal por- tion of the uerve itself, being no longer in connection with the central nervous system, undergoes degeneration, and the muscles supplied by the injured nerve become atrophic and useless. The reuniting of such a nerve is done b}^ the secondary suture. Experience has shown that function can be restored by this procedure years after the injury. Jessop vivified the nerve-ends and applied sutures nine years after iii- jur^^ of the median nerve, and restored function. Langenbeck sutured the sciatic nerve two years after division ; sensation returned in three days, and, later, motion. As a rule, sensibility returns first after nerve suture, followed considerably later by restoration of motor function. The most speedy restoration of function, both sensory- and motor, after secondary suture is reported by Tillaux. He operated on the median nerve three years after division. The ends were found imbedded in a cicatrix and separated from each otiier 4 centimetres. The ends were vivified and sutured. He claimed that physiological function was re- stored completely three hours after the operation. There can be no doubt of the ultimate recovery of nerve function in this case, but that this should have been attained in three hours appears next to impossible. Enough has been said to show that secondary nerve sntui'e can be re- sorted to with good prospects of success years after an injury, but for well-known reasons it should not be postponed after it has become evi- dent that union has failed to take place. Unnecessary delay is danger- ous, because when a nerve has become permanently disconnected from the central nervous system muscular degeneration goes hand in hand with degeneration of the distal portion of the nerve, and the longer the operation is delayed the greater the length of time required to complete the regeneration of the nerve and the muscles. The first secondary nerve suture was made by Nelaton in 1865. In Grermau}', the first opera- tion was made by Guster Simon in 1876, and he was followed b}^ Lan- genbeck the following year. In 1884, Bruns found 33 recorded cases, and in 24 of this number the result was satisfactory. Asa rnle, sensa- tion returned gradually in from two to four weeks, while motion did not return until three weeks to three months after the operation. Complete restoration of function was seldom completed until half a j-ear to one year after the operation. As in oases which require secondary suture the nerve- ends are sealed with a mass of cicatricial tissue, it is always necessary to resect the ends, after which the sutures ai-e applied in the same manner as in primary nerve suture. Both nerve-ends must be freed from all cicatricial adhesions before approximation is attempted, and. if this NERVE SUTURE. 65 cannot be readily clone on account of previous retraction, both ends are carefully stretched and sufficient elongation secured so as to prevent any tension upon the sutures. A great deal can be done to prevent tension, by placing the limb in such a position as will relax the nerve ; for in- stance, flexion of the hand and forearm in suturing the ulnar, median, or musculo-spiral, and flexion of the leg and extension of thigh after re- uniting the sciatic. The position of the limb most favorable for the union of a sutured nerve is best secured by a plaster-of-Paris dressing, which is allowed to remain not only till the external wound is healed, but until the nerve has firmly united. When a nerve has suffered at the seat of injur}' a considerable loss of substance, it is often found impossible to bring their ends in contact by nerve-stretching and position of limb, and in such cases restoration of continuity becomes an exceedingly^ difficult task. Letievant suggested that the defect in such cases should be cor- rected b}' a neuroplastic operation. He proposed that a flap should be taken from each end sufficiently long that, when turned toward each other, they could be sutured at the middle of the defect, thus making a connecting bridge of nerve-tissue between the separated nerves. As could be expected, in a case where he performed this operation the result was negative. In a case operated on by Tillmanns after this method, partial restoration of function was established three and a half months after the operation. The success in this case was probably not the result of conduction of nerve force along the fibres of the flaps, but the pro- duction of new fibres across the gap, perhaps through the tissues com- posing the temporar}'^ bridge. From his experiments on animals, Gluck came to the conclusion that nerve defects could be corrected by trans- plantation of nerves ; that is, inserting a piece of nerve from an animal, corresponding in size to the nerve to be reunited, between the nerve ends, and uniting it with them with sutures. He reports a number of success- ful experiments on chickens, filling the gap with a nerve taken from rabbits. Philipeaux and Vulpian, from their own researches, came to the conclusion that a transplanted nerve alwaj's degenerates and dis- appears, and that restoration of structure and function only takes place by regeneration from the nerve-ends. It is probable that the methods of nerve restoration devised by Letievant and Gluck are useful in reunit- ing separated nerve-ends in the same manner as the suture a distance of catgut suggested by Assakv. The interposition of an aseptic, absorbable substance like catgut or nerve-tissue serves as a temporary scaffolding for the products of tissue proliferation from the nerve-ends, which at the same time determines the direction for the new material, providing the shortest route to meet the same material from tlie other side. When catgut is employed, two or three sutures are used, so that the combined 5 66 PRINCIPLES OF SURGERY. size of the strings will at least approximately correspond to the size of the nerve. VanUiir, who believes that regeneration of a nerve takes place exclusively from the proximal end, resected a piece of the sciatic nerve in dogs, and then sutured both ends of the nerve to the ends of a decalcified-bone tube, which in length corresponded to the section of nerve removed. From the results of his experiments, 10 in number, he became satisfied that continuity of the nerve was restored by the new nerve-fibres from the proximal end growing into the tunnel, bridging the defect in a comparatively short time, as they had no resistance to over- come, and uniting with the end of the nerve on the opposite side of the tube. It appears to the author that this metliod of overcoming the difficulties of reuniting nerve-ends widely apart is not only an ingenious procedure, but, if applied in practice, promises better results than any other method heretofore proposed. In certain cases where the distal end cannot be found, or where the separation is so great that none of the methods of approximation so far devised hold out any inducements of a successful issue, Letievant suggested the idea of grafting the central end upon the intact trunk of a neighboring nerve. This operation failed in his hands, but Tillaux and Tillmanns, slightly modifying the method, were suc- cessful. In Tillmanns' case the ulnar nerve had been divided, the ends were found separated 4^ centimetres, and the proximal end was grafted upon the median nerve. Sensation returned in a month, and by using electricity and massage recovery was complete a year later. Nerve- grafting, as advocated by Letievant, should only be resorted to after implantation of a decalcified-bone tube between the nerve-ends has been tried and proved a failure, or in cases where the defect is very extensive, or, finally, if, after the most diligent search, the distal end cannot be found. Restoration of function does not always follow after the con- tinuity of a nerve has been restored by operative measures. Ehrmann has reported such a case. The radial nerve was divided below the elbow and failed to unite. Complete paralysis of all the muscles supplied by this nerve. After the lapse of .seven months the nerve was exposed, and the ends, which were 5 centimetres apart, were vivified and sutured. Seven months after the operation, no improvement. The nerve was again exposed at the former site of operation, and it was found that union had taken place, but the nerve was compressed by a firm cicatrix 2 or 3 centimetres in length. The nerve was relieved from its imprisonment, and when the faradic current was applied all the muscles supplied by the nerve responded. Four months later, complete recovery. This case reminds us of the importance of securing healing of the nerve and wound with as little cicatricial tissue as possible, which can onh^ be done by absolute asepsis and careful attention to suturing of the wound. CHAPTER III. Inflammation. The subject of inflamuiation is one of deep interest both to the stu- dent and practitioner, as it initiates the former into tlie field of general and special pathology, and the latter meets with it dail}- in some form in his practice. We have already set apart from inflammation those numer- ous processes by which injuries or defects are repaired without destruc- tion of an}^ of the new tissue-elements which have been described in the first chapter under the head of Regeneration. From a scientific and practical stand-point, it is exceedingly important to draw a distinct line between the series of tissue changes which attend regenerative processes, uncomplicated by the action of pathogenic bacteria, and true inflamma- tion, which is always caused by the presence of one or' more kinds of patho- genic microbes. As compared with true inflammation it has been custom- ary for quite a number of years to speak of regeneration as a plastic or regenerative, inflammatory process ; but the term inflammation in the future should be limited to the series of histologiccl changes which ensue in the living body from the presence and action of specific micro-organ- isms, while the word regeneration should be used to designate the histo- logical changes which take place in tissues which have been primaril}^ in an aseptic condition or have been rendered so after the inflammation has subsided. From this it will be seen that the study of inflammation is intimately and inseparably associated with a consideration of the new science of bacteriology. For most forms of inflammation the presence of a specific micro-organism has been demonstrated, and its etiological relationship established by cultivation and inoculation experiments; and in the few inflammatory diseases where no such positive proofs can be furnished we have, from analogy and circumstantial evidence, reason to suspect the presence of undiscovered microbes. Inflammation, in the widest and most comprehensive meaning of the word, should be made to embrace pathological conditions which are caused by the action of patho- genic microbes or their ptomaines upon the histological elements of the blood and the fixed tissue-cells. A correct definition of inflammation, which should embody the etiological, anatomical, and pathological char- acteristics of the disease from our present knowledge of the subject, cannot be given, as many important points connected with the compli- (67) 68 PRINCIPLES OF SURGERY. cated processes await explanation by future investigation. Sanderson defines inflammation as " the succession of changes which occur in a living tissue when it is injured, provided that the injury is not of such a degree as at once to destroy its structure and vitality.''^ As we have restricted the term inflammation to the succession of changes ivhich occurs in a liv- ing tissue from the action of pathogenic microbes or their ptomaines, this definition would cover processes which, for reasons already given, we have considered as instances of tissue proliferation unattended by any of the characteristic features of inflammation. J. Bland Sutton uses the term inflammation in a more restricted sense in coining the following definition : " It is the method by ivhich an organism attempts to render inert noxious elements introduced from ivithout or arising luithin it^ As nothing is said of the method, the most important part of the definition, it certainl}^ cannot be said to cover the whole ground. The conception of the true nature of inflammation for the present, at least, must remain symptomatic. Asa rule, inflammation subsides as soon as the primary cause has disappeared or has been rendered inactive, as is well shown hy the spontaneous disappearance of febrile disturbances in the general in- fective diseases, and the subsequent rapid repair of the local lesions which characterize them. If an acute inflammation become chronic, either from a diminution of the quantitative or qualitative intensity of the primary cause, or from the tissues becoming accustomed to its action, it is sometimes difficult to tell whether the primary cause has disappeared or has ceased to act, or whether it is still present and active. In chronic inflammation the most reliable indications of the presence and potency of the primary bacterial cause are acute exacerbations, as chronic inflam- mation only consists of a series of acute inflammatory processes which repeat themselves at larger or shorter intef^vals. The differences between an acute and chronic inflammation are not in kind, but in degree. The complicated processes which characterize inflammation can be studied most profitabl}^ by considering separateh' and conjointl}^ the s3'mptoms to which they give rise, which Galen enumerated as calor^ rubor, dolor et tumor, to which may now be added the functio Isesa of modern authors. The study of the objective and subjective manifestations of inflammation should be preceded b}' a short description of THE HISTOLOGICAL ELEMENTS WHICH ARE DIRECTLY CONCERNED IN THE INFLAMMATORY PROCESS. Capillary Vessels. — The most important histological changes in in- flammation, acute or chronic, transpire within, and in the immediate vicinity of, capillar}^ vessels. The smallest arteries and veins, the ves- sels on either side of the capillaries, undergo changes, and the disturb- HISTOLOGICAL ELEMENTS IN THE INFLAMMATORY PROCESS. 69 ance of circulation within them constitutes a part of the picture of in- flammation, but it is in the capillaries that the most serious disturbances occur ; it is here where the noxse are brought in closest contact with the para-vascular tissues, and it is here where the inflammatorj^ exudation and transudation take place. The capillaries are minute vessels, or rather channels, which connect the arteries and veins, the walls of which are composed of a thin, elastic, endothelial membrane ; that is, a single layer of nucleated cells held together by an amorphous cement-substance. In Fig. 30.— Capillary Vessels of the Frog's Mesexteey, Stained with Ni- trate OF Silver o>ly; the Wall of the Vessel is \'iEWEr) froji the Sur- face, AND is Seen to Consist of Elongated Endothelial Cells, Marked BY their Outlines only ; the Nucleus of the Individual Cells is not Shown. (Klein.) silver-stained specimens the cement-substance appears as dark lines which outline the boundaries of the cells. The shape of the cells is more or less elongated, with pointed ex- tremities, and their outline smooth or sinuous. The nuclei of these cells are oval, situated either about the middle of the cell or near one ex- tremity. The nucleus contains within a well-defined membrane a net-work of chromatin threads, but no nucleolus. When the capillaries undergo alteration and distention, as in inflammation, the cement-substance yields in many places ; in consequence of this minute openings appear, called by Arnold stigmata, which become gradually enlarged into stomata. 70 PRINCIPLES OF SURGERY. Winiwarter found that by injecting inflamed capillaries the contents of the vessel escaped through these openings. Through these openings emigration of leucocytes takes place, and when the inflammation is very intense the red corpuscles escape, — a process which Strieker has named diapedesis. If the capillary vessels, through which emigration has been going on, be stained with nitrate of silver, it is seen that the emigration is limited to the interstitial cement-substance of the endothelial wall. (Purves.) Klein has shown that the walls of all capillary vessels in the adult state form a direct connection with the process of the connective-tissue corpuscles of the surrounding tissue, — a matter of great interest in studying the relationship between the capillary vessels and the sur- rounding connective-tissue spaces. Blood-corpuscles. — The blood-corpuscles frequently serve as carriers of the microbic cause of the inflammation; they block the lumen of iutlanied capillar}^ vessels, partially or completel}', and constitute the histological elements of the primary exudation. The element of the blood which is more intimately associated with the histology of inflammation is the I. Leucocyte, or White Blood-corpuscle. — This is a nucleated, spherical, transparent mass of protoplasm, witliout a limiting membrane or Fig. 31. — lkucocyte, envelope. Heitzmann made the discovery that ^oToPL\s>fi"*^^fe^TRiNGs!! It Is couiposcd of a reticulum of protoplasmic ^■^**"' strings, with a hj^aline substance in the meshes. The nucleus shows a similar structure, and its net-work is continuous with that of the cell-body. Strieker and Klein, as well as a number of other histologists, have adopted Heitzmann's views in reference to the minute anatomy of the leucocyte. The reticulated structure is well shown by staining with chloride of gold, which stains the protoplasmic strings, but not the interstitial substance. The leucocyte is endowed with intrinsic power of locomotion, — amoeboid movements, — a function which is performed by the reticulum. Whai'ton Jones discovered motion of protoplasm in leucocytes of human blood as early as 1846. In 1862 Haeckel showed that the white blood-corpuscles absorb pigment-granules, — a process which can only take place by amoeboid movements, which by change of form of cell bring the foreign material into its interior by inclusion. These observations enabled Cohnheim to demonstrate later that the white blood-corpuscles found in the vascular spaces of the cornea were derived from the blood ; in other woi'ds, to establish the fact of emigration of leucocytes through the inflamed wall of capillaries. The HISTOLOGICAL ELEMENTS IN THE INFLAMMATORY PROCESS. 71 amoeboid movements of the colorless corpuscles can be well observed for hours in the moist chamber on the warm stage. The movements of a leucocyte are peculiar. The first effort consists of a protrusion of a hyaline film. This is withdrawn, and another is protruded ; in the next moment this is diminished to a very minute process, whereas, on the opposite side, a new, broad process appears. After this the corpuscle is seen to throw out processes of various length and thickness, and thus to alter its shape in a considerable manner. By virtue of the amoeboid movement of leucocj^tes they move from place to place independently of the blood or plasma current. This independent locomotion enables them to pass through the small opening in the wall of inflamed capillaries, and, after the}' have reached the para-vascular tissues, to travel along connective- tissue spaces until arrested by some mechanical obstruction. If pigment-material, in a finely-divided state, is mixed with blood, either before or after withdrawing it from the vessels, the projections thrown out by the leucocytes inclose the l)artieles brought in contact with it, and the granules reach in this manner the interior of the leuco- cytes, and are variously distributed according to the shape and move- ments of the protoplasm. Microbes reach the interior of the' leucoc3'tes in the same manner. In cases of intra-vascular infection the emigra- tion corpuscles conve\' with them inflamed capillaries into tlie tissues surrounding them. 2. Red Blood-corpuscle. — The colored blood-corpuscle serves less frequently as a carrier of microbes than the leucoc3'te, as it does not possess amoeboid movements. For the same reason it is not found so constantl}" as a component part of the inflammatory exudation, as its transit through the capillary wall is entirely a passive process, and is accomplished only by the vis a tergo in case the stomata are sufficiently large to permit its passage. The presence of numerous colored corpus- cles in the exudation is an indication of great acuity and intensity of the inflammation, — conditions causing serious and extensive alterations of the capillar}' wall. The escape of whole blood through a capillary vessel greatly damaged by the cause of the inflammation is called rhexis. Fig. 32.— Change of Fokms of a Moving Leucocyte by Amceboid Move- ments. (Klein.) the microbes through the wall of 72 PRINCIPLES OF SURGERY. 3. Third Corpuscle. — A third cellular element in tlie blood, the third corpuscle, was discovered by Max Schultze, in 1865. He described it as a small, colorless sphere or granule. Elaborate descriptions of this corpuscle were given by Hayem, in 1878, and Bizzozero, in 1882. Hayem, from his observations, believed that these minute structures represented 3'oung colored blood-corpuscles, and hence named them hsematoblasts. Bizzozero entered his protest against this theory and called them blood-plates {Blutpldttchen). Under the microscope they appear as minute, faintly-colored blood-corpuscles. They seem to Fig. 33. (Eberth and Schimmelbusch.) 1. Third corimscle. A, natural appearance when seen on surface and on edge : B. C, C, D. and E, appearance presented by them during coagulation. 2. Shows the little heaps of granules formed by them after coagulation (Hayem). 3. A small blood-vessel as stasia is approaching. A, third corpuscles in periphery of stream ; B, colored blood-corpuscles; C, leucocyte. possess a little stroma like the red blood-corpuscles, but contain no nucleus and are devoid of any cell-membrane. What appears as a nucleus is, according to Hayem, an optical defect. Hayem estimates that they are forty times more numerous in man than the leucocytes, and twenty times more abundant than the colored corpuscles. As there has been no positive proof furnished that the third corpuscle is an embryonal red blood-corpuscle, and as it has been shown that blood-corpuscles are produced from the fixed cells of blood- producing organs, as, for instance, the spleen and medullary tissue, it is HISTOLOGICAL ELEMENTS IN THE INFLAMMATORY PROCESS. 73 advisable not to appl}- to it the term hsematoblasts, but to designate it from the remaining two morphological elements of the blood numerically by calling it the third corpuscle. Under a higher power the third corpuscle can be readily recognized in the blood-stream of capillary vessels in the mesenter^^ or web of a frog. In blood withdrawn from a vessel it is destroyed as soon as coagulation sets in ; hence it disappears almost immediately after it leaves the blood-vessel. In order to study it outside of the bod}', means must be employed to prevent coagulation, which can be done by mixing the blood with the following solution, recommended b}' Hayem : — Distilled water, 200.00 cubic centimetres. Sodic chloride, 1.00 gramme. Sodic sulphate, ....... 5.00 grammes. Mercury bichloride, 0.50 gramme. From a needle-puncture the blood is allowed to mix with the solu- tion in the proportion of about 1 to 20 up to 1 to 100. In this mixture the third corpuscle will retain its shape and size for twelve to twenty- four hours. The third corpuscle is a fibrin-producing structure, and, as such, it takes an active part in the formation and growth of intra-vascular blood-clots. The white mural thrombus, produced intra vitam, is com- posed almost exclusively of this element of the blood. If, from a trauma or disease the endothelial lining of a blood-vessel is injured and the smooth surface becomes uneven, the third corpuscles, floating in the peripheral portion of the axial current, come in contact with projecting points, and are arrested and become attached to the vessel-wall, laj'er after layer is added, and in this manner the mural thrombus is formed. On the surface of recent wounds they appear in large numbers, lose their fibrin ferment, and give rise to the formation of fibrin, which acts both as a haemostatic and temporary cement-substance. In inflammation the third corpuscle escapes through the capillary wall in the same manner as the red corpuscles, but, on account of its smaller size, its peripheral loca- tion in the blood-stream, and its greater abundance, it is numerically more abundant in the inflammatory exudation. The fibrin in inflamed tissues is undoubtedly derived largel}^ from this source. 4. Fixed Tissue-cells. — The fixed tissue-cells behave diflerentl}^ in the inflamed part, according to the intensity and nature of the primary microbic cause. The microbes, or their ptomaines, may possess such intense local toxic properties as to destro}^ their vitalit}' directl}' when the inflammation results in necrosis, as is the case in the centre of an ordinary furuncle, and on a larger scale in cases of progressive phleg- monous inflammation. The fixed tissue-cells may be destroyed by starvation, by the primary inflammatory exudation being so abundant as 74 PRINCIPLES OF SURGERY. to obstruct tlie circulation in the inflamed part. If the cause of the in- tiannnation is less intense, as is the case in chronic inflammation, the fixed tissue-cells are brought in direct contact with the microbes which produced tlie inflammation, and active tissue proliferation is the result, and this furnislies the bulk of the inflammatory product. The histo- logical structure of tubercle furnishes a good illustration of the part taken by the fixed tissue-cells in chronic inflammation. In chronic sup- purative inflammation the fixed tissue-cells are first transformed into embryonal tissue, and, as the protoplasm of the new cells is destroyed by the ptomaines of pus-microbes, they are converted into pus-corpuscles. A passive role in the inflammatory process was assigned to the fixed tissue-cells by Boerhave, who regarded stasis as the essential feature of inflammation ; by Andral, who believed that hyperaemia was the char- acteristic pathological condition in an inflamed part; and by Rokitansky, who taught tliat exudation constituted the most important element in all inflammator}' lesions. Virchow located the primary seat of inflam- mation in the fixed tissue-cells, and asserted that nutritive or formative irritation occurred in them independently of vessels or nerves. He maintained that the more the cells were disposed to take up nutritive material the greater the danger that they themselves would be destroyed. Remaining faithful to the doctrine that inflammation is only caused by the presence and action of a specific microbic cause, we shall find that the more acute the process the less the probability that the fixed tissue- cells take an active part, and that the more chronic the inflammation the greater the amount of the new material that has been derived from the fixed tissue-cells, and the smaller the quantity of vascular exudation. SYMPTOMS OF INFLAMMATION. The structural changes caused by inflammation give rise to a char- acteristic complexus of symptoms, — pain, redness, swelling, heat, and suspension, — elimination or perversion of function. These symptoms vary in intensity, according to the nature of the primary cause and the anatomical structure and location of the tissues aflfected. One or more of the symptoms enumerated may be absent, when the existence of in- flammation must be ascertained by a more careful study of those pre- sented. In acute inflammation the S3'mptoms appear in rapid succession or almost simultaneous!}^, while in the chronic form the}^ come on slowly, often almost insidiously, and frequently one or more are wanting, even when the disease which those that are present represent is far ad- vanced. The number and intensity of the individual symptoms vary not only according to the virulence of the primarj'^ microbic cause, but are also modified by the resisting capacity of the individual and the SYMPTOMS OF INFLAMMATION. 75 tissues affected. We speak of a complete or partial immunity to certain microbic diseases, and of a general or local, hereditary or acquired, dis- position. For diagnostic purposes the symptoms must be studied in- dividually and collectively, and with special reference to their etiology and the location and structure of the inflamed tissues or organ. (a) Pain. — Pain is one of the most variable symptoms of inflamma- tion. It is caused by traction or pressure to which sensitive nerve-fila- ments are subjected in the inflamed tissues, and probabl}^ also, in some instances at least, by extension of the inflammatory process to the structure of the nerves themselves. Some patients are more sensitive to pain than others. The same extent and degree of inflammation of the same part giving rise to sensation of discomfort in a torpid person may cause excruciating pain in patients with a nervous temperament. As the degree of pain will depend largely upon the number of sensitive nerves present in the inflamed area and the amount of exudation, we would naturally expect to find pain a prominent symptom in inflamma- tions of unyielding tissue freely supplied by sensitive nerves. This, as a rule, is the case. Pain is a distressing symptom in cases of phleg- monous inflammation of the fascia and tendon-sheaths of the fingers and palm of the hand. Pain is the most conspicuous symptom in periostitis and inflammation of the serous membranes. Wherever the inflammatory exudation appears rapidly in parts freely supplied with sensitive nerves, pain from tension appears as one of the foremost S3fmptoms, and con- tinues without intermission until tension is relieved. In acute suppu- ratiA'e osteom3'elitis intense pain is present from the very commencement of the disease, and continues unabated until tension is removed by operative procedures, or by the escape of inflammatory product, through some defect in the bone, into the more 3'ielding paraperiosteal tissues. The pain is throbbing, sometimes synchronously, with the pulse in acute circumscribed phlegmonous inflammation. It is sharp and lancinating in inflammation of serous membranes. It is described as a burning sensation in inflammation of the skin. The pain is of a dull, aching, boring character in deep-seated inflammation, especially in the interior of bone. Nocturnal exacerbation of pain is a common occurrence, and seldom absent in painful typhlitic affections. The pain is not alwa3''s referred by the patient to the seat of inflammation, as in the early stages of coxitis it is not in the hip, but over the inner aspect of the knee, and in inflammatory affections of the nerves the pain radiates along the pe- ripheral branches, and is usually felt most severely some distance from the seat of the disease. In ascertaining the existence and exact location of a deep-seated inflammation, tenderness is a more valuable sjaiiptom than spontaneous pain. Tenderness is the pain elicited by pressure. If the 76 PRINCIPLES OF SURGERY. inflamed part is tender on pressure and accessible to palpation, the area of tenderness will correspond to the extent of the inflammation. During the beginning of an attack of phlegmonous inflammation the surgeon is able to locate the affection accuratel}^, by searching for the point where the tenderness is most acute, and the same symptom will indicate to him, earlier than any other, the direction in which the process is extending. In periostitis the area of tenderness will show whether the inflammation is circumscribed or diffuse. The existence of circumscribed points of tenderness about the epiphyses of the long bones is almost a certain in- dication of central osseous tuberculosis, and, at the same time, furnishes a reliable guide in their early operative treatment. Firm pressure relieves pain in nervous hysterical patients, while it aggravates it when it is caused by inflammation. On the other hand, superficial pressure made with the tips of tlie fingers increases the suffering in parts the seat of functional disturbance, while it does not materially affect the pain resulting from inflammator}' lesions. (b) Redness. — The composition of normal blood is admirably adapted for the passage of this fluid through capillary vessels. As long as the relation of corpuscular elements to the blood-plasma remains normal, and the intima of the blood-vessels remains intact, and the vis a tergo is adequate, there is no tendency to capillary obstruction. If the capillary circulation in the mesentery of a frog is examined under a microscope, there is no difficult}^ in distinguishing two currents, — the axial and peripheral. The axial or central current is rapid and conveys the red corpuscles, which have the same specific gravity as the blood- plasma, while the peripheral current between the axial and vessel-wall is considerably slower, and in this current the colorless corpuscles are conveyed, their rotating motion being due to their coming in contact with the wall of the vessel. D. J. Hamilton has shown, by numerous experiments, that in fluids holding in suspension solid particles passing through capillary tubes the heaviest particles are carried along the central current, while those specifically lighter than the fluid seek the periplieral current. The leucoc3'tes are specificall}^ lighter than the fluid in which they are contained ; hence they are forced into the space be- tween the axial current and the vessel-wall (Fig. 33, C). The third cor- puscle, probabl}^ for the same reasons, moves also in the peripheral stream. Tlie colorless corpuscles accumulate more in the peripheral stream when the current is feeble than when it is rapid. This fact is of great importance in the study of the altered circulation when the capil- lary vessels are in a state of inflammation. The accumulation of color- less corpuscles in the peripheral stream in inflamed capillary vessels, according to Thoma, Eberth, and Schimmelbusch, is owing to the slow- SYMPTOMS OF INFLAMMATION. 77 ness of the current, "which, although insufficient to propel the specifically light, colorless corpuscles, is still competent to force onward the less- resisting and specificall}^ heavier-colored corpuscles. Eberth and Schimmelbusch state that in the vessels of a warm- blooded animal four kinds of stream are noticed, in accordance with its velocity: (1) tlie normal stream, in which the axial current and periph- eral zone are readil}- recognizable ; (2) a slow stream, in which the leucoc3'tes accumulate in the periphery; (3) a still slower stream, in which the third corpuscles also leave the axis and accumulate in the peripher}', and in wliich, these observers assert, the leucocytes become less numerous ; and (4) a stream so slow as to approach stagnation, in which all the elements of the blood are indiscriminately mixed. From the above it can be seen that all general and local conditions which tend to diminish the velocity of the blood-current in the capillary vessels are productive of accumulation of the colorless corpuscles and of the third corpuscle in the peripheral stream, — a condition which greatl}' aggravates the existing local impediments to capillary circulation, and when well advanced, by encroaching more and more upon the central stream, will result in complete stasis. Redness as a s3nnptom of inflammation signifies an excess of blood in the part, and the terms used to indicate its existence are hj'persemia and congestion, while complete arrest of the capillary circulation is expressed by the word stasis. Accurately speak- ing, hy2:)e7^8emia should be used to designate that condition of the circu- lation where the part not onl}^ contains an increased amount of blood, but where an increased amount of blood fiows to and returns/ro??i the part, — an exalted physiological process ; while the word congestion literally means onl}- an accumulation of blood in a part, — a condition owing to some form of local or distant mechanical obstruction. The condition giving rise to redness, hyperaemia, congestion, and stasis should not be studied onl}^ from descriptions, but in order to be understood they should be seen. This can be readily done b}^ producing artificially an inflammation in a transparent part of some lower animal, preferably the frog, and studying the circulation in the inflamed part step b}^ step under the microscope. For this purpose experimenters have usually selected the frog's web, mesenterj", tongue, lung, and bladder, and the tadpole's tail. For general use the frog's web should be selected, as the preparations for this experiment are ver}^ simple. Inflammation is provoked by cauterizing the web with a needle heated to a red heat, or by appl3'ing with a small plug of cotton some powerful irritant, as ammonia, tincture of cantharides, or croton-oil, or by touching the surface with a sharp stick of nitrate of silver. Hamilton gives the following directions for making the experiment : " Nothing more is 78 PRINCIPLES OF SURGERY. necessary than a piece of tin or other soft metal, about 1^ to 2 inches broad and about 6 to 8 inches long, or, what is better, a thin piece of hard wood of the same dimensions. At the end Avliere the web is to be stretched it should not be so broad. From tlie narrow end of this a V-shaped piece is cut out, over whicli the web is to be spread. Tlie frog should lirst ])e curarized, as tliis does not interfere with the circulation, provided that the solution employed be not too strong. The ^oVir of a grain, in watery solution, injected under the skin, is sufficient. Chloral may be substituted. Caton recommends a solution of 4 grains to the drachm. As many minims should be injected subcutaneousl}^ as the Fig. 34.— Normal Circtjlation in Frog i "\\ eb {Landercr.) A, artery; B, vein; C, capillaries. Vessels c vered by a net «oik of i olygonal epithelial cells of web, in which pigmented cells are not represented. frog is drachms in weight. The injection is made under the skin of the back with an ordinary hypodermic syringe. The animal is laid on the piece of metal or wood, and, the web being stretclied over tlie cleft at the end, the toes are held by tying a piece of thin thread to them and fixing the ends into a fine slit cut in the metal or wood." Tlie micro- scope is so arranged and adjusted that the field of observation will cor- respond to the point of irritation, A suflficiently high power is used so that the different corpuscular elements in the capillary stream can be readily seen and recognized. In order to witness the different stages of the in- flammatory process it is necessar}' to continue the observation for hours. SYMPTOxMS OF INFLAMMATION, 79 Any one of the irritants mentioned applied to tlie frog's web will produce in the capillaries over a limited area a series of changes which are always present in inflammation, and a description of them will repre- sent what takes place in capillaries the seat of inflammatory process of bacterial origin ; almost simultaneously with the application of the irritant a momentary contraction of the A^essel occurs, caused by the stimulation of the vaso-contractor nerves, which is followed b}' dilata- tion, with increased velocit}^ of the capillary current, — a true hyperemia. The bright-red color of the hyperajmic i)art at tliis stage, according to liT/w/i^ Fig. 35.— Capillakies of Frogs Web in a State of Hyperemia soon after Application of Irritant. {Landerer.) A, artery ; B, vein ; 0, capillaries. Recklinghausen, is due to increase in the rnpidity of the blood-current, but, as the color of the blood indicates a diminished expenditure of oxygen and a smaller quantity of carbon in tlie blood, increased velocitj- alone would not explain this change. Diminished alkalescence in the inflamed tissues may reduce the amount of oxygen used, as is the case in glands during active secretion, where Claude Bernard showed that defective ox3^genation is always present. At this stage the corpuscular elements circulate in their respective streams, and the whole picture is one of increased physiological activity. Dilatation of the vessels follows contraction so quickly that it would be diflRcult to explain it as a para- 80 PRINCIPLES OF SURGERY. h tic phenomenon. Its early ontset and the rapidity with which it ap- pears would point to a neurotic cause, traceable to the action of ganglia in the vessel-wall. It has not yet been satisfactoril}' explained whetlier this early dilatation of the vessel is due to vasomotor paralysis or irritation of the vaso-dilators, but it is more pro])ab]e that it is caused b\' the vaso-dilators, while, later, paral3'sis from overdistention occurs. Division of the sympathetic in the neck brings about increased vascu- larity, but no inflammation. The difference between dilatation of an inflamed vessel and the dilatation following division of the S3'mpathetic consists in alteration of the capillary wall, in the former instance pro- duced by the action of the causes wliich induced the inflammation, while in the latter the dilatation is a purely nervous phenomenon, unattended b}^ other pathological conditions of the vessel-wall. Disturbances of the circulation alone are not sufficient to bring about the local changes which are characteristic of inflammation ; if the velocity of the blood-current is greatly diminished by purely mechanical or nervous causes, mural implantation of the white corpuscles maj'^ take place, but emigration does not occur on account of the absence of the essential condition which gives rise to it, — alteration of the capillary wall. Dilatation is first noticed in the smallest arteries, afterward in the veins and capillaries, and keeps increasing from fifteen minutes to two hours. The vessels often enlarge to double their normal calibre. During the stage of dilatation man}' of the capillaries which were small or con- tained but little ])lood become visible, which greatl}' adds to the turgidity and redness of the inflamed part. As long as the acceleration of the capillary current continues, the different corpuscles move in their respec- tive currents. The white corpuscles that are mingled with the colored are washed along with the latter in the central stream without finding their way into the sloAver side-current which propels the leucocj^tes and the third corpuscles. The leucocytes in the peripheral stream appear more numerous, and skip along by more rapid rotator}^ movements. At this time the circulation has reached its greatest speed, and the tissues present every appearance of well-marked hyperemia. In from fifteen minutes to two hours from the time the irritant was applied, intra-vascular changes are noticed which are calculated to impede the capillary current. The first link in the chain of local causes which obstruct the capillary circulation consists of a crowded condition of the vessels from a greater accumulation of the different corpuscles, which is soon followed by a greater separation of the leucocytes from the central current and their greater accumulation in the peripheral stream, where they often become arranged in heaps and little masses. This change is first observed in the small veins, and somewhat later, and to a lesser extent, in the smallest SYMPTOMS OF INFLAMMATION. 81 arteries. Separation of tlie blood-corpuscles is the necessary outcome of slowing of the stream from greater accumulation. In the peripheral zone of leucocytes the next source of obstruction is created. Some of the colorless corpuscles become momentarily attached to the capillarj'^ wall, when they are again detached by the force of the current, or are rolled away by another leucocyte. As the process adA'ances it appears as though the viscosity of the leucocjtes was increasing constantl}', as more and more of them become adherent, while fewer are again detached. The lumen of the vessel is narrowed more and more by mural implanta- tion of the leucocytes. The small veins now assume an appearance as if the internal surface of their wall were paved with leucocytes, while in the capillaries a similar adhesion of the leucocytes to the wall is noticed. At this stage it often appears as though complete obstruction would occur everj' moment, the capillary stream becoming completely arrested for a moment, and the current may even move in an opposite direction, when the obstruction is again overcome and the current moves once more in the right direction. The smallest arteries exert themselves to the utmost to clear the way, and pulsations can be seen where in a normal condition thej'^ are absent. Hypersemia has now given way to congestion. An intra-vascular obstruction has given rise to accumulation of blood on the proximal side of the inflamed vessel. Increasing slowing of the current gives rise to greater accumulation of leucocytes, which become firmly adherent to the capillary wall, narrowing the vessel more and more until the space for the axial current becomes too small for the pass- age of the red corpuscles, when complete arrest of the circulation takes place. Congestion has resulted in stasis. As soon as complete stasis has taken place the colorless corpuscles become mixed with the red cor- puscles which are forced into the mass of the white, while by amoeboid moA'ements the latter wander toward the centre of the vessel and mix freely with those which were moving in the central current. The most advanced stages of vascular disturbance are, of course, noticed first where the irritant was applied, so that when complete stasis has taken place in the centre a zone of congestion surrounds this, while more distant ves- sels still present every indication of actiA'e hyperjemia. Redness is most marked where hypersemia is extant ; that is, in parts containing a maxi- mum amount of arterial blood. As soon as congestion sets in, the blood- corpuscles, red and white, do no longer pass through the vessel with the same rapidity and number, and the redness gives way to a bluish tinge, wliich becomes well marked and does not give way to pressure when complete stasis has occurred. The blood in the stagnated vessels, accord- ing to Paget, has little tendency to coagulate ; hence the possibility of resistutio ad integrum of the circulation after subsidence of the acute 6 82 PRINCIPLES OF SUKGERY. symptoms. Complete stasis occurs first in such capillaries where the vis a tei-go is greatly diminislied by a circuitous route from an artery to a vein, and increases in the direction in which the blood-current is slowest. In warm-blooded animals the phenomena of inflammation do not differ materially from those observed in the frog's web, except as re- gards the presence and disposition of the third corpuscles. According to Eberth and Schimmelbusch, in warm-blooded animals the third cor- puscles in the normal capillary circulation move along with the colored corpuscles in the axial current, and hence they maintain that they must be of nearly the same specific gravity. A few of the leucocytes, mixed with the colored corpuscles and the third corpuscles, are found in the central stream, but the majority of them are propelled by the peripheral stream, which, according to those observers, is from ten to twenty times slower than the central or axial current. With the slowing of the stream from alteration of the capillary wall and subsequent intra-vascular condi- tions, separation of the corpuscles takes place in the same manner as has been described in the frog's web ; the leucocytes and third corpuscles leave the central stream and accumulate in the slower peripheral zone of capillary stream, where they give rise to a greater degree of slowing of the column of blood by the formation of intra-vascular obstruction, which, if suthcient in degree, finally arrests the central current, thus causing stasis. The inflammatory process in warm-blooded animals can be studied advantageously in the artificially-inflamed omentum of young animals, especially the guinea-pig, as the omentum in these animals is exceedingly delicate and transparent. The animal is narcotized by injecting sub- cutaneously 3 grains of hydrate of chloral for a full-grown animal. As the animal, with the exception of the head, is to be kept immersed in a physiological solution of salt kept at a temperature of the body in a large vat with a glass bottom, it is wrapped in a sheet of gutta-percha tissue long enough to overlap the head, and made so as to inclose a funnel-like space through which it may breathe. An opening is made in the cover- ing at a point corresponding to the abdominal incision, tlirough which the omentum is withdrawn. Tlie object-glass of the microscope is im- mersed in the solution, and the omentum laid over a slide without fasten- ing it. The vat is made so that it will fit on to the stand of an ordinary microscope, so tliat the light can be readily adjusted. Two tubes, one to conve}' the salt solution into the vat and another to conduct it away, are attached at opposite sides. These can be connected with a vessel whose temperature is kept constant by means of a thermostat and Bunsen burner. (c) Swelling. — The primary swelling in inflammation is due to dila- tation of blood-vessels, and its degree will depend on the vascularitv of SYMPTOMS OF INFLAMMATION. 83 the part inflamed. The more numerous the blood-A'essels, the greater the swelling from this cause. As the inflamed blood-vessels will often dilate within two hours to double their normal calibre, the primary swelling in vascular organs in a state of acute inflammation will come on quickly, and will give rise to a not inconsiderable enlargement of the inflamed part. If during this stage of inflammation the tissues are incised, hemorrhage is profuse, and the emptying of turgid blood-vessels by this means has a prompt eft'ect in diminishing the swelling. Nancrede has shown by his investigations that local depletion, during the hyperaemic stage of inflammation, exercises a favorable influence in unloading the distended blood-vessels and in modifying the intensit}^ of the subse- quent conditions in the inflamed tissues. It is also during this stage that the application of cold proves a beneficial resource in the treatment of acute inflammation, as under its effects the distended blood-vessels contract, and in consequence of the diminution of the vascularit}' of the inflamed part the primary inflammator}' swelling is diminished. I. Inflammatory Exudation. — A moderate amount of swelling is present in all regenerative processes, as dilatation of the vessels neces- sarily precedes the increased physiological activit}' of the tissue, and the embryonal material required in the reparative process occupies a larger volume than the mature tissue it is intended to replace. Inflammation is characterized by tlie presence of a superabundance of cells. The cause which has produced the inflammation has, b}^ its direct action upon the capillary wall, produced such alterations of its structure as to render it more porous, hence permeable to the passage of the inclosed cellular elements of the blood. The albuminous cement-substance which holds together the endothelial cells disintegrates at diflerent points, and through these small defects, the stigmata and stomata, the blood-cor- puscles find their wa}^ through the capillar}^ wall into the surrounding l3-mph and connectiA'e-tissue spaces. In acute inflammation the inflam- matory exudation consists principall}' in the extra-vascular accumulation of blood-corpuscles which have passed through the injured capillary wall. The rapidity with which the inflammatory^ exudation appears will depend on the intensity of alteration of the capillary wall and the speed with which the blood-corpuscles escape into the surrounding tissues. In chronic inflammation exudation takes place slowly, and the histological elements of the inflammatory swelling are derived mostly from the fixed tissue-cells. Emigration of Leucocytes. — The passage of a leucocyte through a defect in the capillary w'all is called emigr.ation, — the wandering of such a cell from a place where it has a normal existence into a territor}'^ where, in a condition of health, it is seldom met with. After it has made its 84 PRINCIPLES OF SURGERY. escape from the capillary vessel it is called an emigration or wandering corpuscle. John Hunter came very near being the discoverer of emigra- tion of leucocytes during his researches on inflammation. He incised the tunica vaginalis in animals, and inserted a tallow plug, which he removed after short intervals, and examined the fluid upon its surface under the microscope. He found in this fluid, a short time after the in- cision was made, round, white cells, which could have been nothing else but wandering leucocytes. The credit for having demonstrated the porosity of the capillary wall and the escape of the colorless corpuscles unquestionably belongs to Waller. This author observed emigration in the tongue of the frog as early as 1846, and strongly maintained that the inflammatory exudates were composed largely of leucocytes, in opposition to the blastema theory of formation of pus and other inflammatory products. In 1849 Addison clearly pointed out the relationship of the color- less corpuscles and the corpuscles lying around the vessel in inflamed parts, as becomes evident from the following sentences from his work on "Consumption and Scrofula:" "During inflammation — using the word in the general sense here indicated — there is more or less marked increase of the colorless elements and protoplasm in the part affected. At first — in the first stage — these elements adhere but slightly along the inner margin or boundary of the nutrient vessels, and are therefore still within the influence of the circulating current, belonging, as it were, at this period as much, or rather more, to the blood than to the fixed solid. Secondly — in the second stage — they are more firmly fixed in the walls of the vessels, and, therefore, now without the influence of the circu- lating current. Thirdly" — in the third stage — new elements appear at the outer border of the vessels, where they add to the texture, form a new product, or are liberated as an excretion." Recklinghausen found wandering corpuscles in the vascular spaces of tlie cornea, but he believed that they were a product of tissue pro- liferation from the fixed corneal corpuscles. Our modern knowledge of emigration of leucocytes is founded almost exclusively upon the labors of Cohnheim. This observer demonstrated, in the j'ear 1867, by his own ingenious experiments, that the wandering corpuscles discovered by Recklinghausen in the vascular spaces of the cornea were leucocytes which had escaped from capillary vessels and had wandered into the cornea. He based his statements on the results of an experiment which could leave no room for discussion. He injected finely-divided pigment- material directly into the circulation of an animal, and somewhat later produced artificially a keratitis. In examining the cornea he found the vascular spaces nearest the margin of the cornea crowded with leuco- SYMPTOMS OF INFLAMMATION. 85 cytes loaded with pigment-granules. There could be only one conclu- sion, — that the leucocytes, which had become charged with pigment- granules in the general circulation, had passed through the capillary vessels at a point nearest the seat of irritation ; in other words, the capillary vessels which took part in the traumatic keratitis furnished the primary inflammatory exudation. A slight irritation of a frog's webb will onl}' produce an active Ii3'per8emia, and in a short time the circulation returns to normal without any emigration of leucocj'tes having taken place. In such cases the irritant has been of such a nature or of such mild action as not to produce the necessary alteration of the capillary wall for mural implantation and emigration to take place. Zahn has shown that if the mesentery of an animal is exposed, but carefully protected against injury, emigration of leucocytes does not take place for seven or eight hours, while the remaining disturbances of the circulation indicate the existence of inflammation. If, however, the frog's web or tongue is cauterized with a sharp-pointed pencil of nitrate of silver the necessary conditions for an acute inflammation are created, and the minute eschar is soon surrounded by vessels showing the differ- ent stages of the inflammatory process, from active l^-persemia to com- plete stasis. Emigration of leucocytes takes place most actively in capillaries partly obstructed by mural aggregation of these elements, and the process is arrested as soon as the circulation has come to a complete standstill. The following conditions must be present and are essential for emigration of leucocytes : 1. Alteration of capillary wall. 2. Mural implantation of leucoc3'tes. 3. Permeability of lumen of capillary vessel. 4. Amoeboid movements of leucoc_ytes, 1. Alteration of capillary wall has been repeatedlj'' enumerated as the most important feature of inflammation, and without such a change the rapid escape of leucocj^tes as we find it in inflammation would be utterlj^ impossible. The cause which has produced the inflammation produces such a degree of softening in the cement-substance as to enable its penetration by the leucocytes between the endothelial cells, or, as some of the authors claim, localized minute defects cause the formation of small openings through which the leucoc,ytes escape. 2. Mural implantation of leucocj'tes is an equally essential condition, as without it the leucocytes, which are at any rate larger in circumference than the supposed openings through which they escape, would be rolled over these minute defects b}^ the sluggish peripheral stream, and emigra- tion would not take place. Increased adhesiveness or viscosit}' of the leucocytes is supposed to play an important part in the occurrence of mural implantation. According to Hering, mural fixation of the leuco- 86 PRINCIPLES OF SURGERY. cytes is effected by fine projections, which are thrown out on their sur- face, and which insinuate themselves into the small crevices of the rough- ened intima. Mural implantation cannot take place as long as the capil- lary stream retains its normal velocity ; hence, slowing of the peripheral current is the first and most important cause. The slower the peripheral stream, the more readily does mural implantation occur, and the greater the tendency to aggregation of leucoc^^tes along and near the capillary wall. The rapid tra^isudation of the plasma of the blood through the defective capillary is undoubtedly another cause of impediment of prog- ress and final adhesion of leucocytes to the inner surface of the capil- lary vessel. Finally, mural fixation of leuco- cj^tes is effected by the changed condition of the protoplasm of the leucocytes and the inner surface of the capillary wall by the action of the essential cause which produced the inflam- mation. 3. It has been shown that emigration of leucocytes is most active where the capillary circulation has become impeded, but not ar- rested, and that the process is arrested with the occurrence of complete stasis ; hence, it ap- pears that the intra-vascular pressure is one of the factors in this process. Hering and Schklarewsky maintained that the leucocytes are entirely passive structures in their passage through the capillary wall, that they are forced through defects in the wall exclusively l\y the intra-vascular pressure. That emigration is not such a simple process is evident, as there would be in such case a larger representation of colored corpuscles in the inflammatory exudation. The blood-pressure assists in the extrusion of leuco- cytes that have penetrated the capillary wall, but, without changes in their form, would not be adequate to force them through the minute openings or the softened cement-substance. 4. Leucocytes, in order to pass tlirough an inflamed capillary wall, must possess amoeboid movements ; hence, onl}^ living leucoc^^tes are capable of migration. After the leucocyte has become implanted upon the inner surface of the capillary wall it penetrates the softened cement-substance by throwing out projections, or one of these projections insinuates itself into one of the minute foramina, and as the intra-mural portion increases Fig. 36.— Leucocyte Pass- ing THROUGH Capillary Wall. (Landerer.) A, leucocyte attached to capillary wall ijy delicate processes ; higher up it has penetrated the capillary wall by a large projection ; B, half of the leuco- cyte outside of the capillary wall drag- ging the balance after it. SYMPTOMS OF INFLAMMATION. 87 in size the balance of the leucocyte is drawn toward it ; this step is greatl}^ aided by the blood-pressure, which pushes the intra-vascular por- tion in the direction of the growing projection, until b}^ its own exertions, and aided by the vis a tergo, it has finished its journey through the capil- lar}'^ wall, and has reached the para-vascular lymph or connective-tissue spaces, where it constitutes the most important element of the inflam- matory exudation. In the inflamed capillaries of the frog's web, under the microscope, this process of emigration can be readil}^ followed, and leucoc3'tes can be seen in the same field in various stages of transit through the wall, and finall}' liberated in the para-vascular spaces. Fre- quently one leucocyte after another can be seen passing through the same place, — a fact which points stronglj' to the existence of well-defined circumscribed defects in the capillary wall. As the escaped leucocytes accumulate outside of the capillary vessels, some of them can be seen to change their location b}^ the same forces which have been active in their passage tlirough the vessel-wall, — amoeboid movements and stream of parenchyma fluid. Diapedesis. — This word was devised by Strieker to designate the passage of colored corpuscles through the inflamed vessel-wall. If there could be any doubt as to the existence of minute openings in the inflamed capillary wall in the consideration of emigration of leucocytes, this doubt must be eff'ectuall}' dispelled when the passage of colored corpuscles through the capillaiy wall can be demonstrated under the microscope. Experimental research and clinical observation have shown that when the inflammatory action is very intense red corpuscles form no inconsid- erable part of the inflammator}' exudation. As the colored corpuscles possess no amoeboid movements, their passage through the capillary wall must be an entirely passive process ; the}' are extruded through pre- formed openings or through an exceedingly soft cement-substance by the intra-vascular pressure. It is possible that they are forced tlirough pas- sages made by the emigration corpuscles. It is well known that at first only leucoc^'tes are found outside of the capillary vessels, that the colored corpuscles appear later, and that, while leucocytes also pass through the smallest veins, the colored corpuscles escape only through capillar}^ vessels (Fig. 37, D). Arnold noticed that red corpuscles floating in the capillary stream, when they arrived opposite a stomata, were drawn toward the opening of the transudation stream. Diapedesis becomes a prominent feature where the inflammatory process is very acute, consequently where extensive alteration of the vessel-walls has taken place. In such instances the colored corpuscles are so numerous in the exudation as to impart to it a hsemorrhagic 88 PRINCIPLES OF SURGERY. appearance. An abundant escape of colored corpuscles in inflammation is technicall}' called rhexis. The tliird corpuscles are extruded through the inflamed capillary wall in the same passive way as the colored corpuscles. The primary inflammatory exudation consists of the corpuscular elements of the blood which escape through the porous capillary wall, the products of their disintegration, and blood-plasma. The latter will be again referred to under the head of Transudation. The presence of the solid constituents of the blood differentiates the inflammatory exuda- tion from an ordinary hydropic or oedematous swelling. The question Fig. 37.— Inflammation of Frog\s Web at Stage where Capillary Stream IS Impeded by Commencing Emigration. (Landerer.) a, small artery ; B, small vein ; C, capillaries ; D, red corpuscles which have escaped from capillary by diapedesis. rises. What becomes of the corpuscular elements after they have left the general circulation ? The most favorable termination of the inflamma- tor}^ process consists in the preservation of the vitality of the cellular elements outside of the blood-vessels and their return into the general circulation by a process which is called immigration. This probably seldom, if ever, takes place in the case of the colored and third cor- puscles, both of Avhich possess no amoeboid movements and undergo molecular disintegration, and the granular detritus is removed by absorp- tion. The leucocytes which have retained their vitality can return into the circulation either by re-entering the capillaries which they have left, SYMPTOMS OF INFLAMMATION. 89 after the acute S3"mptoms have subsided and the capillaries have been cleared of the mural thrombi, or b}' a more indirect route through the lymphatic vessels. The latter route is probably the most frequent. If the blood-corpuscles contain the microbic cause of the inflammation in sufl3cient qnantitv and intensity to destroy their protoplasm, they fur- nish the necessarj- nutrient medium for the growth and development of the microbe outside of the vessel-wall, thus bringing it in direct contact with the para-vascular tissues, which then become the seat of infection. In such instances the cellular elements of the primary inflammator}' exu- dation are dead tissue, and act or are disposed of as such. In acute suppurative inflammation the leucocytes which have escaped are con- verted into pus-corpuscles. The einigration corpuscle under no circum- stances assumes a tissue-producing function. When inflammatory proc- esses result in the formation of new tissue, this function is performed by fixed tissue-cells which have been stimulated to a state of activity' hy the increased nutritive conditions incident to some form of inflamma- tion. The albumen, which is alwaj's present in considerable quantity in every inflammator}' exudation, furnishes an additional nutrient supply, and thus assists the process of cell proliferation ; this is especially the case with the globulins. The filtrate which percolates through the in- flamed capillary wall contains coagulable substances, which, in hydropic fluids, are less abundant. The emigration corpuscles, which disintegrate soon after they have left the capillar}' vessels, furnish fibrin ferment. Fibrin production in the tissues is suspended as soon as the product of emigration has become copious. The third corpuscles furnish another source of fibrin production. In suppurative inflammation fibrin forma- tion does not take place. Where no fibrin forms in the exudation, the supposition lies near that the fibrin-producers are taken up by the cells, or that the fibrin which had already been produced is liquefied and assimilated hy them. If the inflamed vessels are surrounded only by a few leucocytes, the latter are destroyed and liberate fibrin ferment ; if abundant, they are more resistant and destroy albuminous substances. AVeigert asserted that cell necrosis resulted in the formation of fibrin, as the dead cells furnish the fibrin ferment. That fibrin production does not always attend inflammation can onl}^ be explained b}' the supposition that the fibrin-producers are assimilated as soon as they have left the blood-channels. If the cells which furnish the fibrin come in contact with necrotic tissue, such an assimilation is prevented and fibrin is formed. Fi])rin production, however, may take place without cell necro- sis, as is the case upon inflamed serous surfaces. Its occurrence in this particular locality can onl}" be explained by the absence of assimilation of the cells which yield the fibrin ferment. The cellular constituents 90 PRINCIPLES OF SURGERY. and fibrin of the inflammatory exndation impart to it one of its charac- teristic clinical features, — a sense of firmness, — which is well marked in proi)ortion to the predominance of these over the fluid portion. Inflammatopy Transudation. — The liquid ])ortion of the blood which escapes through the damaged wall of inflamed capillary vessels is called inflammatory transudation. The same causes which are necessary to extrude the non-amreboid corpuscular elements of the blood constitute also the conditions which enable a part of the blood-plasma to leave the capillary stream. Increased porosity of the capillary Mall is the most important of them. As soon as the capillar}^ wall has become abnor- mally permeable the blood-pressure forces the fluid tlirough the minute pores into the surrounding connective tissue, or, if the inflammation is located in a mucous or serous membrane, upon the surface. In deep- seated inflammation the transuded fluid freely percolates through the connective-tissue spaces, and gives rise to one of the well-known symp- toms of inflammation, — the inflammatory oedema. The transudation is always more widely diff'used than the exudation. Recent bacteriological researches have shown that, while in the tissues, at the seat of exuda- tion, the presence of the microbic cause of the inflammation can be readily demonstrated by microscopical examination and cultivation ex- periments, the cedema fluid some distance from them was found free from micro-organisms. The escape of blood-plasma in inflammation is a proc- ess which resembles percolation through a porous membrane. As the blood-plasma contains fibrinogen and fibrino-plastic material, its presence in the tissues or upon inflamed serous or mucous membranes is impor- tant in the production of fibrin. In some instances the inflammatory product is greatly changed by the presence of a copious transudation, and the inflamed part then presents more the appearance of oedema than inflammation. This is well shown by the two clinical varieties of anthrax. The expression serous inflammation is used to indicate the predominance of transudation over exudation in some forms of inflammation. The liquid transudate predominates over the exudate in some forms of sup- purative inflammation (purulent oedema of Pirogoflf), also when the circulation is feeble, as in the aged and in anaemic individuals. The addition of mucus alters the character of an exudation or a transudation, as may be seen when a mucous membrane is the seat of inflammation. Serous transudation often precedes mucous exudation, as in cases of acute catarrlial inflammation of the nasal passages. After the acute symptoms of inflammation have subsided and the capillary circulation has been restored, the transuded fluid is absorbed, and with its absorp- tion the inflammatory oedema disappears. In suppurative inflammation the transudation becomes the pus-serum. SYMPTOMS OF INFLAMMATION. 91 (d) Heat. — Increase of temperature of the inflamed part is the result of increased afflux of blood and the accompanying augmentation of physiological processes. Cohnheim showed experimentally that inflam- mation, without an increased blood-supply, does not give rise to an increase of temperature. Jolm Hunter was already aware that the temperature at the seat of inflammation is never in excess of the tem- perature of the blood. Heat is both a subjective and objective s^-mptom. In acute inflammation of the skin, or a mucous membrane, the patient often complains of a distressing burning or scalding sensation, which is often effectually relieved by cold applications. The surface thermometer is sometimes an important instrument in setting a differential diagnosis between a deep-seated chronic inflammation and a malignant tumor. Diminution of temperature may indicate either a favorable change or complete arrest of circulation in the inflamed part, in the first instance showing that resolution is in progress, in the latter commencing the speedy occurrence of gangrene. (e) Disturbance of Function. — As inflammation, wherever it occurs, consists essentially of increased nutritive changes in the tissues, result- ing in consequence of a more abundant blood-suppl}' and an exaggerated vegetative capacity of the cells, it ma}^ lead to at least a temporary in- crease of function. This is always the case in inflammation of mucous membranes, where, as one of the prominent clinical features, we observe an increased secretion of mucus usually preceded and accompanied by a more or less profuse transudation. Parenchjanatous inflammation in glands usually produces sudden diminution and often complete suppres- sion of secretion. Acute suppurative osteomyelitis is attended by almost complete suspension of all the functions of the aflfected limb. Myositis arrests the contractility of the muscles aff"ected. The pain caused by an inflammation may interfere with the functions of adjacent organs, as may be seen in the fixed chest-wall in cases of acute pleuritis, and in fixa- tion of the abdominal walls, with diminished or suspended respiratory movements of the diaphragm, in cases of peritonitis. Tlie accumulation of inflammatory products may prove a serious obstacle to important functions, and often constitutes a direct cause of death, as in cases of intra-cranial inflammation, where death is more frequently caused by com- pression of the brain than destruction of the contents of the cranial cavity ; and the accumulation of serum or pus in the pleural cavity or pericardium, where a fatal termination can often be traced to mechanical causes from the presence of a copious eflTusion. Diminution of function often aflTords the earliest indication of the existence of a deep-seated chronic inflam- mation, as is evident from the slight limp which ushers in a coxitis or the imperfect flexion and extension in chronic inflammation of joints other than the hip-joint. CHAPTER IV. Inflammation {continued). MODIFICATION OF INFLAMMATION BY THE ANATOMICAL STRUCTURE AND LOCATION OF THE INFLAMED TISSUE. The clinical course and pathological conditions of inflammatory processes are materially modified not only by the primarj^ cause, but also b}^ the anatomical structure and location of the inflamed tissues. Inflammation of serous or mucous surfaces has a tendenc}' to spread in a peripheral direction, and, as a rule, remains superficial, and the exuda- tion and transudation are poured out in the direction offering the least resistance; that is, upon the free surface. In tissues that are dense and un^'ielding the swelling, for physical reasons, is limited, and the inflam- mator}^ products givQ rise to tension, which may arrest the circulation completely and cause necrosis, as is the case in acute suppurative osteo- myelitis. When the area of inflammation is supplied with an abundance of connective tissue the swelling often attains enormous dimensions in a short time, as may be seen in ever}- case of phlegmonous inflammation of the deep-seated connective tissue of the extremities, neck, chest, and abdomen. Acute inflammation of organs that are exceedingly vascular gives rise to an early and abundant exudation, as can be demonstrated in every case of croupous pneumonia and acute nephritis. Inflammation of non-vascular tissue is accompanied by the formation of new blood- vessels, which grow in the direction of the seat of inflammation from the nearest vascular district. Some tissues are more disposed to inflamma- tion than others ; thus, the connective tissue is more frequently the seat of acute inflammation than muscles, and the medullar}' tissue than the bone-substance proper, and most causes which give rise to chronic inflammation are known to select certain organs and tissues in preference to others. PARENCHYMATOUS INFLAMMATION. In the stud}- of the cardinal symptoms of inflammation special attention was given to the part taken in the inflammatory process b}'^ the capillary vessels and the blood-corpuscles. Alteration of the capillary- wall was alluded to as the most important pathological condition, as (93) 94 PRINCIPLES OF SURGERY. upon it depends the emigration of the corpuscuhir elements of the blood and the occurrence of tiie inflammatory transudation, which together constitute the primary inllammatory swelling. Incidentally it was stated that as soon as the cause wliich gave rise to the inflammation is brought in direct contact with the fixed tissue-cells, these take part in the in- flammatory process and contribute their share to the inflammatory exu- dation. Inflammation is said t® be parenchymatous when the parenchyma of an organ is the primary seat of inflammatory changes, as when the secreting structures of a gland are implicated from the beginning. In all such instances the blood-vessels which furnish the vascular supply have undergone the characteristic changes which have been described, and with few exceptions the microbes have been conveyed to tlie parenchyma through them. The cloudy swelling of parenchyma cells is either an evidence of the existence of degenerative changes, or it denotes the beginning of coagulation necrosis from the specific effect of patho- genic microbes upon their protoplasm. A cloudy appearance of cells is one of the first manifestations of tlie presence of a parenchymatous in- flammation. Lesion of connective tissue or parenchyma cells is next to alteration of capillary wall, and emigration of blood-corpuscles the most important pathological condition of inflammation, and, as far as the ultimate result is concerned, the most important, as extensive destruction of parenchyma cells will result in suspension of function, and death of the organ affected is one of vital importance. As soon as the fixed tissue- cells outside of the vessel-wall have become implicated their physiological resistance is diminished, — a condition which cannot fail in aggravating the existing vascular disturbances. Landerer maintains that the normal elasticity of the tissues surrounding the capillary vessels is an essential factor in preserving the equilibrium between the intra-A'ascular pressure and the surrounding tissues in a normal condition of the circulation. This mechanical theory of inflammation is founded upon the supposition that this normal elasticit3^ of the para-vascular tissues is diminished by the causes which give rise to inflammation, and that when this has occurred the capillary walls have lost their outer support, in consequence of which they become dilated, and hyperemia, slowing of blood-current, emigration, and transudation follow as the result of purely mechanical causes. Ingenious as this theoi-y may appear, it cannot explain the complicated processes which characterize inflammation. The train of pathological conditions which attend inflammation must be regarded as effects of a common microbic cause upon the capillary wall, their con- tents, and the fixed tissue-cells outside of the capillary vessels. In parench3unatous inflammation the cause has reached the parench,yma cells, either directly, as when microbes are brought in contact with a INTERSTITIAL INFLAMMATIOK. 95 mucous surface, become attached to and penetrate the parenchyma cells, multiply in their interior, and, later, reach the connective tissue and blood-vessels, or, what is more common, the microbes reach the paren- chyma through the circulation. In both instances the capillary vessels and the connective tissues between them and the parenchj'ma cells take an active part in the inflammatory process. The microbes may be present in such great number or may possess such intensel}^ virulent properties as to destroy the parenchyma cells, as is the case in diphtheritic inflammation of mucous membranes. When less intense in their action the parenchyma cells proliferate, and the embryonal cells, being less re- sistant, succumb later, as when suppuration occurs in the parench} ma of an organ, or they remain indefinitely in their embrj^onal state, as can be readil}^ verified by examining the difterent forms of chronic inflam- matory swellings, — the so-called granulomata. INTERSTITIAL INFLAMMATION. In this form of inflammation the connective tissue is the seat of cell emigration and tissue proliferation. Many of the microbes select the connective-tissue spaces ; they locate and multiply here, and the inflam- mator}^ product is composed almost exclusively of emigration corpuscles and embr3'onal connective-tissue cells. Tubercle and gummata present such a histological structure. Phlegmonous inflammation represents the acute form of connective-tissue inflammation. If the connective tissue of an organ become the seat of an inflammator}^ hyperplasia the paren- chyma suftel's, either in consequence of pressure or, later, from cicatricial contraction and the inevitable diminution of blood-suppl}^ incident to this condition. Parenchymatous inflammation of an organ is preceded or followed b}^ interstitial inflammation, and a primarily interstitial in- flammation sooner or later involves the surrounding tissue b}' direct extension of the inflammatory process, or indirectly the mechanical causes ; hence, as a rule, it is anatomically and even etiologicalh- not always possible to differentiate between these two forms of inflammation, nor is such a distinction of much practical importance. HEMORRHAGIC INFLAMMATION. A few colored corpuscles escape through the capillary wall in almost every case of acute inflammation, but their presence in the exudation can onl}^ be determined b}^ the use of the microscope. When they are present in sufficient number to impart to the exudation a bloody tinge, we speak of a hsemorrhagic exudation or transudation. A hsemorrhagic transudation into the pleural, pericardial, or peritoneal cavit}' usually indicates the existence of a tubercular or malignant disease of the 96 PRINCIPLES OF SURGERY. respective serous membranes. In cases of acute inflammation with hsem- orrliagic exudation, the quantity of the effused blood will be a sign by which we can at least approximately estimate the extent of alteration of the capillary wall. Rhexis can only take place when the capillary wall at some point has been completel}' broken down and an opening of con- siderable size has formed through which a small stream from the axial current can escape. Aside of the nature and intensity of the primary cause of the inflammation, ha?morrhagic inflammation is more likely to be met with in persons debilitated from other diseases, in the aged, and in patients suflering from diseases which obstruct the circulation, such as valvular disease of the heart, cirrliosis of the liver, emphysema of the lungs, and chronic atlections of tlie kidney. The presence of blood in a transudation or exudation is always a grave sign, and as such should always be taken into careful consideration in rendering a prognosis. SUPPURATIVE INFLAMMATION. In suppurative inflammation at least a part of the exudation is transformed into pus. Transformation of the cellular portion of the exudation, the leucocytes and embr3'onal cells, into pus-corpuscles is due to the destructive effect upon their i)rotoplasm of the pus-microbes and their ptomaines, while the transudate becomes the pus-serum. Suppu- rative inflammation occurs either as tlie result of a primary or secondary infection with pus-microbes. In primary infection with pus-microbes the leucoc^'tes most remote from the blood-vessels, and which have been exposed longest to the specific action of the pus-microbes and their ptomaines, are converted first into pus-corpuscles, while the fixed tissue- cells are first transformed into embryonal cells before the same cause, by destruction of their protoplasm, changes them into similar structures. In suppurative inflammation due to secondary infection, the pus-microbes act upon embr3'onal cells which owe their origin to an antecedent infec- tion witli another microbe of milder patliogenic qualities, as can be seen when tubercular granulations or a gumma undergo suppuration. Sup- purative inflammation, in all of its aspects, will be fully considered in the chapter on Suppuration. INFLAMMATION OF SEROUS MEMBRANES. Inflammation of the serous membranes has been called exudative, adhesive, suppurative, or serous, according to the character of the in- flammatorj?^ product. In most inflammatory affections of the serous membranes the surface becomes covered with a copious exudation, which is composed of leucocytes, fibrin, and the products of tissue proliferation of the endothelial and connective-tissue cell. Tlie leucocytes and third INFLAMMATIOJf OF SEROUS MEMBRANES. 97 corpuscles are rapidl}- destroyed as tliey reach the surface, and the fibrin ferment and fibrino-plastic material "which are liberated form, on com- bining with the fibrinogen of the blood-plasma, fibrin. Tlie inflamed membrane is often covered by a tliick la3'er of fibrin, which is firmly adherent to the surface by means of new blood-vessels and granulation tissue w'hich have grown into it. The endothelial cells take an active Fig. 38.— Germikating Endothelitim, OMENTtJM of Yotjxg Dog. Acute Peritonitis. Silver-staining, X 3.50. (Hamilton.) A, natural endothelium covering wall of a mesh : B, D, endothelial cells beginning to germinate ; C, a chain of germinating cells extending across a fenestra; E, mass of germinating endothelial cells. part in the inflammation, and in case the new product from this source is converted into connective tissue a permanent adhesion forms. In some instances the endothelial cells are destroyed and desquamation takes place, which leaves the subjacent connective tissue exposed. In such cases the superficial dilated capillaries have lost an important sup- port, and transudation takes place freely. D. J. Hamilton has studied 98 PRINCIPLES OF SURGERY. the histological changes which occur in periostitis by producing this disease artificially in young dogs. Besides desquamation, he lias seen the endotlielial cells multiply by division of the nucleus. The new cells resemble the ordinary granulation or embryonal cells. The connective tissue l)etween tlie endothelial lininof and the blood-vessels 4,m c i^§^,i^^^^^,^^^/c/r)j 7/ / IX — - -• -' Fig. 39.— Omentum of Young Dog, Experimentally Inflamed. X 450. (Hamilton.) A, pyriform cell, probably of enflothelial origin, sprouting from wall of a fenestra (S) of the membrane; C, capillary, Biirrounded by extravasated leucocytes ; V, small vein, in similar condition. undergoes tissue proliferation, and the new cells reach the surface and mingle with those derived from the endotlielial lining, so that the inflamed surface becomes covered with a layer of granulation tissue. The granu- lations, accompanied by dilated or new blood-vessels, penetrate into the fibrinous exudation, which is removed in the same manner as a thrombus INFLAMMATION OF SEROUS MEMBRANES. 99 in a blood-vessel undergoing obliteration. Permanent adhesions and obliteration of serous cavities are atfected by the granulation tissue, which removes the inflammatory exudation and establishes an organic union between opposing inflamed membranes. If the fixed tissue-cells do not participate actively in the juflanimatory process, the exudation becomes absorbed in the course of time, and the endothelial lining is repaired; thus the temporar3'' adhesions are removed, and the normal Fig. 40.— Acute Pleurisy, x 300. (Hamilton.) A, A, net-work of fibrin; B, an effuseil leucocyte; C, laminfe of fibrin lying adjacent to the pleura (F) ; D, small round cells eft'used into the pleura ; E, distended blood-vessel of the superficial layer of pleura. relations existing between the serous membrane and inelosea viscera are restored. The blending of the corpuscular elements of the inflammatory exudation of a serous membrane with the product of tissue proliferation of the endothelial cells is well shown in Fig. 39. The pathological anatomy of acute inflammation of a serous mem- brane at an early stage is well represented in Fig. 40. The scarcitj' of leucocytes in the fibrin in the specimen represented by this illustration was undoubtedly due to their rapid destruction as 100 PRINCIPLES OF SURGERY. soon as they reached the surface, whicli resulted in the formation of a copious deposit of fibrin. The round cells in the subpleural connective tissue are elFused leucoc3'tes. Sufficient time does not seem to have elapsed for any marked clianges to have occurred in the fixed tissue-cells. In suppurative inflammation of a serous membrane, if life is sufficiently prolonged, the leucocytes and embryonal cells are transformed into pus- corpuscles, and in this manner empyema, pyocardium, and purulent peritonitis are produced. The introduction of pus-microbes in sufficient quantity into the abdominal cavity, the power of absorption of which has been reduced by an antecedent affection or an accompanying trauma, will produce such a rapidly fatal peritonitis that tiie pei-itoneum, on post- mortem examination, will show little, if any, macroscopical lesions. Death in such cases results from acute septic infection. When life is pro- longed for several days, the post-mortem reveals all the evidences of a fibrino-plastic peritonitis ; that is, numerous adhesions between the intestines and the parietal peritoneum and among the intestinal loops. In purulent peritonitis the exudation often breaks down as the leuco- cytes contained in it are converted into pus-corpuscles. Tubercular peritonitis is usually attended by a copious exudation, which limits the process and encapsulates the serous transudation. If, in an inflamma- tion of a serous membrane, the transudation predominates over the exudation, the character of the process is indicated clinically b}^ a subacute or chronic course and the absence of severe symptoms. H3'dro- thorax often develops insidiously, and perhaps the first subjective symptom is difficulty of breathing. Tubercular peritonitis with copious circumscribed effusion has been frequently mistaken for ovarian cyst, not only because the swelling closel}^ resembles a unilocular ovarian cyst, but also from the absence of au}^ of the usual local symptoms which attend the usual forms of fibrino-plastic peritonitis. It appears that the causes which give rise to the form of inflammation of serous membranes do not act with sufficient intensity on the capillaiy wall and the para-vas- cular tissues to provoke a copious exudation and active tissue prolifera- tion, but create conditions which permit a copious transudation to take place. It has been recently a much-discussed question "whether or not all cases of serous effusion into the chest are of tubercular origin. The fact remains that many cases of subacute and chronic pleurisy die subse- quently from tuberculosis, and the natural conclusion would be that the disease was primarily caused by a localized tubercular focus, which, at the time, could not be detected. It is evident that the causes which produce serous transudation do so not only bj?^ producing changes in the capillary wall which permit free transudation, but also by bringing about alterations which diminish or completely suspend the power of absorp- INFLAMMATION OF MUCOUS MEMBRANES. 101 tion ; hence, not onl^' the occurrence of transudation, but accumulation of the liquid effused. The presence of blood in the transudation is usually an indication of the presence of tuberculosis, carcinoma, or sarcoma. INFLAMMATION OF MUCOUS MEMBRANES. Inflammation of a mucous membrane represents another variet}' of surface inflammation which is greatly modified by the anatomical character of the tissue the seat of the inflammatorj'' process. We have seen that inflammation of serous membranes pi'esents as its most charac- teristic pathological feature a plastic exudation on its surface, composed of the exuded blood-corpuscles and the products of their disintegration, which are firmly attached to the endothelial lining, which in part has been destroj'ed and detached by desquamation, while the cells which have retained their vitality proliferate new tissue, which mingles with and ultimatel}^ removes the exudation. The epithelial cells which line mucous membranes when in a state of inflammation are stimulated to increased activity, and consequently secrete an increased quantit}^ of mucus, which is the characteristic pathological and clinical feature of I. CATARRHAL INFLAMMATION. Inflammation of a mucous membrane is called catarrhal as long as the product consists of an increased secretion of mucus. If a part of the mucous lining is destroyed and the discharge becomes a mixture of pus and mucus, it is no longer proper to call it a catarrhal inflammation, as the pus-microbes have wrought changes that bring the process within the legitimate sphere of suppurative inflammation. Catarrhal inflamma- tion produces a thickening of the mucous membrane bj' infiltration of the submucous tissue, which, if copious, may subsequently give rise to cicatricial contraction, and, if the inflammation is located in a tubular organ, to the formation of strictures. According to Yirchow, a catarrhal inflammation may lead to the formation of superficial ulcers, — the so- called catarrhal ulcers. II. SUPPURATIVE INFLAMMATION. In this form of inflammation of a mucous membrane, the leucocytes which are extruded upon its surface, as well as the embr^-onal cells, are destro^-ed by the pus-microbes and are converted into pus-corpuscles, which, when mixed with the mucus secreted by the cells which have x-etained their physiological function, form the muco-purulent discharge. Most of the ulcers which form i\\)on mucous surfaces result from circum- scribed necrosis or suppurative inflammation, A catarrhal inflammation very frequently precedes the suppurative form, and a circumscribed sup- 102 PRINCIPLES OF SURGERY. purating area is usually' surrounded by a zone of catarrhal inflammation. Cicatricial obliteration of a tubular organ can only take place after ex- tensive defects of its mucous lining from necrotic, ulcerative, or trau- matic causes. Limited defects are repaired by regeneration of the epi- thelial cells, either from the margins of the defect or from remnants of glands. The most frequent causes of ulceration in the intestinal canal are dysentery, typhoid fever, and tuberculosis. Ulcers which result from the sudden obliteration of a small blood-vessel by thrombosis or embolism are met with after extensive burns in the upper portion of the small in- testine and in the stomach in chlorotic females. A strange form of perforative enteritis has recently been described by Mikulicz. A similar case was operated on in the Zurich Klinik, and a careful description of the pathological conditions found at the necropsy has been given by Klebs. He found multiple perforations in a circumscribed portion of the jejunum, and onl}^ a few of them had been found and closed by the surgeon who performed the operation. The perforations on the peri- toneal side were covered by a plastic exudation. The lumen of the intestine corresponding to the affected portion was considerably enlarged. Mucous membrane not much changed in appearance, but, on close inspec- tion, a number of small defects, partly hidden under the folds, were de- tected, and were found to correspond with the covered defects on the outer surface. On microscopical examination, it was found that the villi and mucous membrane were softened and denuded of the epithelial lining and infiltrated with cells over a considerable distance beyond the per- forations. The most marked changes were found in the submucous tissue, which was also much softened, and the scanty intercellular substance was found traversed by wide spaces in which Avere found numerous large cells with large oval nuclei. Besides these enlarged parenchyma cells, and in their vicinity, leucocytes which had undergone fragmentation were found. As the capillary vessels were much dilated and in a con- dition of inflammation, Klebs looks upon the process as a hyperplastic parenchymatous enteritis. As the leucocytes found in the tissues pre- sented all the evidences of fragmentation, there can be but little doubt that this rare form of enteritis presents only another variety of sup- purative inflammation of the mucous membrane of the intestine. III. CROUPOUS INFLAMMATION. When inflammation of a mucous membrane is attended by the formation of a fibrinous exudation or false membrane upon its surface, it is called croupous. The formation of a fibrinous exudation upon a serous surface, we have found, is always associated with a more or less extensive destruction and desquamation of endothelial cells, and a simi- INFLAMMATION OF NON-VASCULAR TISSUE. 103 lar superficial change takes place in croupous inflammation. Weigert states that unless the epithelial surface of a mucous membrane be broken the inflammatory exudation from it will not coagulate. As croupous inflammation of a mucous membrane is probably always pro- duced b}^ direct infection, it is probable tliat the micro-organisms destroj' some of the epithelial cells, and as the inflammatorj^ process penetrates deeper into the tissue, the exudation and transudation coming in contact with dead tissue on the surface, fibrin is deposited, and, becoming entan- gled with the cellular debris, it becomes adherent to the partiall^'-abraded and uneven surface. The fibrin is arranged in layers in the form of a coarse net-work, in the meshes of which is a finer reticulum of the same, with leucocytes and embryonal cells thrown off from the surface. Some membranes contain numerous leucocytes, while in others they are de- stroyed in the process of coagulation. Separation of a false membrane takes place either by the mucus secreted by intact cells underneath it, or if the mucous lining has been completely destroyed by suppuration and granulation. It has been claimed that, pathologically, a croupous mem- brane differs from a diphtlieritic exudation in that, in the former, the lining of the mucous membrane is found intact after stripping it off, while in a diphtheritic inflammation there is always found a loss of sur- ft^'^e substance after removing the membrane. Upon this more apparent than real anatomical diflerence the discussion on the non-identity of croupous and diphtheritic inflammation rests. As superficial coagula- tion necrosis is present in all cases of croupous inflammation, and if this process is etiologically difl!erent from diphtheritic inflammation, the pathological conditions are different only in degree and not in kind. False membranes, wherever they may form upon a mucous or serous sur- face, serve as nutrient media for micro-organisms, and the underlying surface is subjected to the risks of recurring infection from them as long as they remain. INFLAMMATION OF NON-VASCULAR TISSUE. The importance of blood-vessels in inflammation can be best shown b}'^ a study of the pathological conditions in inflammation of non-vascular tissue. The part taken b}^ the blood-vessels and the fixed tissue-cells in the inflammatory process can be most satisfactorily demonstrated in non-vascular organs. Cornea. — Colmheim first demonstrated emigration of the colorless blood-corpuscles in artificially-produced keratitis. He cauterized the cornea in animals, and then observed cell infiltration from its margins at a point corresponding to the nearest vascular supply. For the {)urpose of showing that the cells were not products of the fixed tissue-cells he 104 PRINCIPLES OF SURGERY. injected, a few days before the cauterization, finely-divided cinnabar into the circulation, and found that the leucocytes, as they escaped from the capillary vessels, contained granules of the pigment which he had in- jected. The leucocytes were seen to wander through the vascular spaces of the cornea toward the seat of cauterization. As he could observe no changes in tlie fixed corneal corpuscles at the seat of cauterization, he maintained that the inflanimatorj^ product was derived exclusive]}^ from the blood, and that its escape from the blood-stream depended on altera- tion of the ca})illary wall. He regarded the dilatation of blood-vessels, which occurs soon after the application of the irritant, as a result of reflex action, and attempted to prove, by specimens of keratitis stained with chloride of gold, that the fixed tissue-cells remained unaffected by tlie inflammation. Strieker maintained the opposite view, and proved, in silver-stained specimens, that the corneal corpuscles had undergone changes whicli indicated tliat they performed an active part in the in- flammation. Recklinghausen resorted to a very ingenious experiment to establish his theory regarding the origin of the wandering cells in the vascular spaces of the cornea. He cauterized the cornea of a frog, excised it immediately, and kept it under conditions favorable to cell vegetation, and found, later, wandering cells in the vascular spaces, the origin of which he traced to tissue proliferation of the corneal corpuscles after excision ; but even his assistant, F. A. Hoflfmann, expressed the opinion that the cells might have been leucocytes which had entered the vascular spaces before the cornea was excised. It is more than doubtful that tissue proliferation would take place in an excised cornea, even under the most favorable physical conditions. There can be no doubt whatever that the primary exudation in traumatic keratitis, as in all other forms of acute inflammation, takes place from inflamed capillary vessels, as Cohnheim has demonstrated so beautifuU}' ; but this constitutes onl}' a part of the phenomena which characterize inflammation in the cornea and all other tissues, as, later, the fixed tissue-cells participate in the process, and the new cells derived from them form a part of the in- flammatory products. The parenchymatous changes are even more im- portant than the vascular, as repair after subsidence of inflammation is accomplished exclusively by proliferation of the fixed tissue-cells. Eberth has demonstrated, b}'^ his accurate histological researches, that the corneal corpuscles near an eschar, made for the purpose of producing a keratitis, multiply by karyokinesis, and regeneration is effected exclu- sively b}'^ the embryonal cells derived from this source. The corneal corpuscles possess a high vegetative capacity, resembling in this respect the connective tissue, to which they bear a strong resemblance, having a similar embryological origin, and receive their nutritive supply through INFLAMMATION OF NON- VASCULAR TISSUE. 105 a system of lymph-cbannels or vascular spaces which are in intimate relationship with the sclerotic vessels at the border of the cornea. The plasma or lymph-channel in the cornea are loosely filled with a liquid albuminoid substance, in which can be seen, even in a normal condition, occasionally a Ij-mph-corpuscle. In artificial keratitis these channels are first packed with leucocytes, which escape from the congested capillaries at the limbus cornece, enter them directly, and wander toward the seat of irritation far in advance of the new blood-vessels. Infiltra- tion of the cornea with leucocytes gives rise to cloudiness. At first Cohnheim claimed that infiltration of the cornea alwaj'S occurred from the periphery, but in some of the later experiments on the corneae of spring frogs he noticed cell accumulation around the central eschar made with a sharp pencil of nitrate of silver, and, as he was absoluteh' opposed to the idea that the corneal corpuscles could take any active part in the process, he came to the forced conclusion that the cellular elements of the conjunctival fluid were increased, and that these had wandered into the cornea through the lesion at the centre. Strieker has observed karyomitotic changes in the corneal corpuscles surrounding a central eschar as earl}- as three hours after cauterization, and after twenty-four to forty -eight hours cell proliferation was seen to be present all around the inflamed area. From what different authors have written on the subject of artificial keratitis, wliich, of course, must be accepted as a fair representative of the clinical forms of this disease, it becomes apparent that the first evidence of inflammation is an increased amount of fluid in the vascular spaces, causing distention and, consequentl}', swelling of the cornea. As the plasma canals become distended the cells lining them are in part de- stroj'ed, and the fluid escapes between two laminae and forces them partl}^ asunder. (Fig. 41, C, C.) At this time the endothelial cells and corneal corpuscles undergo tissue proliferation, and the new cells form part of the inflammatory' product. With the breaking down of the vascular spaces resulting in lymph stasis, accumulation of lymph-corpuscles also takes place, by which another cellular element is added to the inflamma- tory product. The plasma channels and artificially-formed spaces between laminae are now blocked with leucocytes, lymph-cori)uscles, and embryonal cells. If the irritation is prolonged for a sufficient length of time, vascularization of the inflamed cornea will take place in the course of one or two weeks by the formation of new vessels from pre-existing sclerotic vessels at the corneal border. The new blood-vessels grow in the direction of the seat of irritation, occupying a triangular field, with the apex directed toward the centre, the base corresponding to the limbus corneae. The vascular portion of such a cornea is called a pan n us. In 106 PRINCIPLES OF SURGERY. suppurative keratitis the emigration corpuscles undergo fragmentation and are converted into pus-corpuscles ; at the same time tlie embryonal cells exposed to the action of the pus-microbes furnish another histo- logical source for pus production. The fibrous tissue within the sup- purating area necroses on account of the disturbed nutrition and the toxic effect of the pus-microbes and their ptomaines, and an abscess results. Yascuhirization of an inflamed cornea furnishes one of the Fig. 41.— Artificial Keratitls, Kitten. Silver-staining, X 450. {Hamilton.) A. isolated and nucleated cell ; B, a group of such still retaining something of the shape of a plasma canal ; C, C, plasma canals breaking into fragments ; D, the fibrous basis of the lamellae, or the ground- substance. most beautiful illustrations of the presence of protective resources in the organism, which, when called upon to meet different emei'gencies, render material aid in the prevention or limitation of destructive proc- esses. Every oculist is familiar with the fact tliat extensive suppurative keratitis manifests no tendency to reparative action when conditions are present tliat retard or coinpletelv prevent the formation of a pannus. As soon as the process of repair has been completed the new vessels dis- INFLAMMATION OF NON-TASCULAR TISSUE. 107 appear, leaving a transparent cornea if the defect has been within the limits of the regenerative capacity of the tissues ; in case the loss of substance has been too great for complete restoration of structure and function, healing is accomplished b}' the formation of ordinar}- cicatricial tissue, which results in the formation of a scar — a permanent opacity of the cornea. In keratitis without suppuration, or attended by a limited ulceration, the cloudiness of the cornea resulting from cell infiltration and the presence of embryonal cells in moderate abundance, transparency is restored with the removal of the wandering cells by gi-anular degenera- tion and absorption, or their return into the circulation, and the repair of the lesion by tlie transformation of the embryonal cells into mature, perfect, corneal tissue. Cartilage. — Cartilage is a structure not only devoid of blood-vessels, but also of any kind of vascular spaces for plasma circulation. Nutrition must here take place by inter- and intra- cellular diffusion of plasma. In its structure it resembles the cornea. On account of the absence of any direct or indirect connection of cartilage tissue with the vessels of the perichondrium all regenerative processes are slow and imperfect, and the inflammatory lesions, which onl}' occasionally are found here as a primary affection, are noted for their chronicity. Artificial chondritis was studied b^- Goodsir and Redfern. Certain parenchymatous changes were noted at different times after cauterization of articular cartilage. They consist essentially in the enlargement of the cartilage-cells, with increase of the nuclei, or of peculiar corpuscles contained in them, or with fatty degen- eration of their contents and fading or similar degeneration of their nuclei. The hj^aline intercellular substance at the same time splits up, and softens into a gelatinous and finely molecular and dotted substance. When molecular disintegration or ulceration of cartilage takes place, the enlarged cartilage-cells on the surface are liberated, and the cement-sub- stance disappears in a similar manner after having undergone liquefaction. Kiiss stated that he had recognized, in articular cartilage under the influ- ence of irritants, certain fibrous transformations, and believed that he had seen, in one case, changes taking place within the cartilage-cells. If articular cartihige be examined in the neighborhood of an ulcerated spot, a complete separation of tlie fibres, the existence of which in its lami- nated structure was demonstrated by Thin, by a special method of silver-staining, and its reversion to ordinary white fibrous tissue can be readily made out. Weber describes new vessels as extending not only over the surface of the ulceratiug cartilage, but afterward penetrating its substance. In long-standing ulceration of cartilage a well-marked pannous condition is usually found present, which has resulted from the development of new 108 PRINCIPLES OF SURGERY. blood-vessels from the vessels of the perichondrium, which grow in the direction of the inflammatory focus in the same manner as in keratitis. Defects of cartilage caused by inflammation, like defects resulting from a trauma, are only partially repaired on account of the low vegetative capacity of the cartilage-cells, and the product of tissue proliferation is transformed into connective tissue. PHAGOCYTOSIS. It has been known for a long time that absorbable aseptic tissues in the living body are capable of removal b}^ the action of certain cells. The absorption of aseptic catgut ligatures by leucocytes and embryonal cells, which accumulate around it and, Inter, inliltrate it, aflords a good illustration of this. Metschuikoff lias introduced the term phagocytosis to designate a process by which leucocytes and other cells remove dead material and destroy- or digest pathogenic micro-organisms. The cells which perform tliese functions he calls phagocytes. The leucocytes are called mikropliagi, and the fixed tissue-cells, which are capable of per- forming the same function, makrophagi. Pigment-granules, minute fragments of tissue, and microbes gain entrance into a cell, either by the projections wiiich are thrown out by amoeboid cells surrounding and inclosing them (intussusception), or, in the absence of amoeboid move- ments, by a special property of the cells, by which they take up into their protoplasm solid particles of various kinds. The cells which are known to possess phagocytic properties are the leucocytes, mucous cor- puscles, connective-tissue cells, endothelia of blood-vessels and 13'mphatic vessels, alveolar epithelium of the lungs, and the cells of the spleen, bone, marrow, and lymphatic glands. Metschnikoff studied first phago- cytosis in the tail of the tadpole, and found that the separation of this organ at the time this animal is developed into a frog is accomplished b}'' leucocytes. At a time when the hind legs begin to bud the leucocytes migrate into the tail, and at the point where separation is to take place they attack the tissues, minute fragments of which may be seen in the interior of their protoplasm. In the daphnia, the common water-flea, he studied the destruction of a fungus with which these insects .'ire prone to be infected, — by the mikropliagi. When phagocytosis proved suceess- fnl he witnessed the destruction of the fungus in the interior of leuco- cytes ; on the other hand, when the fungi were present in such large numbers that the leucocytes were unable to destroy or digest them, the daphnia died. Next, he investigated phagocytosis in a number of diseases, — erysipelas, anthrax, relapsing fever, and tuberculosis. In erysipelas the cocci are first attacked by the leucocj^tes filling the lymph- spaces, and, later, by the fixed connective-tissue cells. In the path of PHAGOCYTOSIS. 109 destruction he saw leucocj'tes loaded with cocci, the latter showing various stages of dissolution. The connective-tissue cells were also engaged in the removal of disintegrated leucocytes. In fatal cases of erj'sipelas the streptococci multiplied with such great rapidity that the phagocytes were unable to cope successfully with the disease. Ribbert experimented with the spores of aspergillus and mucor, and the results were such that he claimed that spores in the interior of leucocytes, the connective tissue of the liver, and the giant cells which develop in the liver and in the lungs are destroyed, but that their destruction is not owing so much to phagocytic action of the cells as to the exclusion from them of nourishment for the spores, particularly of ox3gen. Laer injected into the lungs through the trachea cultures of the staphylo- coccus in rabbits, with the result of causing a catarrhal inflammation. The cocci were removed by leucocj'tes and the embryonal epithelia of the alveoli. During the first week these cells contained many cocci, but during the second week they disappeared in the cells, and the animals recovered. Metschnikoff's doctrine of phagoc3tosis has met with violent oppo- sition by a number of eminent pathologists, and foremost among them we find Banmgarten. In a number of publications, this author has taken a positive and firm stand against the claim that cells have the power to digest or destroy the microbes which inhabit their protoplasm. Holmfeld, Bitter, Prudden, and Nuttal have also arra3'ed themselves against Metschnikoff. With some modifications Klebs is a believer in phagocj^tosis. In a ver^' interesting paper on this subject, Osier gives the result of his own observations on the phagoc3'tic action of the cells lining the bronchial tubes and the alveoli of the lungs. He shows very conclusively how minute foreign particles are eliminated b3' means of the phagocytic action of the cells. In connection with the subject of inflammation, the doctrine of phagocytosis should be employed in a wider sense than was assigned to it by Metschnikoff". In the first place, the accumulation of leucocytes at the seat of inflammation must be consid- ered in the light of a mechanical barrier, an attempt to protect the tis- sues against infection. Unfortunatel3% in acute inflammation, this wall is usually more apparent than real, as the microbes become difl'used through tlie plasma-stream, and are transported by the leucocytes them- selves ; hence the progressive nature of the process. The connective- tissue proliferation proves more successful than emigration in limiting the dissemination of micro-organisms in the tissues, as the new cells, as long as the3- remain attached to the matrix which produces them, remain stationar3-, and mechanically block the avenues through which dissem- ination takes place. It is the impermeable wall of granulation tissue 110 PRINCIPLES OF SURGERY. which surrounds a suppurating depot, Avhich finally limits suppurative inflammation. In the next place, the phagocytes are scavengers which remove foreign dead particles from the tissues. Langhans was tlie lirst to show that extravasated blood did not simply disintegrate and disap- pear, but that the connective-tissue elements were actively at work, and that many of the colored corpuscles disappear in their interior. Rosen- berger implanted stained aseptic tissue into the abdominal cavity of animals, and, on examining the parts a few weeks later, found that not only had the tissues been completely removed by leucocytes, but he was able to follow the course of the leucocytes, after the}^ had left the feeding-gi'ound, by colored lines, all of which were seen to radiate from the place where the stained tissue had been fixed. In different pathological conditions where tissue proliferation was in process, Klebs could find positive evidence that wandering cells wliich had undergone fragmentation had been appropriated by the embryonal cells as food, as fragments of the nuclear chromatin of the leucocytes could be discov- ered in the protoplasm of the new cells. In the reparative process which follows the subsidence of inflammation, a great deal of cellular debris is to be removed, and this work is performed by the phagocj'^tes, notably by tiie fixed tissue-cells in a state of proliferation. The vege- tative capacity of the cells is augmented by the reception into their protoplasm of nutritive material furnished them by cells which have succumbed in the struggle. MetschnikolT believed that the destruction of micro-organisms in the interior of phagocytes was an active process, and that the protoplasm had a sort of a digestive action upon them. To prove the correctness of this supposition, he made some experiments with the bacillus of tuberculosis. He injected a pure culture of the bacilli into the subcutaneous tissue of white rats, and, later, produced artificially suppuration at the seat of injection. Two months later he found bacilli in the pus-corpuscles in an unchanged condition, and with- out having lost their power of reproduction. As in other experiments he had witnessed the destruction and disappearance of the same bacillus in living cells, he concluded that phagocytosis is an active process which can only take place in a living cell, and is suspended with the death of the cell. There are few at this time who regard the destruction and dis- appearance of microbes in phagocytes as an act of digestion. If, how- ever, microbes in the interior of phagocytes are rendered harmless, or disintegrate and disappear, this fact is an important one, and it is im- material in what way this result is obtained, whether the microbes are digested bj'^ the protoplasm, or whether some chemical substance in the cell-body exerts an inhibitory effect upon them, or, finally, whether for want of a proper nutrient material they are starved, as it were. The CHRONIC INFLAMMATION. Ill results of experimental research have furnished positive evidence that infective processes terminate most favorably where the conditions described as phagocytosis are accomplished most satisfactorily. When the struggle between a microbe and a phagocyte turns out in favor of the latter, the microbe does not multiply in the protoplasm, or ceases to do so before the protoplasm is destroyed, and, as the microbe cannot leave without dissolution of the cell, it remains within its narrow confinement and is destro^'ed, either by some as yet unknown chemical substance or dies from starvation ; in either event the vitality of the cell is not impaired, and the microbe disintegrates and disappears. (Fig. 42, A.) If the conditions for the growth and development of the microbe in the protoplasm of the cell are more favorable, intra-cellular multiplication of the microbe takes place, the ptomaines which are Fig. 42.— Phagocytosis. Struggle between Anthrax Bacillus and Leucocyte, A, successful phagocytosis ; B, unsuccessful phagocytosis. eliminated produce coagulation necrosis in the protoi)lasm, the cell disintegrates, and the intra-cellular culture is liberated in an active con- dition (Fig. 42, B). In cases of unsuccessful warfare of the phagocytes against invading micro-organisms, the mechanical obstruction composed of emigration corpuscles and embrj^onal cells is broken down, and the rapid increase of micro-organisms at the seat of inflammation gives rise to extensiA'e local and often general infection. From a practical stand- point it can be said that all therapeutic measures which influence favor- ably the process of phagocytosis, in the broadest meaning of this word, are calculated to exert a potent influence in arresting or limiting infective processes. CHRONIC INFLAMMATION. Chronic inflammation differs from the acute form onl^' in degree. The vascular changes which have been described come on slowlj^, and 112 PRINCIPLES OF SURGERY. are never as mai*ked as in acute inflammation, and on this account the emigration of blood-corpuscles occurs slowly, and in some instances it is entirely wanting. The inflammatory product is largely, and in some cases exclusivel}', composed of embryonal cells derived from fixed tissue-cells. The noxae which excite chronic inflammation are such that exert their deleterious effect more on the tissue-cells directly than the capillary vessels. Their primary action on the tissues consists in increasing the vegetative capacity of the cells ; hence, niatun; cells are transformed into embr3'onal or granulation tissue and remain in this condition as long as the noxae exist, and retain their pathogenic qualities or otherwise until the new ceWs undergo retrograde inetsunorphosis. If in a chronic inflammation degeneration of the embryonal cells has not taken place, and the primary cause has ceased to act, the new tissue is either removed by absorption or is converted into mature tissue, in Avhich event the inflammation has resulted in hyperplasia. S^'philitic gummata, which are composed almost exclusively of embryonal tissue, disappear promptly under a vigorous antisyphilitic treatment, because by such treatment the micro-organisms which have caused the lesion are either destroyed or at least have been deprived for the time being of their pathogenic properties. Chronic inflammation is represented by that large class of affections which are included under the name gy-anulomala. These swellings, irre- spective of their primary microbic cause, are composed of what is known as granulation tissue. Some pathologists have been inclined to classify them with tumors, because their development is seldom attended by well-marked symptoms of inflammation, and in their methods of regional and general dissemination they bear a close resemblance to the malignant tumors. Their obstinacy to successful treatment does not depend upon any malignant qualities of the tissues of which they are composed, but upon the difficulty of eliminating or rendering inert the primary cause by internal medication or operative procedures. All granulomata are inflammatory in their origin, and under the microscope present all the characteristic appearances of inflammation. Histologicall}' the}' are composed of embrN'onal cells which correspond to the type of the tissues in which or from which they have developed. In a tubercular nodule we find giant cells, epithelioid cells, the ordinary granulation cell, and leucocytes. Actinomycotic swellings are comi)osed almost exclusively of embryonal connective tissue. Many of the granulo- mata contain Ehrlich's plasma-cells (Mastzellen), of unknown origin, composed of a finely-granular mass arovmd a vesicular nucleus. On staining with aniline colors, the nucleus remains unchanged, while the granules are deeply stained. The cells are about the size of a leucocyte, CHRONIC INFLAMMATION. 113 either spherical or somewhat elongated in shape. In some cases the outer portion of the inflammatory product, being sufficient!}^ remote from the infected area, is converted into a firm connective-tissue capsule, which limits tlie extension of infection, while in its interior, from the presence of the specific micro-organisms, but probabh' more on account of inadequate blood-supply the tissues undergo rapid retrograde degenerative changes. Secondary- infection in a granuloma, either through the circulation, or, what is more common, from without, through some minute infection- atrium, is a not uncommon occurrence. Secondary- infection almost alwa3's means localization of pus-microbes in the granulation tissue and a breaking down of the latter into pus-corpuscles. The serious conse- quences which follow suppurative inflammation of a gumma developing after incision made upon a wrong diagnosis is well known. Infection of a large tubercular depot with pus-microbes after incision without proper antiseptic precautions, or after spontaneous evacuation, is followed by destruction of the remaining gramilations, profuse suppuration, and not infrequently by death from sepsis. Actinomvcosis gives rise to a large granuloma without any tendency to suppuration until infection takes place with pus-microbes, when the granulations melt awa}' rapidly, leaving a deep ulcer with ragged, undermined margins, and a speedy extension of the combined infective processes following in its course the connective tissue. The secondary infection, however, may prove beneficial and become the means of complete elimination of the products and micro-organisms of the primary infection. In this way a localized tubercular lesion is sometimes cured spontaneously by suppuration. A suppurative inflam- mation of a tuberculous gland of the neck is often followed bj^ complete removal of the bacilli-containing tissues and a permanent cure. All chronic inflammatory processes are attended by recurring attacks of acute exacerbations. If during these attacks in the periphery of the chronically-inflamed area a more active cell proliferation is initiated, the conditions for a more successful phagocytosis are improved and the acute attack has proved a curative measure. The surgeon often resorts to measures which result in the transfor- mation of chronic into an acute inflammation, in imitation of nature's efl^orts in the same direction. In illustration of this, I will only mention ignipuneture. The fenestration of a chronic inflammator}- swelling under strict antiseptic precautions has proved a valuable therapeutic measure by securing drainage, but more especial!}' because around each tubular eschar made with the needle-point of a Paquelin cautery a zone of active tissue proliferation is created, and the new tissue, by under- Ill: J'KINCII'LKS OF SURGKKV. going transfonnation into cicatricial tissue, serves a usel'iil purpose in starving out microbes that have escaped the cautery. Anotlier instruc- tive instance of the benefits which accrue from the substitution of an acute for a clironic inflammation is found in tlie use of jequirity in oplithalmic practice. The powdered bean or some otlier preparation of tliis drug, when brought in contact witli the conjunctiva, produces a violent inflammation which has frequently proved a curative measure in the treatment of trachoma ami some forms of pannus of tlie cornea. One of the ways in whicli an acute inflammation acts beneficially in promoting the process of resolution in tissues tlie seat of a chronic inflammation is bj^ its stimulating action on the capillary vessels. The active h^'per^emia ma^- become the means of clearing partially-obstructed capillary vessels of implanted colorless corpuscles, and thus remove from the weakened tissues not only the mechanical causes which have main- tained the chronic congestion, but also the intra-vascular cause of the inflammation — the microbes. When the infected corpuscles reach the general circulation there is a chance for more effective phagoc_ytosis and elimination of the microbes through one or more of the excretory organs. SYMPTOMS AND DIAGNOSIS OF INFLAMMATION. For practical purposes, inflammation may be divided into acute, subacute, and chronic, according to the intensity of symptoms and the time required to reach one of its terminations. The nature of the pri- mary cause determines the course and nature of the inflammation. The microbes of suppuration, erysipelas, anthrax, glanders, tetanus, and gonorrhoea cause acute affections, while the micro-organisms of tubercu- losis, lepra, and actinomycosis cause lesions which are noted for their chronicity. Acute inflammation may become subacute and finally chronic, as in suppurative osteomyelitis, where, if the disease is multiple, in the first bone affected it pursues a very acute course ; while often in the successive bones attacked it is less intense, and not infrequently in the last bone involved it appears as a chronic affection. A chronic in- flammation may be followed by a subacute or acute attack, as is fre- quently observed in tubercidosis complicated by secondary infection with pus-microl)es. • In acute inflammation the local and general symp- toms are so well marked that no difficulties are in the way of recogniz- ing its existence, and it only remains to decide upon its cliarncter. The fever which attends the inflammation is only a symptom, and indicates the introduction into the general circulation of phlogistic substances from the products of exudation or the fixed tissue-cells which have undergone pathological changes. Microbes that cause acute inflamma- tion differ greatly as to the amount or intensity of action of the phlo- SYMPTOMS AND DIAGNOSIS OF INFLAMMATION. 115 gistic substances which they produce in the iuliamed tissues affected ; also exert an important influence in modifying the febrile disturbance. Suppuration caused by the micrococcus pyogenes tenuis is not attended by so high a temperature as when produced by tlie staphylococcus or streptococcus. The rise in temperature which accompanies inflammation is due either to the introduction into the circulation of fibrin ferment resulting from the destruction of leucocytes or the production of pto- maines b^' the specific action of microbes on the tissues, which act as phlogistic substances when introduced into the general circulation, — a fact which has been abundantly demonstrated by clinical observation and experimental research. As soon as the causes which have produced the rise in temperature in inflammation have been rendered inert by phago- cytosis, or have been eliminated with the removal of the inflammatorj- product, the fever subsides. The general disturbances, such as headache, vomiting, loss of appetite, thirst, and the ever-present feeling of lassitude which attends acute inflammation of all kinds, are caused b}^ the fever and the presence of toxic substances in the blood. The s^-mptoms of inflammation, which have been described at length, must be studied sep- arately and conjointl}' in each form of inflammation, and their individual and mutual significance carefully estimated. A local rise in temperature is of more diagnostic value in ascertaining the existence of inflammation than fever, as the latter can be caused by the absorption of fibrin ferment from any causes which destro}^ the colorless blood-corpuscles and the absorption of the products of tissue disintegration in malignant tumors ; while a permanent increase of the temperature at the seat of the disease denotes almost infallibly the existence of inflammation. In reference to the extension of the inflammatory process, it can be said that this will be influenced b}- the anatomical structure of the part involved and the manner of diffusion of the microbe which causes the inflammation. If a mucous or serous surface is affected, infection is prone to spread rapidl}^ b}' continuit}^ of tissue and the mechanical dissemination of the microbes on the siirface in the mucous secretion, and b}' the movements of one serous surface upon the other. In er3'sipelas the inflammation spreads rapidly, as the microbe is diffused through the Ij-mphatics and connective- tissue spaces. In phlegmonous inflammation the pus-microbes find no mechanical barriers, and are rapidly distributed OA'er a larger area through the connectiA'e-tissue spaces. The same manner of diffusion is observed in anthrax if the bacillus finds ingress into a part supplied with an abundance of loose cellular tissue, while the disease remains circumscribed and presents itself in an indurated form if it is located in tissues which do not present such favorable anatomical conditions for extension of the local invasion. The nature of the inflammatory product 116 PRINCIPLES OF SURGERY. ahviiys answers to the specific action of the microbe as the tissues which caused the inflammation. Thus, an inflammation caused by pus- microbes will result in the formation of pus ; while the microbes which produce chronic inlhunmation, as a rule, onl}^ convert the pre-existing mature into embryonal tissue. The microbes which have a short exist- ence in the tissues may give rise only to intense hyperremia and a mod- erate emigration of the colored blood-corpuscles, as, for instance, the streptococcus of erysipelas. The genuine, uncomplicated erysipelatous inflammation is of such short duration that perfect restoration of the parts is accomplished in a few daj's. PROGNOSIS. The most favorable termination of inflammation is resolution, with restitutio ad integrum of structure and function of the tissues which were the seat of the inflammatory process. Resolution is only possible if the emigration of blood-corpuscles is moderate in quantity and none of the cellular elements of the exudate are transformed into pus-corpuscles. If exudation take place rapidlj', the connective-tissue spaces are com- pletely blocked with the emigration corpuscles and the products of coagulation necrosis, which seriously impairs or completely arrests plasma circulation, and, by pressure upon the l)lood-vessels, may interfere with the capillary circulation to such an extent as to cause necrosis. Resolution, as has been previousl}' stated, signifies that, after subsidence of the symptoms of inflammation, the part is left in a condition capable of removing the inflammatory product and of repairing the damage done. Many of the leucocytes which have retained their vitalit}'' immigrate back into the general circulation either through the walls of capillaries or, what is more frequent, through the lymphatic S3^stem. The remain- ing leucocytes and colored corpuscles undergo degeneration and are removed by absorption. Fibrin which has formed in the tissues is trans- formed into a granular mass, and is removed in a similar manner. Embr^'onal cells which have become detached, or have been damaged by the inflammation, are also removed b}^ absorption after they have under- gone granular degeneration. The transudation is removed by absorp- tion as soon as capillary circulation is restored and the connective-tissue spaces have been cleared of their cellular contents. The capillar^'- wall is repaired, and an^^ tissue defects are restored b}^ proliferation of the fixed tissue-cells. The inflammator}' ex\idate ma}- prove a source of danger when, by its mechanical pressure, it interferes with the function of important organs, as the brain, heart, or lungs. A moderate transu- dation within the skull from inflammation of any of the meninges can produce death from compression of the brain; a pericardial effusion, TREATMENT. 117 when sufficient in amount to interfere mecliauica,!!}^ with the action of the lieart, causes death by syncope ; and a copious effusion into the pleural cavity, especialh' if it come on rapidly, may impair respiration to such an extent as to result in death from apnoea. A slight croupous exudation upon the vocal cords or oedema about the entrance to the larynx destroys life bj- preventing, in a purely mechanical way, the en- trance into the lungs of an adequate quantit}' of air. Inflammation is greatly modified by the age and general condition of the patient. Infants and persons advanced in yeiivs possess little power of resistance, and, when attacked b^^ inflammation, the disease is prone to become diffuse and lead to serious pathological changes. The same can be said of persons who have been debilitated by antecedent diseases or intemperate habits. The greatest danger in the different forms of inflammation, as far as life is concerned, consists in the introduction into the general cir- culation of septic material produced in the inflamed part b}' the action of microbes on the tissues. This general infection, occurring in the course of a localized inflammation, appears eitlier as a sj-mptomatic fever, which disappears with the subsidence of the local process, or as a pro- gressive septicEemia, pygemia, or septico-pysemia. The latter diseases will be considered in separate chapters. Tubercular affections are ahvaj'S attended by the danger incidejit to extension of the process to other organs b}* dissemination of bacilli through the lymphatic channels or blood-vessels. Chronic suppuration finally causes am3loid degeneration of important organs, and death ensues from this cause. In summing up what has been said nnder this head, it is evident that the prognosis rests mainly upon the intrinsic pathogenic qualities of the microbe which has caused the inflammation; the anatomical structure, location, and physio- logical importance of the part or oi'gan inflamed ; the general condition of the patient, and the accessibility to and feasibility of treating the disease by direct radical surgical means. TREATMENT. As inflammation per se is no disease, but an effort on the part of the organism and the tissues affected to eliminate or render harmless the primary cause, the treatment must be, in each individual case, purely S3'mptomatic. A proper appreciation of the nature and tendencies of inflammation is an essential prerequisite to rational treatment. In surgery- the prophylactic treatment of inflammation is the most important and satisfactory. The prevention of inflammation in accidental and oper- ation wounds by strict antiseptic precautions has made modern surgerj' what it is. The surgeon has it now in his power, b}' resorting to anti- septic measures, to prevent the innumerable and formerly too often fatal 118 PRINCIPLES OF SURGERY. wound complications. Lister has inaugurated a new era in surgery, and his work, as w^ell as that of his early enthusiastic followers, has been the means of saving annually thousands of lives. The mortality of even the most desperate operations where the antiseptic treatment can be followed to perfection has been so much reduced that operative surgery has received a new impetus, and operations are devised and put in prac- tice almost daily which formerl}' would have been looked upon as a freak of imagination or the outcome of a diseased brain. The prophy- lactic treatment of inflammation in dealing with wounds, or other avenues through Avhich infection can take place, consists of securing for the place deprived of the effective protection against the entrance of patho- genic micro-orgnnisms — the intact skin or mucous meml)rane — an aseptic condition by antiseptic measures, and to bring in contact with it only things that have been thoroughly sterilized. In inflammation without an external tangible infection-atrium we must take it for granted that microbes have entered the circulation through slight defects, the existence of which, perhaps, the patient does not remember, and which have left no appreciable marks of their former existence, or infection has taken place through some of the appendages of the skin, or through a mucous membrane, with localization of the microbes in a part or organ previously prepared for their reception and growth ; that is, in a location presenting a locus minoris resistentiae. Recognizing the fact that inflammation, wherever it occurs, is pro- duced by the action upon the vessel-wall and the tissues outside of it of specific micro-organisms, it would appear that the most rational indica- tion for treatment would be to resort to such means wdiich would destroy the microbes in the tissues as soon as their presence is manifested by their action. This would imply the saturation of the inflamed tissues with ger- micidal solutions,which from laboratory experiments are known to be effec- tive in destro^'ing such microbes ; hence, it has been advised to resort to Parenchymatous Injections. — This method of treatment was strongly advised and extensivel}^ practiced b3" Heuter long before the direct relationship between certain microbes and definite forms of inflammation had been demonstrated. Heuter claimed that ever}" inflammation was caused by certain iioxae introduced from w'ithout, and which he aimed to destroy by saturating the inflamed tissues with an antiseptic solution. His favorite remed}'^ was a 3- to 5-per-cent, solution of carbolic acid. The instrument which he used was an ordinar}^ Pravaz syringe, with a long needle provided with a number of small lateral openings. In adults he injected as much as 10 grammes at a time of a 3-per-cent, solution. In using this method in the treatment of large, granulating, tubercular foci he emploj^ed Avhat he termed an infusor, composed of a graduated glass TREATMENT. 1 1 9 cylinder, joined with the needle by means of a rubber tube. By this method of injection the fluid diffused itself through the soft, granular mass by its own weight. In the treatment of tubercuhir lesions Heuter claimed for the parenchymatous injections of carbolic acid great curative powers. Rational as this method of treatment appears, it has not yielded the results tliat were anticipated. The living tissues cannot be compared with a test-tube. IS^itrate of silver, iodine, permanganate of potassa, corrosive sublimate, and other potent germicidal agents have been used since, but tlie results, oi) the whole, have been anything but satisfactory. If this method of treatment is to be successful in the treatment of acute inflammation, it n)ust be instituted at an early stage, at a time when only a limited area of tissue has been infected, as, under such circumstances, if the area of infection could be accurately outlined, it would be possible to saturate the tissues with an antiseptic solution without running the risk of killing the patient Iw administering a toxic dose of the drug employed, which might be the case if a larger area were treated in a similar manner. If we remember that the microbes are diffused through- out the entire exudation, and constitute the most important element of the inflammatory product, it is easy to understand that sterilization of the inflamed tissues by means of parench3'matous injections is not an easy task, and we are then in a position to realize why this method of treatment has not proved more uniforml}' successful. Most of the germi- cidal agents heretofore eniplo3'ed in this manner, when brought in contact with the tissues, form compounds which prevent further diffusion, and therefore each needle-puncture sterilizes only a very small portion of the inflamed district. It is possible that in the future non-toxic, but at the same time effective germicidal, substances will be discovered which can be used in larger quantities, and in this event the treatment of inflamma- tion by parenchymatous injections will have a wide range of application, and will be practiced with better success. At present this method has a limited field of application in the treatment of the various forms of in- flammation. Under no circumstances should the amount of the drug iTsed exceed the dose which it would be safe to administer internally, and the danger of a poisonous dose should be remembered in repeating the injection. An ordinary hypodermic syringe with a long needle can be used in making the injection. That the needle and sj^'inge should be perfectly aseptic is to be understood as a matter of course, as unclean instruments have often been the means of conveying a fatal disease. Multiple punctures are to be preferred, as in this manner, 1)3' using the same amount of fluid, more tissue can be saturated than bv a single puncture. Before making the punctures the surface must be disinfected. The object should be to bring the antiseptic solution in contact with as 120 PHINCirLES OF SURGERY. much of the injected tissues as possible, and if the disease show a ten- dency to spread it is advisable to go beyond the zone of infection, as, for instance, in cases of erysipelas and anthrax. Many accessible tuber- cular aftections are greatl}^ benefited ])y parenchymatous injections of carbolic acid. Kecently, intra-articulur and parenehynuitous injections of iodoform have been strongly recommended in the treatment of articu- lar and other forms of surgical tuberculosis. Antiphlogistic Treatment. — ^An erroneous conception of the nature and tendencies (jf intlammation has for centuries induced the ablest teachers and practitioners to advocate and practice what they termed the antiphlogistic treatment of inflammation. This included blood-letting, cupping, leeching, and the internal use of emetics and cathartics. It was urged that as iuttainnuition was attended by an increase of heat, swelling, and redness, such remedies should be employed as will reduce arterial tension. Venesection is now seldom, if ever, resorted to in the treat- ment of anj'^ form of inflammation. An unimpaired ins a tergo is one of the best means to prevent stasis within the inflamed capillaries, and practical experience has shown that all remedies and agents which diminish the intra-arterial tension only diminish the prospects for a favorable termination of the inflammation. Cohnheim showed experi- mentally that the threatened stasis in the exposed mesentery of the frog was avoided by injecting into one of the veins 1 centimetre of a 6-per- cent, solution of sodic chloride. If, under similar conditions, a consider- able quantity of blood is abstracted, the congestion can be seen to terminate in a short time in complete stasis. While venesection in the treatment of inflammation has been discarded, the direct abstraction of blood from the inflamed part liss proved a useful therapeutic resource. Genzmer showed that in the inflamed mucous membrane of a frog scari- fication hastened resolution. In order to be of benefit the scarification must be made through the inflamed part, so as to unload directly the dilated and engorged capillary vessels, and on this account this method of treatment is only applicable when the inflammation is superficial and affects accessible parts. Leeches should never be used, as infection from this source has frequently resulted disastrously. The scarification used for cupping is difficult to keep aseptic, and tlie number and deptli of the scarifications to be made are not under the control of the surgeon, and for these reasons this instrument has only an historical interest and antiquarian value. The scarification should be made with a sharp scalpel, and the bleeding encouraged by applying warm water. Scarification is followed by great relief in inflammation of accessible mucous membranes, and has recentlv been very strongl}' recommended in the treatment of erysipelas for the purpose of preventing the extension of this disease. TREATMENT. 121 In the different forms of septic inflammation attended by severe general S3'mptoms the gastro-intestinal canal often participates in the process, and vomiting and diarrhoea become conspicuous and often dis- tressing symptoms. These symptoms should not be checked, as they indicate an attempt on tlie part of the organism to eliminate through the gastro-intestinal mucous membrane microbes and ptomaines which have reached it through tlie general circulation. The sui-geon should assist this effort by administering a few doses of calomel, followed b}' a saline cathartic, whicli will often control the vomiting and diarrhoea more promptl}' by removing the cause than medicines employed to arrest the process of elimination. Physiological Rest. — One of the most urgent indications in the treat- ment of inflamuuititm is to secure for the part afi'ected a condition approacliing physiological rest. In ulcerative affections of the gastro- intestinal canal the patient should abstain from taking food b}' the stomach. Fixation of the chest by means of broad strips of adhesive plaster affords great, relief in pleuritis. An inflamed point must be im- mobilized b}' some kind of a splint. A chronic c^^stitis usually j-ields to supra-pubic or perineal drainage of the bladder after all other measures have failed. In inflammatory- affections of the eye exclusion of light is one of tlie most essential features of successful treatment. Patients suffering from inflammatory affections of tlie tonsils, pharynx, and larynx should use their voice as little as possible. In cases of acute inflammation of the brain or its envelopes the patients must be kept in a dark room, and absolute quietude enforced. Elevation of Inflamed Part. — From the diminished vis a tergo on the distal side of the capillaiy vessels, venous engorgement is as pronounced as increased arterial tension on the proximal side of the inflamed capillary vessels, and elevation of the inflamed part improves the vascular dis- turbances b^' the force of gravitation favoring the return of \tiious blood. The importance of elevation of the inflamed part becomes manifest in the treatment of inflammatory^ affections of the extremities. In phlegmonous inflammation of the hands or feet the throbbing pain is always aggravated if the limb is kept in a dependent position, and promptly relieved npon placing it in an elevated position. Elevation not onl}' alleviates the pain, but is at the same time the most effective means of removing tlie oedematous swelling. If necessary elevation can be combined with suspension in order to secure more jjerfect rest for the inflamed part. In severe acute inflammation it is not only necessary to secure rest for the part inflamed, but of the whole body, and in such cases the patient must observe the recumbent position in bed, as all muscular movements and all unnecessarj- strain upon the blood-vessels 122 PRINCIPLK8 OF SURGERY. cannot but l)e j)roductivo of harm by favoring the ingress into the circu- lation of micro-organisms and tlieir ptomaines from the seat of inflam- mation, or, i)erliaps, result in embolism from detachment of a portion of a tlirombus, — an accident which possibly might not have occurred otherwise. Application of Cold. — Cold has been resorted to indiscriminately and empirically in tiie treatment of inflammation. Cold is a potent agent for good or harm, according to the stage of inflammation during which it is applied. The sensation of heat, both sul)jective and objective, naturally suggested the use of this remedy. The application of cold is of great benefit during the earliest stage of inflammation, at a time when exuda- tion is only beginning and the capillary vessels are dilated and only partially obstructed. Cold, when applied under these circumstances, becomes a valuable remedial agent (1) by producing contraction of the small blood-vessels ; (2) by producing at least an inhibitory eftect upon the micro-organisms in the inflamed tissues. The contraction of blood- vessels which takes place under the application of cold has a tendency to clear the capillaries of their contents and to prevent further mural implantation. Micro-organisms can only multiply at a certain tempera- ture, and if this can be kept at a point low enough to prevent their in- crease in the tissues by the application of cold this agent fulfills one of the causal indications in tlie treatment of inflammation. If, however, stasis has already taken place in the capillaries first affected the applica- tion of cold will prove harmful, as it will tend to prevent the formation of an adequate collateral circulation. Cold acts most beneficially when the inflammation is located in the superficial parts, but its prolonged use will reach even deep-seated structures, as the pleura, peritoneum, the brain and its envelopes, the joints and bones. When it appears desirable to resort to the use of cold, this remedy should be applied in the form of an ice-bag. The part to which the ice-bag is to be applied can be covered with several la3^ers of a wet towel, as otherwise the prolonged use of the direct application of ice may freeze the skin. The sensations of the patient can actually be taken as a safe guide as to the length of time it should be continued. Antiseptic Fomentations. — The ordinary filthy poultice of flaxseed, slippery elm, bread and milk, has no longer a place among the resources of the aseptic surgeon. The common poultice is a hot-bed for bacteria, and, as such, it should be discarded. In the treatment of an ordinary- furuncle with poultices, I am sure that almost every surgeon must have seen occasionally the development of innumerable minute daughter- furuncles in the surface coA^ered by the poultice. In phlegmonous in- flammation of the fingers or hand the prolonged use of the poultice is TREATMENT. 123 followed by maceration of the skin, extensive oedema of the superficial structures, a flabby condition of the granulation, — in fact, all the evidences which point to the poultice as a means of favoring the extension of the infective process. When inflammation has passed beyond the stage where cold exercises a favorable influence, or where cold applications in- crease the suffering, warm aaitiseptic fomentations should be empIo3'ed. The surface to which the}' are to be applied should be thoroughly cleansed with warm water and potash soap. The antiseptic solution to be used should be selected according to the age of the patient, or the area attected, with a special view of guarding against the absorption of a toxic dose of the drug employed. Acetate of aluminum, in the strength of 1 per cent, dissolved in sterilized water, is a safe preparation under all circumstances. Boracic and salicylic acid are efficient and safe preparations. Greater care is necessary in the use of carbolic acid and corrosive sublimate, as, when concentrated solutions of these drugs are used for any length of time in infants, the aged, or persons suffering from organic disease of the kidneys, there is danger of poisoning from absorption through the intact skin. In children and marantic persons it is safer to use acetate of aluminum, salicylic or boracic acid, and re- serve the more potent antiseptics for adults suffering from circumscribed inflammatory lesions. Hot fomentations act as derivatives and favor the formation of collateral circulation ; at the same time they relieve pain. A number of layers of hygroscopic gauze or flannel cloth are wrung out of one of these antiseptic solutions and applied over the affected part, and for the purpose of retaining the heat and of preventing evaporation of the solution the compress is to be covered either with gutta-percha, rubber sheeting, or macintosh cloth, and the dressing is retained b}- an appropriate bandage. The compress is removed two or three times a da}', again wrung out of the hot solution, and re-applied as before. Absorption through the skin of the antiseptic substance used ma}^ have a direct influence in diminishing the intensit^y of the cause which pro- duced the inflammation, and prepares, in an admirable manner, the field for any operation which ma}^ become necessary in the future. Antipyretics. — If the rise in temperature which attends many of the acute inflammatory affections is due to the introduction into the circu- lation of phlogistic substances which are produced by the action of the micro-organisms in the inflamed tissues, it is not difficult to conceive that its artificial reduction by the internal use of chemical substances is not followed by any permanent benefit. The rational treatment of the fever consists of such local measures as will remove its cause. Antifebrin, antip3'rin, salicylated soda, quinine, and other antipyretic drugs, when employed in large doses, will usually reduce the temperature several 124 PRINCirLES OF SURGERY. degrees for a lew hours, l)ut this is always accomplished at the expense of the forces which are laboring to clear obstructed paths, and on this account their use has resulted in more harm than good to the patient. Quinine is the least objectionable of the drugs which have been men- tioned, and in the beginning of an inflammation, by its known tonic effect on the small blood-vessels, when administered in a large dose, has a favorable effect in preventing rapid dilatation of and stasis within the ca[)illary vessels. If used at all, it should be given in a decided dose, — 1 gramme, in solution, — immediately or soon after tlie development of the first symptoms. Sponging the surface of the body with warm water or the use of warm baths are the most rational antipyretics, as these simple measures do not weaken the heart's action, while they have a decided effect on the temperature, and at the same time add to the comfort of the patient and favor the elimination of microbes through the excretory organs of the skin. As the kidneys are known to eliminate micro- organisms that reach them through the general circulation, their func- tion should be carefully inquired into, and if the secretion of the urine is scanty, diuretics, like liq. amnion, acet., or acetate of potash should be given. Stimulants. — Just as soon as symptoms of sepsis develop in the course of an inflammation, alcoholic stimulants should be freely admin- istered to meet in time the dangers incident to heart-failure. Stimulants have largely taken the place of antiphlogistics at the present time in the treatment of septic inflammations. Brandy, cognac, or whisky, not in measured doses, but given in quantities large enough to produce the de- sired effect on the heart, are given at intervals of one or two hours. Cham- pagne is a more diffusible stimulant, and is to be resorted to when the stomach does not tolerate other alcoholics. In chronic cases, Tokayer or Greek sherry are to be preferred. In wasting diseases, a good qualit}' of beer, ale, or porter will do excellent service. In cases where, from any cause, the heart's action is suddenly diminished, camphor or musk can be administered subcutaneously to bridge over the time for the employment of more substantial stimulants. Diet. — The treatment of inflammation by starvation has been abol- ished long ago. The strength of the patient must be sustained in time by a nutritious, well-selected diet. Animal broths, beef-tea, and milk should be freel}^ given from the very beginning, and if more substantial food can be digested it should not be withheld. Oysters, eggs, fine- scraped raw meat, or rare roast are excellent articles of food for patients whose strength is l)eing undermined by debilitating, suppurative affec- tions. If the stomach does not retain food, the patient should be nour- ished by rectal enemata of peptonized milk and beef-tea in quantities TREATMENT. 125 not exceeding 4 ounces, given alternatel}^, every eight hours. Ripe oranges and grapes are most alwaj-s grateful to the patient, and theii' use should never be prohibited, unless the gastro-intestinal canal is the seat of inflammation. Tonics and Alteratives. — In protracted inflammatorj' affections ton'c doses of quinine are indicated. Tincture of chloride of iron is an excel- lent • remedj^ after the acute febrile sj^'mptoms have subsided. Under similar circumstances, one or more of the bitter tonics can be given with benefit if the appetite is defective. If there is any history of specific disease, a thorough antisjphilitic treatment will often produce a marked effect for the better on the inflammatorj- process. Catarrhal inflamma- tion in rheumatic patients is favorably influenced by antirheumatic rem- edies. Syphilitic lesions are to be treated b^- potassic iodide and small doses of corrosive sublimate. Tubercular affections call for arseniate of iron, sj-riip of iodide of iron, and, if the patient's stomach can tolerate it, pure codliver-oil. The latter drug should be given alone, and not in emulsion, in gradualh-incrcasing doses an hour and a half after each meal. Anodynes. — Remedies to relieve pain must alwa3'S be used with caution, as in painful chronic affections their prolonged use frequoitlv engender a habit. The cause of pain must be sought for, and, if possible, removed by local measures. In acute inflammation, pain indicates ten- sion in the inflamed part, and prompt relief is obtained b^^ subcutaneous incision. Periostitis and paronychia should be treated b}- this method. In superficial inflammations scarification answers the same purpose. If opiates are used, a decided dose is better than smaller doses frequently repeated. The anodyne effect of opium is increased by the addition of a minute dose of atropine. Chloral and potassic bromide are to be pre- ferred to opium to relieve the pain of intra-cranial lesions. Phenacetine in ^-gramme doses is a very excellent anodj'ue in cases of peripheral neuritis. Inhalations of chloroform to allay intense pain should never be resorted to except by the direction of find under the personal supervision of a competent phj'sician. Massage. — In chronic inflammator3' affections systematic massage, scientificall}' practiced, is an exceedinglj- important and valuable thera- peutic resource. It stinnilates the surrounding vessels to increased action, and exerts a potent influence in restoring the normal circulation in the affected capillar}- vessels, and alwa3S promotes absorption. The mnsseur should be instructed to apply some absorbent preparation before making the manipulations, as the endermic use of absorbent drugs in this manner will increase the efficacy of the treatment. A drachm of potassic iodide or half a drachm of iodoform to an ounce of lanolin will be an 126 PKJNCIl'J.KS OF SUKGKllV. excellent prepsiration for this purpose. Cold and hot douches, pussive and active motion, combined with massage, will often expedite a cure. Counter-Irritation. — Like so many other time-honored methods of treatment, counter-irritation in the treatment of acute inflammation has almost entirely gone out of use. In chronic inflammation, ])listering and painting with the tincture of iodine will at least satisfy tlie patient, if no good I'esult from them ; and if he does not recover, he is at least prevented from passing into the hands of charlatans until the time has arrived to resort to more effective and radical measures. Kocher praises the appli- cation of the actual cautery in the treatment of chronic tubercular osteo- myelitis and synovitis. The seton and moxa have fallen into well- merited disuse for all time to come. Ignipuncture. — In many chronic affections, where the inflammatory exudation remains stationar}^ for a long time, multiple punctures with the needle-point of a Paquelin cauter>', made under strict antiseptic pre- cautions, will have a prompt effect in diminishing the primary cause, as well as in promoting absorption. CHAPTER V. Pathogenic Bacteria. Bacteria, micro-organisms, microbes, and germs are synonymous terms for certain minute, microscopical, vegetable organisms wliicli, when introduced into the living body, produce the fever and the tissue changes described in the preceding chapter. For a time it was claimed that these minute organisms belonged to the animal kingdom, as some of them were seen to possess spontaneous movements ; but now it is gener- ally agreed that they are minute plants, and botanists have made great progress in perfecting a scientific classification. Among the men who have developed this part of botau}', the names of Cohn, Zopf, and Nageli stand pre-eminent. CLASSIFICATION. The pathogenic bacteria which will claim our attention belong to the class known as schizomycetes (Spaltpilze). In diameter they vary from 0.001 to 0.004 millimetre, and are composed largely of an albu- minoid substance called by Nencki mj^co-protein. Toward the periphery this substance becomes firmer, and forms a gelatinous envelope, a sort of a membrane, which is said to contain cellulose, and, in some instances, even fattj^ material. The outer surface of bacteria is frequentl}' cov- ered with a viscid substance, by which many of them are often held together in a mass or group, technically called zoogloea. Each bacterium represents a cell, although the presence of a nucleus, or something repre- senting such a structure, has not been demonstrated ; but its cellular structure is made evident b}' its intrinsic power of germination or repro- duction when surrounded by the necessary conditions for its growth. Some of the bacteria are })rovided with processes, or cilia, by which, when suspended in a fluid, movements are accomplished ; in others motion is entirely deiiendent on molecular movements described by BroAvn. Niigeli, and formerly Billroth, claimed that all bacteria had a common botanical source, and that the different forms and actions only represented alteration of form of action of the same plant at different stages of development and under different circumstances, — in other words, that a coccus could be transformed into a bacillus, and vice versa; and that in one instance the same plant caused fermentation, in another putrefaction, and that all infective diseases were caused by the same (127) 128 PRINCIPLES OP SURGERY. microbe. Buchner maintained tliat, b}^ cultivation in different nutrient media, he was able to transform the dangerous bacillus of anthrax into A l5 c r--\3 .»•» 3 ••....- •; . A ••m.»«»"*% '••••••••«»^ ••'53 ,M*»«>*'o /^ .y V.' h \ 1 I . j^f^^'^^^^^^^^^Xr Fig. 43.— Different Forms of Bacteria. (Baumgarten.) A, cocci ; B, bacilli ; C, spirilli. the harmless bacillus subtilis, and, again, the latter into the former. Cultivation and inoculation experiments on a large scale by most careful MULTIPLICATION OF BACTERIA. 129 observers have shown conclusively that such transformations never take place, and that each microbe not onl}' always retains its shape, but also its specific pathogenic properties. Pus- and other microbes have been cultivated through thirty and more generations without suffering any morphological deviations or losing any of their inherent characteristic pathogenic properties. The three principal forms of bacteria discovered up to the present time, and which have been demonstrated as causes of disease, are: (1) the ball (coccus); (2) rod (bacillus); (3) corkscrew (spirillum). As illustrations for these different forms, de Bary very appropriately^ takes the billiard-ball, lead-pencil, and corkscrew. The surgeon has to deal only with the two first forms, — the cocci and bacilli. Modifications of form are frequently met with, as an oblong coccus closeh' resembles a short bacillus, and a short, broad bacillus with rounded ends approaches the coccus form. Again, a double coccus, or diplococcus, with ill-defined constriction at the point of junction, might, from superficial examination, be mistaken for a bacillus (Fig. 43, A, 2). More than 2 cocci in a row, or a chain of cocci, are called a streptococcus (A, 3). Four cocci arranged in the foi'm of a square are called a micro- coccus tetragones (A, 4). Cocci arranged in the form of a bunch of grapes are called streptococci (A, 6). An iri'egular mass of cocci, when at rest and held together bj- a viscid substance, is described as a zooglcea. MULTIPLICATION OF BACTERIA. Bacteria multiply with great rapidit}' in tissues presenting favorable conditions for their growth, or in proper nutrient media kept at a tempera- ture approaching that of the body. Multiplication takes place either by fission or segmentation, b}^ the production of spores, or by both of these methods. The bacillus of anthrax multiplies by fission in the bod}', by spores outside of the bod}'. Fission. — The round or globular bacteria, — the cocci, — as far as we know, multiply only by fission. The cell elongates prior to segmenta- tion, when a constriction appears in the centre, which, b}' becoming deeper and deeper, finally results in complete division of the cell into two equal halves, which soon attain the size of the mother-cell, and, in turn, again undergo the same process. If the new cells remain adherent, and arrange themselves in the form of a chain, a streptococcus is formed. Flugge observed complete division of a coccus in bouillon, kept at a tem- perature of 35° C, in twenty minutes. If it should require one hour to complete segmentation and for the new cell to attain maturity, a single coccus multiplying by fission, according to Cohn, during one da}'^, would produce sixteen millions of cocci, and at the end of the second day the product would represent two hundred and eighty-one billions in number, 130 PRINCIPLES OF SURGERY. 0coqh, / 4r und at the end of three (htys the extraordinary number of forty-seven trillions would be reached. Rod bacteria which reproduce themselves by fission undergo transverse segmentation in the middle, and after com- plete separation each segment grows to the size of the parent-cell before the process repeats itSelf. Spores. — The spores of bacteria represent the seed of flowering plants. Kacli spore develops into a ])acterium, and thus one crop after another is produced, the multiplication increasing with the number of ))actcria in the soil. Most of the bacilli multiply by spoi-es. Fructifica- tion again takes place, either Avithin the ])rle, but a probable occurrence. Abnormality of the placental circulation must, therefore, be recognized as a condition which favors the occurrence of hereditary microbic disease. Both clinical observation and experimental research leave no room for doubt that in some infectious diseases, at least, heredity is traceable to direct transmission of the specific microbes, either by meayis of transportation by the spermatozoa to the ovum, or by their DIRECT TRANSMISSION OF PATHOGENIC BACTERIA. 155 entrance through the thin wall which separates the maternal from the fcetal circulation. It is no more difficult to explain the migration of microbes through such a thin septum tlian their transportation from one tissue to another, and from organ to organ in other parts of the body, more especiall}' as the anatomical conditions for mural implantation in the placental vessels are most favorable for such an occurrence. CHAPTER VI. Necrosis. , Necrosis, gangrene, mortification, and sphacelus are terms used S3'nonymously to indicate the deatli of a part. Englisli and American writers have usualh' restricted tlie meaning of the word necrosis to death of bone, while the remaining terms were used to express the same con- dition affecting the soft tissues. Recently a sharp distinction has been made between necrosis and gangrene from an etiological stand-point, according to which necrosis is said to have taken place when the circu- lation and nutritive changes in a part have completel}^ ceased to be followed by gangrene as soon as saprophj'tic bacteria invade it and give rise to putrefaction. Death of bone will never be described as gangrene, and the moist putrefactive form of gangrene of the soft tissues will, in all probability, be never designated by the term necrosis. Necrosis of bone takes place in the same manner and results from the same causes as gangrene of the soft parts, and on this account tliere does not appear to be sufficient reasons to apply diflerent terms to identical processes occurring in different anatomical structures ; and 3'et b}' long usage they have become so intimately associated with the anatomical character of the part affected tliat it is difficult, for the present at least, to drop either. In modern literature we speak of necrosis of the soft tissues when the dead structures do not undergo putrefaction ; that is, when this process takes place in the internal organs not readil}^ accessible to putrefactive bacteria. In its extent necrosis varies greatly ; it may involve an entii'e limb, an entire organ, or may be limited to a single cell. As a ph3'siological process it occurs everywhere in the tissues, being limited, however, to individual cells incident to the wear and tear of the body, the pulling down and building up of the tissues, the cells that are lost being replaced b}^ the normal process of regeneration. A simpU', numericall}^ increased cell necrosis, without normal restitution, leads to atrophy, — necrosis atrophica. When all the cells of a part undergo death simultaneously, the circulation corresponding to the area of dead tissue is arrested completely, and with this absolute ischsemia, plasma circula- tion, and all functions are, of course, completelj' suspended, — a serious pathological condition. A total necrosis has occurred. (157) 158 PRINCU'LKS OF SURGERY. ETIOLOGY. Necrosis is a condition, not a disease. As a symptom it represents a local condition which has been bronght about b}' different causes. The most frequent causes of necrosis are the following : — Inflammation. — Inflammation may produce necrosis in two different ways : 1. Exudation and transudation take place so rapidly that com- plete stasis is produced by the extra-vascular pressure. 2. The bacterial cause of the inflammation is present in such large quantities that the vitality of the tissue is destroyed directly from this cause. If during an acute inflammation the capillary walls undergo such serious alteration that within a few hours or daj's the connective-tissue spaces become so densely packed with the corpuscular elements of the blood that the plasma circulation is greatly impeded or completely arrested, the primary inflammatory product encroaches upon the capillar}^ vessels to such an extent as to completely arrest the already sluggish circulation. If such a copious and rapidly-forming inflammatory exudate give rise to complete stasis over a considerable area, the extent of the resulting necrosis will correspond to the district deprived of the requisite blood-supply. The same bacteria which produce inflammation frequentl}^ if present in suflScient quantities, also cause cell necrosis. Ogston maintains that the staphj^lococci invade the tissues in the form of dense, roinid masses, which advance like clouds of a dense vapor, and, coming in contact with the tissues, induce necrosis, the cells, nuclei, and intercellular sub- stance being changed into a homogeneous, wax-like substance before purulent liquefaction occurs. On the other hand, the streptococci of suppuration invade the intercellular spaces, the nuclei of the cells re- maining visible. Bonone found the staphylococcus pyogenes aureus in such metastatic and broncho-pneumonic foci wliich presented a gangre- nous character. He maintains that the staphylococcus at first produces in the lungs a neci'osis by its multiplication, and that suppurative in flammation follows later around the necrotic tissue. Pnti-efaction of the dead tissue develops in consequence of the entrance of saprophytic bacilli through the bronchial tubes. He verified these assertions by experiments. He obtained pure cultures of the yellow coccus from such pulmonar}^ foci made by intra-parenchymatous pulmonary injections, and succeeded in producing artificiall}^ identical lesions in the lungs of animals. The same result was obtained by the intra-venous introduction of small particles of elder-pith impregnated with pure cultures of the yellow staphylococcus. The gangrenous foci produced by emboli con- taminated with the yellow coccus presented a characteristic appearance. The centre of such foci, at an early stage, is composed of necrotic tissue and remnants of dead leucocytes. The dead tissue is surrounded by a ETIOLOGY. 159 granular zone, which is again inclosed by a hsemorrhagic zone, and beyond this an area of catarrhal pneumonia. The staphylococci occupy the central portion and from here invade the granular zone, ^vhere putre- factive bacteria are also found. The pus-microbes do not reach the haemorrhagic zone, or the tissues the seat of catarrhal pneumonia. As Bonone was unable to produce gangrene of the lung, either by parenchj^- matous injections of other bacteria, as the pneumococcus or mikrosporon septicuvi, or by aseptic emboli of elder-pith, he naturally came to the conclusion that the gangrene resulted from the specific ettect of the yellow COCCUS; He compares gangrene of the lung with furuncle of the skin from an etiological stand-point. There can be no doubt that the primary effect of pus-microbes, when brought in contact with living tissue, under certain circumstances, is to produce necrosis before sufficient time has elapsed for parenchj-matous inflammation to become established. This occurs in gangrene of the lung, furuncles, carbuncles, and endo- carditis hacteritica staphylococcica. In the ordinary connective-tissue abscess, however, the connective-tissue cell undergoes the ordinary in- flammatory changes before the}* are converted into pus-corpuscles, and if gangrene occur it is owing as much to mechanical obstruction to tlie circulation caused by a copious exudate as to the local toxic effects of the pus-microbes and their ptomaines. This difference in the action of pus-microbes on the tissues depends largely upon the rapidity with which they multiply at the point of primary localization. If the microbes are rapidh' reproduced the chemical substances which they produce in the tissues are present in such large quantities that the^^ destro}' the cell protoplasm, and cell necrosis takes place as the result of their primar^^ action ; if the microbes multiply with less rapidity their effect on the tissues is less severe, and parenchymatous inflammation is produced instead of necrosis. Bonone used large quantities of pus-microbes in his injections, and the infected emboli caused circulatory disturbances, which only could favor rapid reproduction at the point of primarj^ localization. Passet and Liibbert repeated his experiments, but used more diluted cultures, and probably on this account they were never successful in producing gangrene of the lung, while they frequently observed the development of a pulmonary abscess. The centre of a furuncle, as well as a carbuncle, is occupied by a mass of dead connective tissue, which later becomes detached by suppurative inflammation. The connective tissue in these cases is killed by the bacterial cause of the suppurative inflammation, which, toward the peripherj^, appears to become mitigated so that, behind the suppurating zone, a wall of granu- lation tissue is established which limits further extension of the disease. 160 PRINCIPLES OF SURGERY. Specific Bacteria. — All bacteria which can produce an inflammation sufllciently severe to completely arrest circulation can become an indirect cause of necrosis. Among these can be included the pus- microbes and the bacillus of anthrax. The necrosis which occurs regu- larl}^ almost in every case of anthrax is probably due to the intensity of the inllannnation resulting from the presence of the anthrax bacillus, to secondary Infection with pus-microbes, or to the combined effect of both microbes. The absence of necrosis in artificially-produced anthrax, when pus-microbes are excluded by the strictest antiseptic precautions, does not prove that tiie anthrax bacilli possess no necrotic effect on the tissues, as in such instances death follows so soon that not sufficient time intervenes between the inoculation and the death of the animal for the local inflammation to terminate in necrosis. Necrosis is, however, much more likely to occur if the anthracic infection is complicated by the presence of pus-microbes. It is well known that certain chemical substances have the power to produce cell necrosis independently of their action to excite inflammation. Digitoxin, a poisonous principle of digitalis, is one of these. The primary effect of this substance on the tissues is to produce cell necrosis. We should expect that some of the ptomaines possess similar properties. Ortliinaun made some very inter- esting experiments in this direction with pus-microbes. He inoculated both corneae in rabbits by making a puncture with a needle infected with a pure culture of the streptococcus pj^ogenes. One of the eyes was irri- gated for ten minutes with a warm phj-siological solution of salt, by using an apparatus constructed for this si)ecial purpose. In the eye not thus treated a suppurative keratitis was initiated by the leucocj'tes from the conjunctival sac reaching the infected field, while in the cornea treated by irrigation the streptococci invaded the vascular spaces, and, multiplying with great rapidity, produced by their accumulation dilata- tion of the spaces and necrosis of the fixed tissue-cells. In most of these cases the central necrosis led to perforation of the cornea and complete destruction of the eye. As the corneal corpuscles in the necrotic area had lost their nuclei and the parenchyma cells showed no signs of inflammation, we cannot escape the conclusion that cell necrosis was induced by the direct action of the ptomaines, elabo- rated by the masses of streptococci in the vascular spaces. The most conclusive proof of the destructive effect of ptomaines on the tissues has been furnished by the great master and founder of modern bacteriology, Robert Koch. In his experiments on septicaemia in mice he found, besides bacilli, a micrococcus in the neighborhood of the place of injec- tion. Of the numerous kinds of bacteria contained in the putrid fluid used for injection, only the fine bacilli upon which the induction of the ETIOLOGY. 161 septicaemia depended and the chain cocci found a suitable soil in the mouse, while all the rest perished. The chain coccus was never found in the blood, but only in the tissues at the seat of infection. He found it exceedingly difficult to isolate it from the bacillus. At last he succeeded in cultivating it in the field-mouse, which, as experiments proved, is immune to the bacillus of septicsemia. The chain coccus injected into the subcutaneous tissue of the ear of the field-mouse invaded the tissues slowl}', causing paleness and death of the cells without extravasation. The microbe entered and plugged the capillary vessels, but never found Fig. 48.— Expeeimentally-produced Growth of Streptococci in Centeb OF Cornea of Rabbit. Horizontal Section, X 40. {Baumgarten.) A, normal cornea ; B, central necrotic portion, corresponding in outline to the star-shaped streptococci culture. its way into the general circulation. Examination of the specimens showed that progressive gangrene occurred in advance of the microbes, hence could have occurred only by the action of ptomaines diffused through the tissues ahead of the microbic invasion. Inflammation of the fixed tissue-cells occurred around the zone of gangrene, and all leucoc^'tes which reached the infected field perished. If the same animal was inoculated at the root of the tail, gangrene occurred ond spread in a central direction, and resulted in death on the third day. The microbe did not change in its morphology or pathogenic properties after passing through a series of inoculations. Both Ogston and Rosen bach are of 11 162 PRINCIPLES OF SURGERT. the opinion that the chain micrococcus with wliich Koch produced progressive gangrene in the field-mouse is identical with the strepto- coccus pyogenes. This question will have to be decided by future research, which must have for its object the isolation and cultivation of the chain coccus from the necrosed tissues of the field-mouse. Baum- garten is of the opinion that microbes can produce necrosis not only b}' the production of a tissue poison, but also b3^ causing decomposition and by the assimilation of material necessary for cell nutrition. The expla- nation ndvanced by Koch ten years ago, however, appears more rational : " Introduced by inoculation (chain cocci) into living animal tissues, thej^ multiply, and as a part of their vegetative process they excrete soluble substances which get into the surrounding tissues by diffusion, and when greatly concentrated, as in the neighborhood of the micrococci, this product of the organisms has such a deleterious action on the cells that these perish and finally disappear completely. At a greater distance from the mici'ococci the poison becomes more diluted and acts less intensely, only producing inflammation and accumulation of lymph- corpuscles. Thus it happens that the micrococci are always found in the gangrenous tissue, and that in extending they are preceded b}' a wall of nuclei which constantly melts down on the side directed toward them, wiiile on the opposite side it is as constantly renewed by lymph deposited afresh." An almost identical form of gangrene, as experimentally produced in the field-mouse by Koch, is occasionally met with in man. It is known as progressive gangrene, and is so called from its most conspicu- ous clinical feature — rapid extension. Before antiseptic surgery was known it frequently developed in cases of compound fracture and com- pound dislocation of large joints, and often proved the direct cause of loss of limb or life, or both. Two cases came under my own observation where it occurred after extirpation of carcinoma of the breast, in one without, and in the otlier with, removal of the axillary glands. In both cases the first symptoms appeared on the third day. The general symptoms were those of intense sepsis, while the local conditions resembled first what used to be called phlegmonous erysipelas. An erysipelatous blush appeared at the margins of the wound and extended rapidly in all directions, accompanied by infiltration of the deep tissues. The gangrene attacked the tissues first involved and followed the course of the phlegmonous inflammation. In spite of the most energetic local and general treatment, both patients died at the end of the first w^eek. Rosenbach describes two cases tlmt came under his care. In one the disease started from a small wound of a finger, the process finally extending to the lower extremities, with death on the sixth day. In ETIOLOGY. 168 the second case, the local lesion appeared first as a red indumtiuii, around which cedema developed rapidl}-, the skin covering the part presenting a reddish-blue discoloration before gangrene set in. Tills patient had an eruption of the skin over the whole surface of the body which resembled the rash of scarlatina. From the lesions of both of these cases Rosenbach cultivated npon peptone-meat gelatin the strepto- coccus pyogenes. Ogston calls this affection erysipelatoid-wound gan- grene,' and always found in the gangrenous tissue the streptococcus. Gangrene produced by staphylococcus, the same author calls sloughing inflammation or inflanimator}- mortification. Tiie streptococcus of erysipelas never produces gangrene, and when this complication occurs in this disease it is always a positive indication that secondary infection with pus-microbes has taken place. Putrefactive Bacteria. — Necrosis occurring from the action of anj^ other microbes than those of putrefaction is not attended by an}' disa- greeable odor or other evidences of putrefaction, and, if limited in extent and protected against the invasion of saproph3'tes, the dead tissue may be completel}^ removed b}- absorption. Putrefactive bacteria feed on dead tissue, and in the absence of such tlie}' are comparatively harmless. Putrefaction onh' takes place in moist gangrene, and is alwa3's caused by the invasion of dead tissue with one or more species of saprophj'tes. Progressive gangrene, complicated by secondary infection with sapro- phj'tes, is characterized 1)}' the formation of gases which give rise to emphysema. Progressive gangrene with emph3-sema is one of the most fatal of all wound complications, as the ptomaines elaborated by the saprophytic bacilli greatly increase the danger from sepsis. Sulphuretted hydrogen is one of the gases formed during putrefaction of necrosed tissue. Rosenbach cultivated from the infected tissues, in 2 cases of progressive gangrene with emphj'sema, a saproph^'tic bacillus with spores. Hauser cultivated from putrefying organic substances one or more kinds of the jorote us, Wxe proteus mirabilis {Zenkeri) and vulgaris. Trauma. — The vitality of a part is completelj'- destroj^ed if a trauma is sufficient in intensity to arrest the circulation completel}^ and of such a character and extent as to render a return of it impossible. Such injuries, for instance, ai'e caused b}' the passage of a car-wheel over a limb, wdiere the skin often remains intact, while all of the deeper tissues are completel}'' crushed. A blow against a part of the bod^' where only a thin la^'er of tissue is interposed between the skin and an underlying bone may crush the subcutaneous tissue to such an extent as to preclude the possibilit}' of a return of an adequate circulation, and ncrosis follows as an inevitable result. Deep-seated contusions from the application of external violence are often attended by circulatory disturbances, which 164 PRINCIPLES OF SURGERY. necessarily result in necrosis. Necrosis of ganglion-cells following con- tusion of the brain affords a good illustration of the occurrence of traumatic necrosis at a distance from where tlie force was applied. In such cases the cells are separated from all tlieir anatomical connections by the trauma, and either undergo calcification or are removed by at)- sorption. If such a contused area become the scat of a subsequent infection, suppuration or putrefaction can occur, according to the location of the part injured, infection taking place Avith pyogenic microbes or saprophytes. In the so-called railway-spine the cell necrosis following a contusion of the spinal cord leads to remote, central, and peripheral disturbances. A trauma may be of such a nature as to inflict an injury not incompatible with the integrity of a limb, but may create conditions which subsequently result in complete obliteration of a main artery. If an arter}' is subjected to serious i)ressure or traction, tlie intima gives way and its lumen is subsequentl3' obliterated by tlie formation of a thrombus at the seat of injury. In such a case the artery is at first per- meable, and the distal pulsations are unaffected until the lumen of the vessel is narrowed and finally completely' obliterated by the formation of a thrombus. Professor von Wahl has called attention to an early and important symptom in these cases, the detection of which enables the surgeon to recognize the vessel injury before the appearance of the positive peripheral symptoms, viz., a hruit^ which can be heard by placing the stethoscope over the seat of injury. The vessel injury in such cases is of serious import, as the contusion of the soft tissues which is usuall}'' also present retards or prevents the formation of an adequate collateral circulation, and gangrene occurs in consequence of complete interruption of the arterial circulation. A vein may be injured in a similar manner, and the venous stasis following obliteration by a thrombus may become a determining cause of gangrene of a limb, the vitalitj'^ of which has been otherwise impaired by the injury. Decubitus. — Prolonged uninterrupted pressure causes necrosis by interrupting the circulation. Tight bandaging and pressure of splints have often been productive of gangrene. Bed-sores are liable to form in patients suffering from acute infectious diseases, and in persons suffering from fracture of the spine, or disease of the spinal cord ; also, in aged obese persons treated in the recumbent dorsal position for fracture of the neck of the femur. Decubitus is most prone to appear in consequence of pressure over bony prominences, and on this account we look for it in persons who are going through a long-enforced confinement in bed, first over the sacrum, the trochanteric regions, the spinous processes of the vertebrae, and the heels, parts most affected by the dorsal decubitus. The deleteri- ous effect of pressure is greatly aggraA-ated by filthj'' surroundings, as ETIOLOGY. 165 under these circumstances the necrosed tissue becomes the seat of infec- tion ■with pus-microbes and saprophytic bacteria, -which inaugurate a progressive gangrene and sepsis, often constituting the direct cause of death. It is not unusual, in cases of septic decubitus, to find the whole sacrum exposed, and in one instance that came under the author's obser- vation the spinal canal was opened and through the opening the cerebro- spinal fluid escaped, first clear, later purulent. This patient lived for several daj-s after the cerebro-spinal fluid had commenced to escape, and before his deatli he presented s^-mptoms which indicated that the menin- gitis had extended to the envelopes of the brain. Defective Arterial Blood-Supply. — The aseptic ligature, combined with the antiseptic treatment of wounds, has been the means of greatly diminishing the freqnenc}' of gangrene after ligation of the principal arteries of a limb in their continuity. Gangrene usuall}' occurred, not so much from the sudden interruption of the arterial blood-supply as from the septic inflammation following the operation, which interfered with the formation of a satisfactory collateral circulation. Ligation of Arteries in their Continuity. — Statistics of a number of years ago show tiiat gangrene has followed ligation of the subclavian in the outer third iu 9 per cent, of the cases reported; external iliac, 15 percent.; common femoral, 11 per cent. The results after ligation of these vessels have much improved since the introduction of the aseptic ligature. In a healthy person witli normal blood-vessels there is but little danger of gangrene following the ligation of the principal arteries of a limb with an aseptic ligature under antiseptic precautions. Gradual obliteration of an artery by a thrombus is not attended by equal danger of the occurrence of gangrene as when the same vessel is suddenlj' and completely blocked by impaction from the arrest of an embolus, because circulation is on a fair way of becoming established before the lumen of the vessel is completely closed, while in the latter case the demand on the collateral vessels is more urgent and sudden, and consequenth* the failure on their part to act as substitutes for the obliterated trunk is more frequent. Valvular disease of the heart, fatt^^ degeneration of this organ, atheroma of the arteries, — in fact, all pathological conditions which diminish the vis a tergo are instrumental in the causation of gan- grene, when from any accidental cause or oj^erative interference the blood-supply to a limb lias been diminished, or when the tissues are the seat of a progressive septic inflammation. Gradual diminution of the arterial blood-supply general!}' gives rise to drv gangrene, as is the case in senile gangrene, Avhile sudden interruption of tlie circulation through a lai'ge arter\' from the application of a ligature or the impaction of an embolus is usually followed b}- moist gangrene. 166 PRINCIPLES OF SURGERY. Obstructed Venous Circulation. — Impeded venous circulation is fraught with as much danger, as far as the production of gangrene is concerned, as obstruction of the arterial circulation. Langenbeck was impressed with this fixct so strongly that he recommended, if it became necessary to ligate one of the principal veins of an extremity near the trunk, to ligate at the same time the accompanying artery in order to guard against the evil results following ligation of a large vessel. Anti- septic surgery has minimized the danger of ligaturing, for instance, the axillary or femoral vein, and no surgeon at the present time would deem it necessary, or even justifiable, to ligate the corresponding arteries simply for the purpose of preventing excessive venous engorgement and of favoring the formation of an adequate venous collateral circulation. The same advantages which have resulted from antiseptic operations for the timely formation of an arterial collateral circulation after ligature of an arter}' are secured for the maintenance of an inadequate venous cir- culation after the ligation of a vein. Venous obstruction from patho- logical causes often proves more disastrous, as the causes which have brought about the formation of a thrombus frequently do not remain local, and the thrombus increases in length in both directions, thus rendering the formation of a collateral circulation a difficult, if not an impossible, occurrence. As venous obstruction gives rise to oedema gangrene, if it occur under these conditions, it always represents the moist variety, and is usually accompanied by putrefaction. Heat. — Heat produces pathological conditions according to the de- gree of the temperature and the length of time a part is exposed to its action. A momentar}' exposure even to a high temperature produces only a burn of the first degree ; that is, simply an active hyperemia and redness of the surface. If the part is exposed for a somewhat longer time the hyperaemia is followed by a superficial inflammation and blis- ters form, — a condition w^hich is described as a burn of the second degree. In such cases the necrosis is limited to the epidermis, which is detached from the papillary layer. In burns of the third degree the deeper tis- sues are destroyed by tlie heat, and extensive necrosis is the result. Cohnheim determined that a temperature from 54° to 58° C. was sufficient to produce gangrene in the rabbit's ear. If he immersed the ear for a short time in water heated to this temperature, necrosis always followed. A somewhat lower temperature continued for a longer time produced the same eflfect. Heat produces necrosis by coagulating the cell-protoplasm, if its action is superficial ; if it penetrate more deepl}', the blood in the blood-vessels is coagulated, and necrosis of the tissues deprived of circulation in this manner follows as an inevitable result. Intestinal ulceration, in case of extensive burns, is also a necrotic process, caused ETIOLOGY. 167 b}' capillary obstruction with dead or dying blood-corpuscles derived from the burned district. It has been found experimentally that a temperature over 45° C. has a destructive effect on the blood-corpuscles. Welti ascertained that if the ear of a rabbit is kept immersed in water, gradually heated to 70° C, bleeding from the nose and hsemo- globinurea followed, — symptoms which he attributed to partial or complete obstruction of capillary vessels with the third corpuscle of the blood. Cold. — The action of cold in producing necrosis is closely allied to that of heat. Frost-bites are classified the same as burns. Cold, like heat, causes gangrene by producing by its action cell necrosis and vas- cular obstruction. Cohnheim produced gangrene of the rabbit's ear by exposing it for a short time to a temperature of 16° C. The length of time a part is exposed, either to heat or cold, exerts an important influeuce in determining the extent and depth of the subsequent gangrene. Gangrene resulting from a burn or exposure to cold remains dry and aseptic as long as the entrance from without of pus-microbes and sapro- phytes is prevented, but with microbic invasion suppuration and putre- faction are established. Caustics. — Chemical substances which by their local action on the tissues produce extensive cell necrosis are called caustics. Of these the strong acids and mineral salts destroy cells by causing coagulation. The necrosed tissue, or eschar, resulting from their action is firm, and the contour of the cells is well preserved. The alkaline caustics, on the other hand, dissolve the tissue elements, and the slough resulting from their application is soft. A peculiar form of necrosis of the maxillary bones occurs in persons exposed to the fumes of phosphorus. The most recent explanation of the occurrence of necrosis of the jaws in persons employed in match-factories is to the effect that the phosphorus fumes in the mouth are transformed into phosphoric acid, and that necrosis of the bone is produced by the direct action of the acid on tlie bone and myeloid cells, while the periosteum remains intact and produces new bone. Ergot. — The prolonged administration of ergot in large doses is attended by the risk of causing gangrene. The gangrene from ergotism is alwa^'s of the dry variety. It is generally believed that it is caused by the drug keeping up an angio-spasm, which shuts off the full blood- supply to the peripheral portion of the extremities, — the most frequent seat of the gangrene. Zweifel, of Erlangen, believes that the toxic effect of ergot results in a vasomotor paresis, and that the gangrene is due to defective innervation. 168 PRINCIPLES OF SURGERY. SYMPTOMS. Internal Necrosis. — In simple cell necrosis the tissue elements may- have luulergoue no clianges in form, but the cell-protoplasm has lost its vital properties, and function has been completely arrested. Such cells present a cloudy a[)pearance, and if the necrosis has resulted from a gradual or sudden ischtiemia the part affected presents a pale appearance. In the periphery of such a necrotic area the vessels become dilated and a hyperreniic zone forms, in which the collateral circulation is to be establislu'd. If an artery in any of the internal organs is suddenly' obliterated b3' the impaction of an embolus, the tissues supplied by the closed vessels are deprived for a time, and perhaps permanently, of their blood-supply, and in consequence of this they become pale, while around the wedge-shaped, aufemic territory the vessels concerned in the forma- tion of collateral circulation are distended to their utmost, and often yield to the increased intra- vascular pressure when extravasation of blood occurs. If the collateral circulation is not speedily establisiied, necrosis of the tissues supplied by the obliterated vessel is the result. In mycotic cell necrosis karyolysis — that is, dissolution of the cells — usually occurs. If the cell-membrane rupture and the contents of the cell escape, we speak of a karyorhexis. Absolute ischsemia of certain parts or cell territories continued for only one to two hours is sure to result in necrosis. If any portion of the In'ain, intestines, or kidney is deprived of blood-supply for this period of time, nutrition is completely sus- pended, and cell necrosis follows as an inevitable consequence. Litten ligated the renal arter}' in animals, and found, at the end of an hour and a half to two hours, the renal epithelia in a state of necrosis. Limited necrosis of the parenchyma of the brain may give rise to focal symptoms by which the lesion can not only be recognized, but often accurately located. Infarcts of the kidney can frequently be diagnosticated by a careful chemical and microscopical examination of the urine. A similar condition in the lungs gives rise to circumscribed catarrhal pneumonia, which can be recognized by a careful physical examination of the chest. Ulcer of the stomach, the result of a circumscribed necrosis, is attended by a complexus of symptoms pointing directly to the seat and nature of the lesion. Necrosis in internal organs is seldom followed by putrefac- tion, as saprophytes seldom reach the dead tissue. Necrosis of the lungs is sometimes followed by gangrene, by the entrance into the necrosed tissue of putrefactive bacteria from the respiratory passage. Gangrene of External Parts. — As it is often impossible to recognize during life a limited cell necrosis in the internal organs by the symptoms presented, this subject has been briefly disposed of, but the s3^mptoma- tology of external gangrene will receive a more thorough consideration. SYMPTOMS. 169 It might appear that the recognition of the existence of gangrene of any of the external parts would require no special care or erudition. But this is not so. It is true that when gangrene is fully developed, when all the characteristic symptoms are present, a correct diagnosis can be made on first sight. But cases occur where it is exceedingly difficult to determine whether the part affected is dead or onlj- in a state of inflammation. In illustration of this the author will onlj^ allude to the difficulties which surround the surgeon in many cases of herniotomy, when he has to determine whether it is justifiable to return a portion of intestine that has been strangulated for some time if he simply relies on the appearance of the intestine. The intestine presents a duskj^, almost black appear- ance, and the casual observer might come to the conclusion that it is gangrenous, and treat it as such, when, in fact, a more careful obser- vation will soon reveal the fact that the circulation is not completely arrested, and that it is safe to return it. (a) Pain. — Sudden, severe, often excruciating pain in a limb is the first indication which announces the occurrence of embolism in one of the large arteries. In the lower extremit}' the embolus is often arrested at the bifurcation of the poi)liteal arterj', but the pain extends along the whole limb, from the toes to the groin. The sudden anaemia is the cause of the pain. In senile gangrene the gradual ischaemia caused by the atheromatous degeneration of the arteries gives rise to pain and a sen- sation of numbness, which precede the gangrene for weeks or months. Acute inflammation resulting in gangrene is attended by intense pain from the very beginning; the pain abates, as a rule, with the occurrence of gano;rene. Pain may be absent at the seat of necrosis, and referred to some other part or locality. In strangulated hernia the patient often sufl'ers little or no pain at all in the swelling, but complains of a period- ical pain in the region of the umbilicus. The absence of pain and tenderness over the region of a hernia speaks rather for than against the presence of gangrene. Osteomyelitis is attended by severe pain, which is diminished or subsides with the escape of the products of inflamma- tion from the bone into the surrounding tissues. In cases of intestinal obstruction the cessation of pain, with continuance of the sj-mptoms of obstruction, is an indication that gangrene has occurred. (b) Tenderness. — The pain elicited by pressure is a more important symptom in the diagnosis of necrosis than spontaneous pain. As long as the part suspected to be necrotic is sensitive to the touch it is a sign that necrosis has not taken place. To test the sensation of a part it is advisable to resort to puncture with an aseptic needle. Absence of pain and all sensation on puncturing the tissues with a needle is often the best argument to convince the patient and friends that necrosis has occurred. 170 PRINCIPLES OF SURGERY. (c) Temperature. — The difference in the temperature of a part threatened with gangrene has given rise to the expressions hot and cold gangrene. If gangrene follow an acute inflammation, the local tempera- ture remains high until other evidences of gangrene make their appear- ance, when the complete arrest of circulation and tissue metamorphosis result in a sudden fall of the local temperature. In gangrene following atheroma, tlirombosis, embolism, and ligation of arteries the local temperature is reduced before gangrene occurs. (d) Pulse. — After ligation of the principal artery of a limb the sur- geon examines anxiously from day to day for the appearance of pulsa- tion in the distal portion of the arter}', — an occurrence upon which depends the fate of the limb. The re-appearance of the pulsation in the distal part of the artery is a certain indication that collateral circulation has become established, and that gangrene will not occur. With the ap- pearance of distal pulsations the local temperature increases, and the diminished tissue metamorphosis is restored to its normal state. In em- bolism or thrombosis of a large artery, the same disturbances in the peripheral circulation of the limb are observed as after ligation. By searching for pulsation in different parts of the limb the surgeon can often locate the thrombus or embolus. If, for instance, the embolus or thrombus is located in the terminal portion of the popliteal artery, pulsa- tions of the femoral artery can be felt from Poupart's ligament down to the seat of obstruction, while no pulsations below this point can be felt until collateral circulation is established. Obliteration of an artery from patliological causes is prone to prevent the formation of an adequate collateral circulation by the growth, in both directions, of the thrombus or embolus. The pulse furnishes the most important means to follow from day to day the growth of the intra-vascular blood-clot. In senile gangrene a thrombus frequently forms in one of the smallest arteries and grows in a proximal direction, extending from the digital branches to the dorsalis pedis, to the anterior tibial, or from the plantar arteries to the posterior tibial, the popliteal, and finally the femoral. In such cases the arteries can be felt as firm cords, but pulsations are limited to the previous portion of the vessels. An embolus often becomes the centre of an enormous thrombus, which seriously impairs the chances of pres- ervation of the limb by the establishment of an early and adequate col- lateral circulation. If an embolus obstruct the popliteal artery, pulsa- tions can ])e felt above this point, but the}' disappear with the extension of the secondar\' thrombus in a proximal direction. (e) Swelling. — In moist gangrene the necrosed tissue imbibes moist- ure to a considerable extent, and the slough is larger than the tissue it represents. The swelling is twice more increased if gas forms in the SYMPTOMS. 171 tissues. In dry gangrene the parts shrink, become firmer, and instead of swelling there is diminution in their size as compared with their volume in a normal condition. (f) Emphysema. — The presence of emph3\sema in gangrenous tissue is a certain indication of the presence of gasogenic bacteria. The char- acter of putrefaction depends on the kind of saprophytes which are present in the dead tissues. The different kinds of proteus possess gas- producing properties. The proteus, according to Hauser, appears in dif- ferent forms, according to the chemical reaction of the soil upon which it grows. On acid gelatin the culture consists of cocci and short bacilli ; on alkaline gelatin it grows in the form of threads, vibrios, spirilli, etc. All these different forms of proteus growing in dead tissue exposed to the atmospheric air produce sulphuretted hydrogen. Hauser cultivated the proteus from ulcerating carcinomas and bed-sores. In the cases of progressive gangrene with emphysema examined bacteriologically hy Roseubach, he found the bacillus saprogenes. Emph3'sema is sometimes so marked that on percussion a tympanitic resonance is elicited. When less in degree its presence can be readily recognized by pressure, which causes a crackling, crepitating sound. (g) Color. — If gangrene take place in consequence of interrupted arterial circulation, the part at first presents a preternaturally pale ap- l)earance until the first visible evidences of the actual occurrence of gangrene are announced by a livid or lead color, at a point where the circulation has first been completelj' arrested. The lividity, when it is due to complete, irreparable capillary stasis, is not affected by pressure. Blisters containing a sanious fluid form at points where the deeper tissues have already undergone necrosis. As soon as the circulation has been completely arrested, tissue metamorphosis is at once suspended, and the further changes are entirely of a chemical nature. The colored corpus- cles of the blood undergo rapid disintegration ; the coloring material is diftused through the dead tissue and into the interior of the bullae. The black color of gangrenous tissue is produced by sulphuret of iron, — a combination of sulphuretted hydrogen and hoemoglobin. (h) Condition of Tissues. — The condition of the dead tissues will de- pend on the cause of the necrosis. In dry gangrene they become firmer hj evaporation of the fluids. In moist gangrene they imbibe fluids and undergo maceration, becoming soft and friable. A fetid, sanious fluid escapes from the dead tissue. Adipose tissue in a condition of gangrene undergoes speedy disintegration, and free globules of fat are mixed with the sanious discliarge. Maceration of tissue is considered by Ravoth as tlie most important condition in determining the pi'esence of gangrene in cases of strangulated hernia. He maintains that if the tissues of the 172 PRINCIPLES OF SURGERY. intestinal wall can be readily separated and teased asunder with a dis- secting forceps there can be no doubt that gangrene has occurred. This maceration, however, takes place only some time after the circulation has ceased, and is entire!}^ absent in necrosis of bone, cartilage, and tissues well supplied witli elastic elements, as the arteries. In determining tlie presence of gangrene in strangulated hernia, where any doubt as to its presence exists in the mind of the operator, it is much better to liberate the strangulated gut, draw it forward and irrigate it every few minutes with a hot solution of boracic acid, wliich will stimulate the sluggish cir- culation, and will soon furnish reliable proof of the actual condition of the vessels and the tissues. Mechanical stimulation of the intestinal wall is also a valuable diagnostic measure, as, if gangrene has occurred, no amount of irritation Avill excite peristaltic action, while with the restoration of the impeded circulation the muscular fibres will respond to irritation. (i) OdoP. — Necrosed tissue does not emit any unpleasant odor unless it has become invaded with putrefactive bacteria. The almost unbearable stench which attends extensive moist gangrene is always the result of putrefactive changes. Dry gangrene is odorless. In acute inflammatory affections of the lung, where a communication has been established between the inflammatory focus and the bronchial tubes, the presence or absence of fostor is of great diagnostic value, as its presence speaks in favor of gangrene and its absence indicates an abscess. (j) Mummification. — By this term we mean a drying up of a gan- grenous soft part iroui the loss of fluids which it contains by evapora- tion. It is a state of preservation of dead tissue while still attached to the living body. It can onlj- occur if the dead tissue is exposed to the atmospheric air, and on this account it is always absent in necrosis of internal organs. Mummification can only take place where putrefaction is absent, and, therefore, is most frequently met with where gangrene is first limited, and increases gradually by an aggregation of the causes which produce gradual diminutian of the arterial blood-supi)ly, as in cases of senile gangrene. (k) Line of Demarcation. — The line of demarcation is the line where the further extension of gangrene has been arrested by an adequate col- lateral circulation and a wall of living granulations. Back of this line of demarcation, on the side of the living tissues, there is to be found a hyperaemic zone, which precedes and attends the regenerative process, and by which the further extension of the gangrene is prevented. In septic gangrene the line of demarcation marks the limits of the area of "infection, while in aseptic gangrene it indicates the point where the vascular conditions answer the physiological requirements of the part. SYMPTOMS. 173 (I) Elimination of Gangrenous Part. — Spontaneous elimination of a gangrenous part is of frequent occurrence. Tlie necrotic tissue may be disposed of in a spontaneous cure in tliree different ways : 1. Absorption of dead tissue. 2. Separation of necrosed part b}' granulation. 3. Separation of the sphacelus or sequestrum by suppuration. A limited quantity'' of necrosed aseptic tissue can be completely removed by ab- sorption in the same manner as absorbable aseptic substances are re- moved when implanted in the tissues. This is the most desirable termination of gangrene, and takes place frequenth' in cell necrosis of the internal organs. Such a disposal of aseptic necrosed tissue is also possible on the surface of the skin when the area does not exceed a square inch, and an aseptic condition is secured throughout. The capacit}^ of the tissues to remove aseptic necrosed tissue is limited, and when the quantity of tissue surpasses this capacity the dead part is con- siderabl}' diminished in size, and the balance is detached b}' the granula- tions which form at the line of demarcation, and is finally eliminated spontaneously or by operation. Repair after this manner of elimination is rapid and satisfactorj*. If infection with pus-microbes has taken place in the beginning of the lesion which has caused tlie necrosis, or, later, at the line of demarcation, separation of the slough takes place by means of a suppurative inflammation. In such cases the dead part is not diminished in size, and the healing, after its elimination, takes place more slowlj'^, and the result, as a rule, is less satisfactory. Separation takes place ver}- slowlj' in necrosis of bones, intermuscular connective tissue, and tendons, requiring often weeks and months before the dead tissue can be removed, (m) Liquefaction of Necrosed Tissue. — Where no putrefaction or suppuration takes place, and the amount of necrosed tissue exceeds the absorptive capacity of the surrounding tissues, liquefaction takes place, and months and 3'ears later the seat of necrosis is occupied by what appears, and has often been falsel}^ described, as a cj^st. This method of disposing of the dead tissue is observed most ft-equentl}^ in organs scantil}' supplied with connective tissue, as the brain and spinal cord and in adipose tissue. (n) Encapsulation. — A limited area of aseptic necrosed tissue, not amenable to absorption, is often rendered harmless b}' encapsulation. The surrounding living tissue throws out a wall of granulation tissue which is converted into connective tissue, forming a capsule around the dead tissue. This method of disposal of dead tissue frequentlj^ occurs in the internal organs. A sequestrum occasionallj' becomes encapsulated after the interior of an involucrum has been rendered spontaneously, or by treatment, aseptic. 174 PRINCIPLKS OF SURGERY. (o) General Symptoms. — These will have reference to the loss of function caused by cell necrosis in internal organs and sepsis in external necrosis. Function will be affected according to the location and extent of cell necrosis. If cell necrosis is of mj^cotic origin and general it fre- quently becomes a direct cause of death. If it is limited to a single organ the symptoms will point to it as the seat of the disease. Limited areas of cell necrosis, in most of the organs, may give rise to ill-defined or no symptoms whatever, and is then completely beyond the grasp of a correct diagnosis. The most important general s3'mptoms of gangrene arise from the introduction into the general circulation from the gan- gi-enous part of soluble toxic substances. As this subject will be treated of more exteusivel}' in the chapter on Septicaemia, it will suffice here to make the broad but correct statement that septicaemia complicates gan- grene only when the dead tissues are infected with pus-microbes or putrefactive bacteria. Dry gangrene is, therefore, not attended by an}'' danger of septic intoxication, while patients suffering from moist gan- grene with putrefaction die, as a rule, not from the loss of tissue from gangrene, but from sepsis incident to the gangrene. Sepsis in gangrene is usually of that variety which arises from the introduction into the circulation of preformed toxines, the symptoms subsiding with the removal of the cause, with the exception of those cases of progressive sepsis caused by infection with pus-microbes. CHAPTER VII. Necrosis {continued). PATHOLOGICAL AND CLINICAL VARIETIES OF NECROSIS. The pathological and clinical classification of necrosis is based upon its causes, location, extent, and the age of the patient. The causes of necrosis have alread}^ been considered, and it has been shown that it results either from arrest of the circulation from purelj^ mechanical causes or from the action upon the tissues of toxic, chemical, or thermal influences which destroy the protoplasm of the cells directly. The location of the necrosis is important to remember, as when it occurs in organs inaccessible to saprophytic micro-organisms putrefaction never takes place; on the other hand, necrosis in parts accessible to atmos- pheric air is prone to be followed b}- putrefaction, with all the dangers which attach themselves to this condition. The extent of the gangrene has an important bearing on the prognosis, as, when the causes are such as to determine a circumscribed form of the disease, life is not in danger, while the progressive form, with few exceptions, ends in death, in spite even of the most heroic treatment. The age of the patient often deter- mines the form of gangrene, as, for instance, senile gangrene is a disease of the aged, while noma, almost without exception, attacks only children. The simplest and an exceedingly common form of necrosis is what has been described Iw Weigert as Coagulation Necrosis. — This is essentially a cell necrosis. It is called coagulation necrosis because the tissues present the appearance of coagulated albumen, and also on account of the process resembling coagulation of the blood. Coagulation necrosis is probablj' identical with, or, at any rate, nearl}' allied to, the hj'aline degeneration of Reck- linghausen and fibrinous degeneration of E. Wagner. The chemical process which results in coagulation necrosis is as yet imperfectly under- stood. Weigert maintains that the cell-protoplasm and, perhaps, all albumen-containing substances are converted b}' it into a substance re- sembling fibrin. Macroscopicallj', tissues which haA'e undergone this form of necrosis present a yellowish or whitish appearance, and are of variable consistence. Under the microscope the cells either appear un- changed in form or their place is occupied bj' thread-like fragments and (175) 17() PRINCIPLES OF SURGERY. gruuuliir material. Weigert lays down as the earliest change witnessed in a cell undergoing coagulation necrosis disappearance of the nucleus, wliich is the case twelve to twentj'-four hours after the process com- menced. Fibrin is a product of coagulation necrosis of the hlood. According to Alexander Schmidt, during the coagulation of blood the colorless corpuscles disappear ; the product of their destruction is fibrin ferment and fibrino-plastic material, which, Avith the fibrinogen of the plasma, form fibrin. Isolated cells destroyed by coagulation necrosis exfoliate, and are transformed into a homogeneous granular substance, which, according to circumstances, is removed by absorption, or becomes encapsulated. Cell necrosis en masse is often followed by calcification, and on surfaces b3' ulceration. The transformation of a tubercular product into a cheesy mass is the result of coagulation necrosis. As essential conditions for coagulation necrosis to occur Weigert enumer- ates : 1. Death of tissue-cells. 2. Presence of plasma-fluids. 3. Tissues must contain coagulable substances. Coagulation necrosis is retarded b}' the ptomaines of pus-microbes, putrefying material, and living epi- thelial cells. An entire organ ma^' be destroyed by coagulation necrosis. Pale infarcts after embolism are products of this change. The so-called fibrin wedges, which were formerly regarded as a decolorized blood-clot, consist of such tissues. At first the cells are normal in outline and appearance ; later, the nuclei disappear and the cells break up into granular masses. In the internal organs coagulation necrosis is most frequently met with in the kidneys, spleen, typhoid deposits, tubercular lesions, the vicinity of mycotic foci, and in atheroma of the blood- vessels. In the parenchyma of organs it attacks the epithelial cells, while the connective tissue remains intact. On raucous surfaces it is represented b}"^ the diphtheritic and croupous exudations. While the chemical jyrocesses which take place in coagulation necrosis cannot as yet be explained satisfactorily, there can be no doubt that this form of necrosis is nearly always, if not always, of mycotic origin, and it must be regarded practically in the light of a bacterial necrosis. Klebs describes the same condition askarijolysis, karyorhexis, !xnd vacuolar degeneration. He claims that early disappearance of the nucleus is not an essential, but an accidental, condition. In a case of pseudo-diphtheria Klebs found the l)acilli between cells devoid of nuclei, and onl}- in the centre of the necrotic patch did he find bacilli within the cells ; from this he concluded that karyolysis is due to the action of chemical products of the bacilli. In the second group of mycotic necroses the process differs as in typhus. Here the necrotic centre, which contains no cells, is surrounded by a zone, in which both cells and nuclei are also absent, but which contains a large number of chromatin bodies, Ijdng free in the tissues. As these bodies PATHOLOGICAL AND CLINICAL VARIETIES OF NECROSIS. HT are found in a location where the cells and nuclei have been destroj'ed, it can hardly be donbted that they represent remnants of these. Accord- ing to Wolmkom and Grassle, these bodies are liberated by rupture of the nuclear envelope. This method of cell destruction is called karyo- rhexis. A third form of cell necrosis is vacuolar degeneration^ in "which the change is initiated in the protoplasm itself. This must not be mis- taken for cell oedema. In vacuolar degeneration the protoplasm ruptures, and the nuclei of epithelial cells, which line a hollow viscus,are liberated, as Langhans observed in this form of cell necrosis in the kidne3\ The cell ruptures on account of increased intra-cellular pressure, and the process well deserves the name plasma rhexis. This form of cell destruction was formerly considered a post-mortem change. For the sake of simplicity it is advisable to substitute for the different forms of cell necrosis described b}^ Klebs the general term, coagulation necrosis, devised b}' Weigert. Necrobiosis. — This is a term applied b}' Yirchowto the spontaneous wearing out of living parts. Death of isolated cells is a ph^'siological process as long as the}' are replaced by new cells of the same tissue type. Necrobiosis occurring on a more extensive scale is a pathological con- dition, and is etiologically identical with coagulation necrosis. The term can be used to signify circumscribed cell necrosis without reference to its etiology or minute morbid anatomy. Progressive Gangrene. — This form of gangrene is alwa3^s of bacterial origin. The microbe most frequently found in the tissues is the strep- tococcus p3'ogenes. It occurs most frequently after w^ounds which open up a large surface of loose connective tissue, as in compound fractures, compound dislocations, excision of the breast, with removal of axillary glands and extirpation of large, fatty tumors. The streptococcus in- vades the connective-tissue spaces rapidly, somewhat after the manner of diffusion of the streptococcus through the lymphatic vessels. Much of the connective-tissue necrosis results from the direct action of the pus-microbes and its ptomaines on the cells. The necrosis of the skin is no indication of the extent of the disease in the deeper tissues. The infection is initiated by a chill, and the fever which follow resembles severe sepsis from other causes. If infection occur during the operation, or at the time of accident, the first symptoms may be looked for within fortj^-eight to sevent3'-two hours. If suppuration has occurred it is diminished with the appearnnce of septic infection, and the discharge becomes thinner and sanious. Lymphangitis fi-equentl}^ accompanies the deep-seated phlegmonous inflammation. Gangrene appears in the tissues first affected, and spreads rapidl^'^ along the connective tissue. Not only the gangrene is progressive, but also the attending septicaemia. 178 PRINCIPLES OF SURGERY* The larger the area of necrosis, the more extensive the field for the gf owth of pus-microbes and putrefactive bacteria. Pi'ogressive gangrene is an exceeding!}^ dangerous form of infection, and unless treated by heroic measures at an early stage is sure to lead to a speedy fatal termination. Progressive Gangrene, with Emphysema. — Etiologically this form of gangrene is identical with the preceding plus secondary infection with gasogenic bacteria. The necrosed tissue answers the purpose of a nutrient medium for saprophytic micro-organisms, which not only generate gas which is diffused through the dead tissues, but the soluble toxic substances which they elaborate in the necrotic area are absorbed into the circulation, — an occurrence which gives rise to toxaemia. Em- physema almost always extends far beyond the limits of the visible gangrene, but its presence is a sure indication of the extent of the in- fection in the deep-seated tissues. Progressive gangrene, with emphy- sema, is the most fatal form of gangrene, and only in exceptional cases will the surgeon succeed in warding off a certain fatal termination b}- early operative interference. In both kinds of progressive gangrene the part is swollen, cedematous, the skin presenting first a livid, bluish color, which afterward shades into a greenish or reddish-black hue. Bullae, containing a reddish serum, form at points where the gangrene is spread- ing. Besides sulphuretted hj^drogen, butyric and valerianic acid, am- monia sulphur, etc., are some of the many chemical products of putre- faction. The rapidity with which progressive gangrene, with and without emphysema, spreads, has led the French authors to apply to them the term gangrene foudroyante. Moist Gangrene. — Progressive gangrene is necessarily a moist gan- grene, as bacteria cannot germinate without moisture. All forms of mycotic gangrene are forms of moist gangrene. All necrosis in the interior of the body belong to this variety. The moisture of the dead tissue is due to imbibition of the a?dema-fluid, and consequently moist gangrene is apt to follow vascular conditions, in which there is some im- pediment to the return of venous blood, as in cases of obstruction in a large arter^^, and more especially when a large vein has become obliterated by a thrombus. Moist gangrene is attended by all the dangers incident to putrefaction. In this form of gangrene the line of demarcation is the seat of suppurative inflammation. Dry Gangrene. — In dry gangrene the dead tissue undergoes mum- mification, and on this account the soil is unfitted for the germination of putrefactive bacteria. Dry gangrene is usually the result of a trauma, the action of a chemical substance, or it follows a diminished blood- supply. In senile gangrene it follows in consequence of a gradual diminution of blood-supply, owing to atheromatous degeneration of the PATHOLOGICAL AND CLINICAL VARIETIES OF NECROSIS. 17!) arteries, while tlie return of venous blood remains unimpaired. Dry gangrene is often an aseptic gangrene. If no infection take place with pus-microbes the line of demarcation is formed by granulation tissue, and the gangrenous part, if small, is absorbed, or if this is impossible on account of its size it is separated b}'^ the granulations. If suppuration take place this occurs at the junction of the dead with the living tissues. Dry gangrene is usually not attended by any general s3'mptoms, and all attempts to remove the dead tissue should be postponed until the line of demarcation has formed. Senile Gangrene. — This is the gangrene of the aged, or, rather, it is the gangrene which is caused by atheromatous degeneration of the arteries. Senile marasmus, in the form of atheromatous degeneration of the arteries, may occur in persons less than 40 years of age, and is often absent in octogenarians. Senile gangrene alwaj's occurs in parts where the circulation is feeblest ; consequentlj' it usually commences in one of the toes. If the necrosed tissue remain aseptic the rapidit}' of the extension of the gangrene depends on the condition of the blood- vessels. It may remain limited to one toe, or it maj^ extend from toe to toe, and then creep along the dorsum or plantar surface of the foot, or on both sides simultaneous!}', and extend quite rapidly to the leg as far as the knee. Usually the disease extends along the course of one of the principal arteries, and extends later to other parts of the foot in con- sequence of greater embarrassment of the arterial and venous circula- tion. If infection in the vicinity of the necrosed tissue with pus- microbes take place, a suppurative inflammation maj^ follow senile gan- grene, which will give rise to a progressive and rapidly-fatal form of the disease. In the dr}' form of senile gangrene the tissues mummify, are firm, and perfecth' black in color. In the moist variety the parts present the same appearances as in progressive gangrene. If a line of demarca- tion form, the separation of the dead from the living tissues requires an unusualh' long time, as the circulation is enfeebled to such an extent that tissue proliferation takes place very slowly. Diabetic Gangrene. — It is a well-known clinical fact that persons suffering from diabetes are verj^ prone to be attacked by gangrene. The reasons for this are as yet unknown. Gangrene occurring from trivial causes in persons presenting the appearances of usual health, and in whom no evidences of atheromatous degeneration of the arteries can be detected, should awaken the suspicion of the existence of diabetes, and no time should be lost in making a careful examination of the urine. A strictl}' antidiabetic diet has often resulted in arresting further extension of the gangrene. Kdnig has found that after amputation for gangrene in diabetics the quantit}^ of sugar in the urine is diminished. 180 rRTNCIPLES OF SURGERY. Decubitus. — Gangraena per decubitumliteraWy means gangrene from pressure. It occurs in consequence of pressure from splints, bandages, and the prolonged recuml)ent position in bed, especially in persons suffering from fracture of the spine, or acute infectious diseases attended by great impairment of the circulation. Pressure without infection is productive of dry aseptic gangrene, but usually gangrene from this source is complicated by infection with p3'ogenic or putrefactive bacteria, or both. If gangrene from pressure is inevitable, it is apparent that its occurrence should be met b}-^ timely precautions for the purpose of pre- venting accidental infection. Gangrene from splint pressure can be prevented by interposing between the splint and bony prominences a thick cushion of salic3dized cotton. Bed-sores should be prevented by changing the position of patient frequently and protecting the parts most exposed to the ill effects of pressure with fenestrated rubber cushions, by enforcing absolute cleanliness, and b}^ keeping the skin in a healthy condition by applications of spirituous lotions. Both in gangrsena per decubitum and senile gangrene the necrosis is caused by impairment or complete suspension of the capillary circulation. Noma. — Noma, cancer aquaticus, is characterized by rapid, gan- grenous destruction of the cheek, which usuallj- commences some distance from the lips. This disease is exceedingly rare in this country, but quite prevalent in the large cities of Europe. It attacks exclusively children, occurring most frequently between the ages of 3 and 8 years. Healthy children seldom suffer from this disease ; it either appears in badly- nourished, cachectic subjects, or it occurs as a complication of some of the eruptive fevers or typhus. In reference to the etiology of noma, little is known. The almost constant occurrence of the disease in a dis- tinct part of the cheek and its limitation to one side of the face would indicate that it might be the result of some nervous disturbance. It is, however, more probable that it is a form of m3^cotic necrosis. A few observations on the bacterial origin of noma have been made. Lingard found in the tissues a long bacillus, which he believed was the cause of the disease. In gangrenous stomatitis in the calf, which affects this animal at particular seasons of the year, he found bacilli which are very similar in appearance to those present in noma in man. On cultivation they present characters which render them easily distinguishable from other bacteria, and on inoculation of these micro-organisms into the calf a gangrenous stomatitis is again produced. Ranke's investigations on noma led to the following conclusions: Different forms of gangrene resulting from noma can unquestionably occur spontaneously in children who have a tendencj' to disease of this character; that is, without infection from contact. The frequent occur- PATHOLOGICAL AND CLINICAL VARIETIES OF NECROSIS. 181 rence of noma in public institutions, and the apparent preference of the disease for localization upon the mucous membrane of the different openings of the body, suggest that the origin of it may be referred to the invasion from without of micro-organisms. In the zone of tissue contiguous to that which has iindergone necrosis ma}^ be found cocci, which in number appear like a pure culture. At the periphery of the necrotic zone which has been invaded by cocci the connective tissue is found, in a state of active proliferation. The entire condition is suggest- ive of the tissue necrosis in field-mice, which is caused b\' a chain coccus, described b}' Koch. Up to the present time the specific nature of the cocci wiiieh Ranke found in noma tissues has not been shown. Undoubt- edl}', further bacteriological research will prove that noma is a mj'cotic necrosis, an3 ary haemorrhage. During the pulpy degeneration or molecular disinte- gration of the tissues vessels are implicated, and a sudden haemorrliao-e from a large vessel frequently leads to a rapidly fatal termination. The large vessels show an unusual resistance to the destructive effect of hospital gangrene, but not infrequently the}' give way, especially if the disease attack a stump after amputation. Septic intoxication is never so well marked in hospital gangrene as in diphtheritic affections of mucQUS membranes. Billroth believes that hospital gangrene is caused by a specific micro-organism which is onl}- reproduced under certain atmospheric conditions; hence tlie appearance of the disease formerly in an epidemic form. Clinical observations leave no doubt that tlie disease is carried from one patient to another by means of sponges, instruments, hands, etc. Perforating Ulcer of Stomach and Duodenum. — These ulcers follow circumscribed necrosis of the wall of the stomach or duodenum, caused by a diminished arterial blood-supply of a limited vascular district. Tliat these ulcers are of vascular origin is shown by their shape and direct relation to an arter3\ The defect is in the form of a cone, the base being directed toward the lumen of the viscus, and the apex cor- responds witli a small arter\' which must have been partially or com- pletely obstructed before the necrosis occurred. These ulcers are sometimes multiple, and in the stomach they are found in preference along the lesser curvature. After interruption of the arterial circula- tion the wedge-shaped ischeemic, necrosed portion is removed by the action of the gastric juice, and the ulcer is made. As perforating ulcer of the stomach or duodenum never occurs in cases of ulcerative endocar- ditis, but selects in preference 3'oung females, the causes of vascular obstruction must be of a local nature. The sphacelus shows molecular decay, but no trace of inflammation. Perforating ulcers of the stomach and intestines are of interest to the surgeon, because in case of perfora- tion their treatment has been brought within the legitimate sphere of abdominal surgery. The more frequent occurrence of perforation is prevented by circumscribed plastic peritonitis, which seals the defect or establishes an adhesion between the affected portion of the organ and some other organ. Perforating Ulcer of Foot. — This ulcer follows a localized necrosis of the foot, wliich is supposed to be in part, at least, the consequence of vasomotor disturbances, to whicli are added impediments to the circula- tion and frequently infection with pathogenic micro-organisms. This ulcer is remarkable for the regularity of its outline, looking as though a piece had been cut out with a punch. The defect corresponds to the shape of the detached necrosed tissue. The necrosis affects all of the 1S4 PRINCIPLES OF SURGERY. tissues of the part in which it occui's, not even sparing the bones and articuhitions of the foot. The dissections of Duphxy, Morat, Fischer, and others leave no doubt that this strange ulcer originates from necro- sis following degeneration of the nerves of the affected region. Infec- tion with pus-microbes follows the necrosis, — an occurrence which renders the treatment more intractable. Ergotine. — One of the effects of chronic ergot intoxication is symmetrical dry gangrene. Bread made of flour containing ergot has not infrequently occasioned, in Euroi)e, fatal epidemics, usually attended with dry gangrene. As before stated, the gangrene following the i.>ro- lonjred administration of this drug is either the result of a chronic angiospasm, or of a paralytic effect of the drug on the peripheral nerves. Prognosis. — ^The prognosis in a case of gangrene should be based on the etiolog}^ location, and extent of the disease which caused the gan- grene. The existence of complications must also be taken into careful consideration. Acute, rapid ly-s[)reading gangrene, irrespective of the causes which may produce it, must always be considered as an exceed- ingly grave condition. Mycotic progressive gangrene, with and without emphysema, unless treated early and heroically, proves fatal almost with- out exception, death resulting from septiciemia. Gangrene following obliteration of the principal artery of a limb would result in death, in the majority of cases, unless a fatal sepsis is prevented by early amputa- tion. Necrosis of the entire or greater part of important internal organs is incompatible with life from the greatly diminished or com- pletely suspended function of important organs. The prognosis, so far as life is concerned, in cases of senile gangrene, is rendered exceedingl}'^ grave when the gangrene spreads rapidly, in consequence of an ascending arterial thrombosis, or thrombo-phlebitis, and life is in imminent danger when the gangrene due to diminished blood-suppl}'^ is complicated by a rapidly-spreading suppurative inflammation, or if septic intoxicntion arise from invasion of the moist necrosed tissue with putrefactive bac- teria. The general condition and age of the patient play an important part in arriving at correct prognostic conclusions. Patients debilitated from antecedent, acute, and chronic disease are in greater peril of life than robust, healthy persons whose circulation and tissue resistance has not been impaired. Infants and the aged succumb to gangrene more readily than young adults and persons in middle life, although the gan- grene may have resulted from the same causes, reached the same extent, and inoculated the same parts. Gangrene of some important organ, as the lungs or intestines, is more dangerous to life than peripheral gan- grene. The co-existence of complications, such as diabetes, Bright's PATHOLOGICAL AND CLINICAL VARIETIES OF NECROSIS. 185 disease, tul)erculosis, valvular disease of the heart, and cirrhosis of the liver will iiilluence the prognosis correspondingly. Treatment. — The prophylactic treatment includes such measures, medicinal, dietetic, and otherwise, that are calculated to improve the blood-supply of the part threatened with gangrene, and if this has occurred, or is inevitable, to prevent putrefaction of the dead tissues, in threatened gangrene from obstruction of the main artery of a limb, the estal)lisiiment of collateral circulation must be aided by placing the limb in a horizontal or slightly-elevated position, and by the external application of dry heat. In the aged suffering from premonitory periph- eral symptoms of gangrene, its actual occurrence can often be posti)oned by massage, rubbing the limb from the toes toward the body for ten or fifteen minutes twice daily, and by the avoidance of all causes which would bring about stasis in the enfeebled blood-vessels. The minutest lesions of the skin, as abrasions, corns, bimions, ulcers, etc., should receive careful attention in all persons the subjects of a feeble circulation, as they frequently are the starting-point of a gangrenous inflammation. Diabetic persons are exceedingly liable to be attacked with gangrene after the slightest operation or the most insignificant injur}-, and on this account it is advisable to examine the urine before undertaking an operation in persons presenting the faintest evidences of this disease. As most forms of gangrene are of mycotic origin, all infective atria should be protected against infection from without by thorough antiseptic precautions. The prevention of decubitus has already been referred to, and here will be only mentioned the necessit}^ of securing for the iiecrosed tissues an aseptic condition by rigid cleanliness and antiseptic measures in cases where the necrosis has occurred, or where it cannot be prevented. In moist gangrene the prevention of putrefaction is a most diflScult task. Where gangrene of this tj-pe has occurred, or is antici- pated, the whole surface far beyond the area involved or threatened should be rendered aseptic in the same manner as in the preparation for an operation, and the parts protected as far as possi])le against invasion with putrefactive bacteria bj' an absorbent antiseptic dressing. A few layers of gauze and a thick compress of salicylized cotton answer an excellent purpose in meeting this indication. If gangrene with putre- faction has occurred, the etiological indications for local treatment are best met by multiple incisions through the necrosed tissues and under- mined skin and the application of a compress wrung out of a 1-per- cent, solution of acetate of aluminum. If the fcBtor is intense, Labar- raque's solution of chlorinated soda, properlj' diluted, answers an admirable purpose. In gangrene with partial separation of the slough and considerable undermining, permanent irrigation with either of these 186 PRINCIPLES OF SURGERY. preparations answers tlie best purpose. All patients suffering from iianffrene are debilitated from antecedent or concomitant causes, and consequently are badly affected b}' any form of the so-called antiphlo- gistic or sedative treatment. Fever is always the result of the entrance of septic material, and should therefore not be treated by antipja-etics, but by local measures directed toward the primary cause. Quinine in sedative doses does more harm than good. Veratrum viride, tartar emetic, and the innumerable chemical substances which have recently been so miicli lauded as anti-fever remedies should never be prescribed in the treatment of fever attending necrosis. The patient's strength must be supi)orted from the beginning b3' a liberal diet and the use of stimulants. If the heart's action is feeble, digitalis can be given with benefit. Quinine in tonic doses is indicated. Anorexia not dependent on high fever calls for some one or a combination of bitter tonics. The part affected must be placed at rest and in a position most favorable for the passage of the blood through tlie capillaries. The question of removal of gangrenous tissue and the amputation of a gangrenous limb should receive thoughtful, conscientious consider- ation before an operation is undertaken. The favorable results which have followed the operative removal of a gangrenous part after the line of demarcation had formed, and the great mortality of operations under- taken without such a positive indication, have led many good surgeons to advise postponement of all operative procedure until nature has indi- cated the site of operation. This conservative rule, however, is incom- patible with the teachings of modern surgery. We know that death in cases of rapidlj'-spreading gangrene is caused by septic intoxication. We also know that the cause of the septic intoxication inhabits the dead tissue, and we are also aware that the extension of the immediate cause of gangrene (vessel-obstruction), ascending thrombosis in the arteries, and ascending thrombo-phlebitis in the veins proceed from the gangre- nous part. In view of these facts, the delay of operative measures in the treatment of gangrene until the line of demarcation has been estab- lished would be to wait for something which, in the most urgent cases, never occurs. In the absence of sjmptoms indicating danger from septicaemia it is not only advisable, but absolutely necessary, to postpone the operative removal of the gangrenous part until nature locates the site for the operation by the formation of the line of demarcation. In aseptic dry gangrene involving parts where no formal operation is neces- sary- to secure a favorable healing, later spontaneous elimination should be waited for, and after separation of the necrosed tissue the granulating surface is treated in the usual manner. In moist gangrene the dead tissue is removed as soon as partial separation has taken place bv divid- PATHOLOGICAL AND CLINICAL VARIETIES OF NECROSIS. 187 ing with scissors the more resistant structures, as fascia and tendons, after which the resulting wound is treated upon antiseptic principles. In gangrene of the extieraities amputation can be done safel}', and with good prospects of success, as soon as the line of demarcation has formed. In such cases it is necessary to remove as little as possible of the health}' tissue b}' carrying the incisions in such a manner as to leave flaps composed of health}^ tissue simply long enough to cover the bone. No t^'pical operation should be adopted, as the flaps must be made not in conformity with an}' text-book rules, but the condition of the limb. If the patient is febrile, and the character of the fever indicates as its origin the gangrenous part, delay, to sa}' the least, is attended b}^ in- creased danger of extension of the gangrene, and death from septicaemia. Such cases fare best at the hands of prudent but courageous surgeons. Procrastination in such eases is a sign of timidity or ignorance. What is to be done must be done at once. The patient and friends must be made acquainted with the dangers incident to dela}', and the only pros- pect of recovery by early amputation. Consultation Avith one or more of the neighboring physicians is an absolute necessity in such cases. Fortified by a fair understanding with the patient and his friends, sup- ported by the advice and counsel of one or more of his colleagues, no surgeon need fear to follow the dictates of his conscience, even in the most unpromising cases. The distinguished Hueter related several cases where early amputation saved the life of patients who were in stupor from the eflJects of septic intoxication to such an extent that an anaes- thetic was unnecessary. Early amputation should be urged and done in all cases where life is placed in jeopardy from absorption of septic material from the gangrenous part. The results after amputation under such circumstances will always remain uncertain, because in many in- stances fatal general infection occurs soon after the development of the first general s3^mptoms, and the local infection frequently extends to the site of operation, rendering a recurrence of gangrene in the stump a great probabilit}-. Amputation should be done, as near as possible, through healthy tissue. Much good judgment is necessary to determine this location. It is safe to maintain that the more acute the attack, the more distant should the amputation be made from the apparent boundar}'- line of the gangrene. In gangrene from obstruction of a large blood- vessel and in gangrene attended by ascending thrombo-phlebitis, arterial thrombosis, or both of these conditions, the line of amputation should fall through a point where the vessels are patent, otherwise a recurrence of the disease is almost sure to take place. Before the amputation is made the part to be removed should be enveloped in towels wrung out in an antiseptic solution for the purpose of preventing contamination of 188 PRINCIPLES OF SURGERY. the wound with septic iiuileiiul Troin the dead tissue. It is almost need- less to mention that Esmarch's elastic bandage should never be used, as b^' its application septic material might be forced into the circulation. The limb should be rendered as nearly as possible bloodless by holding it for a few minutes in a perpendicular position, when an elastic con- strictor is applied some distance above the point selected for tiie ampu- tation. In septic patients the parenchymatous oozing sometimes is dilHcult to control, but is managed most successfully by keeping the limb in the elevated position, and by making surface-pressure with a large, flat sponge or gauze compress wrung out in hot water. As most of these patients are prostrated from the effects of the disease, they are liable to suffer from shock, and measures should be resorted to to prevent this complication, or, at least, diminish its severity. For this purpose a subcutaneous injection of yj^ to ^1^ grain of atropia with ^ grain of morphia is administered hypodermatically before the anaesthetic is dimin- ished. Two ounces of whisky or the same amount of brandy is given at the same time per oi-em, or, preferably, jper i-ectum. Ether is preferable to chloroform in these cases as an anaesthetic. After the operation the most careful after-treatment is required to meet possible emergencies. Shock is treated b}^ alcoholic stimulants, camphorated oil, musk, and coffee. If the stomach is irritable, brandy, whisk}', or coffee is admin- istered by the rectum. Camphorated oil or musk is given hypoder- maticall}^ every half-hour until the patient reacts. External heat is use- ful in relieving congestions of internal organs and in stimulating the action of the heart. Amputation wounds made through tissues that are not positivel}^ known to be aseptic should alwa^'s be drained ; this is the more necessary if the soft tissues are oedematous. Should the tissues at the seat of amputation not present a satisfactory appearance, it is advis- able to go up higher, more especially if the vessels are obstructed by a thrombus. The fate of the patient is decided within a few days after the amputation. Tiie most favorable symptom is a reduction of the temperature to normal within a few hours after the o[)eration, which will be the case if the fever has been caused by a septic intoxication. With the removal of the tissues which furnished the toxic substances and the elimination of these through the secretory orgaiis the septic symptoms subside, and if the patient has sufficient strength left to carry him over the immediate effects of the operation the prospects of recovery are good. If the patient is the subject of a progressive sepsis, the amputa- tion, in all probability, will prove powerless as a life-saving measure, as the microbes which have reached the circulation reproduce themselves with great rapidity, and death from this cause results within a few hours to several days. Prompt improvement soon after the operation, with PATHOLOGICAL AND CLINICAL VARIETIES OF NECROSI?. 1 S9 recurrence of febrile sj-mptoms in a few da^'s, indicates the occurrence of gangrene in the stump. Such S3-raptoms demand a change of dressing. If gangrene is present, all sutures are removed, a tiiorough local disin- fection practiced, after which the stump should be treated b}^ constant irrigation. Reamputation at this time would, in all probabilitj^ prove fatal, and reliance on local disinfection, combined with the use of stimu- lants and tonics, is advised, with a feeble hope that these measures may become the means of limiting the extension of the disease, and of sup- porting the heart's action until the line of demarcation is established, when the surgeon's services are again required to assist nature's efforts in the elimination of the dead tissues. In noma and hospital gangrene, the infected tissues are removed with the sharp spoon, and after thorough antiseptic irrigation the actual cautery is applied, and the further man- agement of the wound is the same as in case of infected wounds from other causes. Chlorinated water or a solution of bromine are excellent preparations after the primary disinfection and cauterization in the treatment of these diseases. CHAPTER VIII. Suppuration, bacteriological causes and histogenesis of suppuration. Suppuration is the most frequent termination of acute inflammation. Inflammation terminating in the formation of pus is called suppurative, both on account of its etiology and the nature of the inflammatory product. Suppuration is the process by which the morphological elements of the iuflaramatory product, the leucocytes, and embryonal cells are converted into pus-corpuscles. Suppurative inflammation is caused b}' the action upon the tissues of specific micro-organisms, the pus-microbes, and the transformation of leucocytes and embr^'onal cells into pus-corpuscles is accomplished by the same cause. The brilliant results which have been obtained b}'^ the antiseptic treatment of wounds made it exceedingl}^ probable that all wound-infective diseases are caused by living micro-organisms. The probability was increased when Koch, in 1879, showed the direct connection existing between certain traumatic infective diseases in animals and the never-absent definite micro-organ- isms. It requires no longer any arguments to show, at this time, that all inflammatoi'y wound complications, among them suppuration, are, without exception, caused by the introduction into the tissues of specific pathogenic microbes. Etiological!}', most of the purulent processes constitute more of a unity than was formerly believed, and the clinical varieties are mostly determined by the intensity of the infection, the manner of localization, and the degree of resistance possessed b}' the tissues. The most conclusive evidence of the correctness of this asser- tion is furnished by the fact that the same streptococcus which produces a simple abscess is likewise the most frequent cause of progressive gan- grene, and of that most grave form of suppuration — p^'aemia. I. HISTORY OF MICROBIC ORIGIN OF SUPPURATION. As in the case of nearly all infective diseases, j^ears before the specific pus-microbes were discovered, living organisms were found and described in pus, and were believed to be the essential cause of suppura- tion. T\vent3^-five j'ears ago Klebs discovered, in the tubuli uriniferi in cases of pyelo-nephritis following suppurative cvstitis, between the (191) 192 PRTNCrPLES OF SURGERY. pus-cells, small, round cocci, which he believed produced the infection. In 1872 the same author published the result of his researches, during the Franco-Prussian war, on septic-wound diseases. In this work he again referred to the micro-organisms which he had previously described, and showed that they existed in the tissues and organs — the seat of suppu- rative inflammation — before pus had formed. He also showed how these micro-organisms enter the circulation and become the direct cause of pathological conditions in distant organs. Even at that time he placed great stress on the fact that, as long as the cocci remained only in the tissues at the point of infection, they produce only local inflammation or necrosis, but as soon as the}' enter the circulation fever and other symp- toms of general septic infection follow. Ogston, the discoverer of pus-microbes, published the results of his observations and researches in 1881. This patient investigator examined the pus of 69 abscesses for micro-organisms, and found in 17 of them a chain coccus (streptococcus), in 31 cocci which arranged themselves in groups which resemble a bunch of grapes (staph^'lococcus), and in 16 both of these forms were present. In cold abscess he was unable to find either of these micro-organisms. He also ascertained that these two forms of microbes differed in their manner of diffusion in and action on the tissues, as the streptococcus, following the lymph-channels and con- nective-tissue spaces, was seen to be the cause of diffuse suppurative processes, while the staphylococcus was found by him only in abscesses which were circumscribed. Rosenbach took up the work where Ogston left it, and, as the fruit of a number of years of patient study and research, published his classical work in 1884 (" Microorganismen bei den Wundinfections Krankheiten des Meuschen," Wiesbaden, 1884), This work must serve as a basis for all future research on suppurative inflammation. Rosen- bach availed himself of the advantages offered b}^ an improved technique in bacteriological research, cultivated the different pus-microbes upon solid nutrient media, and pointed out the difference in the macroscop- ical appearances of the cultures of the different kinds of pus-microbes, which enabled him to differentiate between them hy the naked-eye appearances of the cultures upon the different nutrient substances. He discovered the staphylococcus p^'ogenes aureus, the micrococcus pyo- genes tenuis, and three kinds of bacillus saprogenes. Passet should be mentioned next in the long list of distinguished names of original investigators who have made the bacteriology of suppuration a special study. He discovered and described the staphy- lococcus citreus and the staphylococcus cereus albus and flavus,and from a perirectal abscess he cultivated the bacillus pyogenes foetidus. The INDIRECT CAUSES OF SUPPURATION. 193 streptococcus which he found lie uuiintained was different from the one described b}^ Rosenbacli, as it resembled more close)}' the streptococcus of erysipelas, but this claim has not been substantiated b}' subsequent investigations. The bacillus pyocyaneus was described by Gessard and Charrin. The gonococcus, the specific microbe of gonorrha\a, was dis- covered b>' Neisser in 1879. In our own countr^^ the micro-organisms of pus have been studied by such men as Sternberg, Osier, Councilman, Ernst, and Park. II. INDIRECT CAUSES OF SUPPURATION. Inflammation produces in the tissues conditions which must be regarded as indirect causes of suppuration. These conditions favor the suppurative process by bringing the histological elements of the inflam- matory product in a position or relation to the blood-vessels which impairs or suspends their nutrient supply. In acute inflammation the connective-tissue spaces become crowded, in a short time, with the corpuscular elements of the blood, which, b}' their presence in such great number, cause dilatation of these spaces and pressure upon the adjacent capillary vessels, which often result in complete stasis and consequently arrest of blood-suppl}'. In consequence of suspended nutrition arising from vascular obstruction, the leucoc^'tes undergo coagulation necrosis and lose their power of resistance to the action of pathogenic micro- organisms. If inflammation attack the fixed tissue-cells with an in- tensity short of producing necrosis, the cells proliferate and the embryonal cells thus produced constitute another source of histological elements of the inflammatory product. If the cells are produced in excess of the capacity of the inflamed part to supply them with new blood-vessels, the local anaemia thus created i)laces them in the same unfavorable condition as the leucocytes in the crowded connective-tissue spaces, and they are exposed to the same risk of death from malnutrition. If, as the result of rapid tissue proliferation and local ischtemia, the embryonal cell become completely detached from the matrix which produced it, it is placed in the worst condition, so far as its vitality and vegetative capacities are concerned, and it readily succumbs to the deleterious action of the pus-microbes. It can be set down as a rule that all conditions, local or general, which impair cell nutri- tion favor the suppurative process. Suppuration in inflammatory foci is always observed first where cell nutrition is most impaired, hence in the primar}^ inflammatory product among the leucocytes most distant from capillary vessels, and among embrj-onal cells that have become isolated or occupy a place most remote from the vascular supply. 194 PRINCIPLES OF SURGERY. III. DIRECT CAUSES OF SUPPURATION. Clinical suppiiration is caused by the action of pus-microbes on the leucocytes and embryonal cells, by which these cells, the morphological elements of the inflammatory product, are converted into pus-corpuscles. A number of investigators maintain that suppuration can be produced artificially in animals by injecting into the tissues certain Chemical Pyogenic Substances. — The substances which have been found to possess the property of exciting suppurative inflammation are metallic mercury, turpentine, and croton-oil. Councilman introduced turpentine and croton-oil in aseptic glass capsules into the subcutaneous connective tissue of animals under strict antiseptic precautions, and, after the wound had healed and the capsules had become encysted, rup- tured them subcutaneousl3\ He found that both of these substances caused a circumscribed suppuration. Uskoff claimed that a consider- able quantity of indifferent su])stances, sucli as milk, olive-oil, etc., if injected subcutaneously in animals, either at once or b}'^ repeating the injection from time to time, caused suppuration, and that turpentine administered in the same manner always acted as a pj'ogenic agent. Orthmann, under Rosenbach's supervision, repeated UskofTs experi- ments, and, by resorting to more strict antiseptic precautions, could not verif}^ the correctness of his conclusions in reference to the pus-pro- ducing properties of indifferent substances. His experiments with croton- oil, turpentine, and metallic mercury always resulted in inflammation and suppuration. Graw'itz and de Bary ascertained that croton-oil, when injected in small quantities into the subcutaneous tissues of rabbits, caused a serous transudation or a fibrinous exudation, while larger doses acted as a caustic, and were only occasionally followed by suppuration. If they injected a mixture of pus-microbes and croton-oil it always was followed by the formation of pus. The}- maintained that certain chemi- cal substances, used in a definite degree of concentration, injected into the subcutaneous tissues of animals, prepared the tissues for the growth of the pus-microbes. From a later series of experiments Grawitz became more firml}' convinced that aseptic turpentine, used in sufficient quantities, always causes a suppurative inflammation in the connective tissue. Inoculations of different nutrient media with pus produced bj^ turpentine showed that it contained no pus-microbes. He also deter- mined that such chemical pus had a destructive effect on pus-microbes. Tills action of sterile pus he attributes not to the presence of ptomaines, but to the action of its albuminous constituents. His experiments also lead to the important observation that when gelatin cultures are over- saturated with album^^u, or peptone, pus-microbes cease to multiply. Very recently Rosenbach has made a series of experiments which has DIRECT CAUSES OF SUPPURATION. 195 convinced him tliat the chemical p3'ogenic substances which have bciii mentioned, when injected into the tissues of animals, cause suppuration independently of the presence of pus-microbes. Among those who, from their own experimental work, have come to diametricall}^ opposite conclusions, can be mentioned Scheuerlen, Ruigs, Natlian, and Biondi. If we consider for a moment how difficult it is, in experimenting on animals with indifferent substances and chemical irritants, to procure for the seat of injection a perfectl}' aseptic condition, it is not difficult to conceive that opinions still ditler in regard to the immediate and essen- tial cause of suppuration. Taking it for granted that certain chemical pyogenic substances, wlien injected in sufficient quantities into the tissues of animals, have the power to produce suppuration, inflammation and suppuration produced in such a manner represent clinically suppurative affections. Neither the inflammation nor the suppuration following it are progressive in their character. The chemical substance produces inflammation over an area which corresponds with the extent of its diffusion, and the cellular elements of the inflammatory product are converted into pus-corpuscles by the destructive action of the substance or their protoplasm. The whole course of the artificial aflection remains aseptic throughout, and the pus which is produced is aseptic and sterile, — not clinical, but chemical, pus. In suppuration, as we observe it at the bedside, the direct cause which produced it multiplies in the tissues, hence its tendenc}" to become progressive, and from the pus which is produced the immediate and essential cause — the pus-microbes — can be cultivated. Practicalh', in man, the occurrence of suppuration from the action of pyogenic chemical substances would be possible only on the surface of the body. Pus-Microbes. — That the pus-microbes are the immediate and essen- tial cause of suppurative in/lamination and jms formation has been well established by clinical observation and experimentation. Clinical experi- ence during the last twenty years has shown bej'ond all doubt that sup- puration in wounds can be prevented b}' measures which are calculated to remove, destro}', and exclude pathogenic micro-organisms from with- out. Rosenbach found that in dogs and rabbits a small quantity of a pure culture of the staphylococcus pyogenes aureus injected under the skin produced a most violent suppurative inflammation ; cultures of the staphylococcus pyogenes albus had the same effect. Cultures of the streptococcus p3'ogenes produced only slight inflammation in rabbits, while they proved very fatal in mice. Passet took a pure culture of the staphylococcus pj^ogenes aureus the size of a pea, grown upon potato, and mixed it with 1 cubic centimetre of distilled water. Of this mixture he injected under the skin of a mouse 0.1 cubic centimetre ; the animal 196 PRINCIPLES OF SURGERY. recovered. Another mouse was treated in the same manner, but 0.04 cubic centimetre of a liquefled-gelatin culture was used, and this animal died in eighteen hours. Cocci were found in the blood. In rabbits and dogs a subcutaneous injection of 1 cubic centimetre of liquid-gela- tin culture of the aureus usually produced an abscess at the point of inoculation. If the dose was increased to 5 cubic centimetres of the same culture the animals died in from eighteen to twenty hours. At the same time a local inflammation was found at the site of inoculation. In all of tlie fatal cases the pus-microbe was found in the blood. Of the culture of the streptococcus pyogenes it was found necessary to inject a considerable quantity in order to produce suppuration. Liquefied-gela- tin cultures of the staphylococcus p3^ogenes aureus and albus, in doses of 1 cubic centimetre, injected into the abdominal cavit}^ of rabbits, were well tolerated, and death was produced only when the dose was increased to from 4 to 6 cubic centimetres. Injection of cultures of the strepto- coccus pyogenes into the peritoneal cavity was even better tolerated, and usually had to be repeated several times before the animal died of septic peritonitis. A needle dipped into a culture of pus-microbes he could insert into points without causing suppuration ; but the injection of from 0.3 to 0.5 cubic centimetre of a mixture of pus-microbes, sus- pended in distilled water, into the hip-joint of rabbits, was followed by suppurative arthritis, rupture of the capsule, and diffuse para-articular phlegmonous inflammation and suppuration, and often death of the animal. Injection of 1 or 2 drops of a liquefied-gelatin culture of the staph3dococcus pyogenes aureus, or albus, into a vein of a rabbit did not produce any serious disturbance, but if the dose was increased to from 0.5 to 1 cubic centimetre, it, as a rule, caused fatal disease. In such cases, multiple suppurating foci were found in the kidneys, liver, spleen, and lungs, with pleuritis and peritoneal eff'usions, pericarditis, and myocarditis ; also serous and purulent eff'usions into joints and muscular abscesses. The effect of inoculation with pus-microbes in man is the same as in animals. Garre made a superficial abrasion on one of his fingers, and applied a pure culture of the staphylococcus pyogenes aureus ; the only symptom observed was a slight redness eighteen to twenty-four hours after the inoculation. He then made three small incisions, and inocu- lated himself with a larger quantity of the culture, which was followed by superficial suppuration. Fehleissen repeated the same experiments upon himself with cultures of diflTerent kinds of pus-microbes, and, if he succeeded in causing suppuration, this was alwa3's slight. He also found minute doses, administered subeutaneously, harmless ; while larger doses, suspended in water, almost without exception caused abscesses, and, in DIRECT CAUSES OF SUPPURATION. 197 animals, very large doses produced death from sepsis before suppuration could take place. Brockhardt introduced a trace of a mixed culture of staphj'lococcus aureus and albus into the cutis of his left fore-finger; after forty-eight hours a small abscess had formed, which was opened, and in the pus the same microbes were demonstrated, Bumm injected a pure culture of the 3'ellow staphylococcus into the subcutaneous tissue of his own arm, and into the arms of two other persons. In each in- stance an abscess developed, which varied from the size of a pigeon's egg to that of a man's fist, according to the time which elapsed before they were opened. In the pus of these abscesses the same pus-microbe which had been injected was found. The above observations are con- clusive in showing that pus-microbes can be cultivated from the pus of every acute abscess, and that, in man and animals, the injection of a sufficient quantity of a pure culture into the tissues is followed by sup- puration ; and thus far positive proof has been furnished of the direct etiological relationship which exists between pus-microbes and suppura- tion. Rinne has recently published an accovmt of his experiments, and his results are somewhat in conflict with the authorities quoted above. He frequently failed to produce suppurative inflammation, even when he injected a large quantit}^ of a pure culture, and by repeating the injec- tion from time to time. He is of the opinion that, when the absorptive capacity of the tissues is not diminished, the pus-microbes are removed too rapidly to produce their pathogenic effect. The eflect of inoculation with pus-microbes will, of course, always var}^, according to the quantity of the microbes and the local and general susceptibility of the animal experimented on. Watson Cheyne has shown most conclusively that the number of bacteria introduced greatl}' modifies not only the intensity of the s^'uiptoms, but also the character of the disease. His experiments were made with cultivations of Hauser's proteus vulgaris. He estimated that j^o cubic centimetre of an undiluted culture of this microbe con- tains 225,000,000 bacteria, and when this quantity was injected into the muscular tissue of a rabbit it produced speedy death. A quantity of the same culture corresponding with -^-^ cubic centimetre, administered in the same manner, caused an extensive abscess at the point of injection, and death of the animal in six or eight weeks. Doses of less than -^^-^ cubic centimetre produced no effect, — in fact, doses of less than ^^ to ^^^ cubic centimetre, or, in other words, fewer than about 18,000,000 bac- teria, seldom caused any positive result. The same author found that in the case of the staphylococcus pj'Ogenes aureus it was necessary to inject something like 1,000,000,000 cocci into the muscles of rabbits, in order to cause a rapidly-fatal result, while 250,000,000 produced a small abscess. In the case of the tetanus bacillus, death did not occur in 198 PRINCIPLES OF SURGERY. rabbits when fewer than 1000 bacilli were introduced. He believes, as does Rinne, that the action of the preformed ptomaines on the tissues modifies the result. It is, therefore, probable that, in the experiments in which injection of pus-microbes did not produce suppuration, an insufficient number of active microbes were used, and that where indif- ferent substances and chemical irritants caused suppuration the implanted or injected material was contaminated, or that infection at the point of injection occurred through the wound, or subsequently through the cir- culation. The latter method of injection should always be borne in mind in cases where the presence of an aseptic substance in the tissues has apparently been the cause of suppuration. The tissues altered by the action of chemical irritants constitute a foreign substance, which ma}^ determine localization of microbes floating in the circulation, while, at the same time, the chemical alterations which they have caused in the tissues have prepared a favorable soil for their reproduction. Of late a number of pathologists have gone one step farther, and maintain that pus-microbes are not the direct cause of suppuration, but that their presence is essential for the production of ptomaines, to which they attribute p^'ogenic properties. If certain pyogenic, aseptic, chemical substances can convert living cellular elements into pus-corpuscles, as has been asserted upon good authority, we should naturally expect that chemical substances produced by pus-microbes in inflamed tissue might possess the same pathogenic propert}^, and we will briefly consider what is known in reference to Ptomaines of Pus-Microbes as a Cause of Suppuration. — Grawitz and de Bar}', after detailing the results of their experiments with injections of chemical irritants in their investigations on pus formation, give an account of their experiments with the ptomaines of pus-microbes. They maintain that these ptomaines, like chemical irritants, prepare the tissues for the growth and reproduction of pus-microbes. The action of these substances can be studied b}' injecting sterilized cultures of pus-microbes, in which the only active agents could be the preformed toxines. These observers injected 4 cubic centimetres of a sterilized culture of the staphylococcus pyogenes aureus under the skin of a dog, with the effect of causing suppuration. The pus was examined for microbes, but none were found. They assert that the presence of ox3'gen is of the greatest importance in the production of ptomaines. Grawitz experimented also with a pure preparation of cadaverin, prepared by Brieger from bacteria. Cadaverin is a colorless fluid, the chemical formula of which is identical with pentamethylendiomin ; a 2^-per-cent. solution of this substance destro3'ed the staphylococcus p3'ogenes aureus in an hour, and a small quantity added to a culture of pus-microbes arrested further growth. DIRECT CAUSES OF SUPPURATION. 199 A solution absolutely free from microbes, injected under the skin of animals, according to strength and quantity' used, produced cauterization or inflammation, terminating in suppuration or inflammatory oedema, followed by resolution and absorption. The pus produced by cadaverin contained no bacteria as long as the skin remained intact. The injection of a mixture of a solution of cadaverin and pus-microbes was alwa^'s followed by a progressive phlegmonous inflammation. Schenerlen was the first to study the local action of ptomaines on the tissues. He intro- duced into the subcutaneous connective tissue of rabbits aseptic glass capsules containing sterilized infusion of meat. The wounds healed by primary union. As soon as the capsules had become encysted, he broke off both ends of the capsule, so as to saturate the tissues in its imme- diate vicinity with the fluid it contained. Three to six weeks after implantation of the capsule an incision was made down to it, and the parts submitted to a thorough examination. The ends of the capsule were always found to contain a few drops of thin, 3'ellow pus, which, under the microscope, showed all the characteristic appearances of that fluid. No inflammation of the surrounding tissues. Cultivation experi- ments with the pus 3-ielded negative results. It is evident that suppura- tion in these instances was caused by the action of the preformed ptomaines on the leucoc3'tes and embryonal cells, and that its extension did not occur because the cause did not multiply in the tissues. In about twenty experiments the pus was found only inside of the cap- sule. Weigert has repeatedly' shown that the diflTerence between a purulent and fibrinous exudation can be readily demonstrated, as the former does not coagulate, although white corpuscles and plasma may be present. Klemperer believes that this difference is due to previous destruction of fibrogen in the pus by the pus-microbes. The putrid-meat infusion used b}' Schenerlen caused limited suppuration, and on that account it must also have possessed the propert}' to prevent coagulation. To prove this he made the following experiment : The abdomen of a rabbit was opened while the animal was under the influence of chloroform, and blood was drawn directl}' from the aorta into a glass tube containing putrid extract of meat. As the fluids graduall^^ became mixed the blood assumed a brownish-red color; coagulation did not occur for hours and da}'S, while in the control experiments, with solution of salt, the blood coagulated firml}' after the lapse of a few minutes. He next made thirty cultures of the staphylococcus pyogenes aureus upon agar-agar gelatin, and the same number of cultures of the albus, and after completion of their growth, fourteen days later, he sterilized them with l)oiliiig water, and, after shaking the fluid, removed the cultures and boiled them for a 200 PRINCIPLES OF SURGERY. few minutes, and fiufilly filtered them ; he thus obtained about 150 cubic centimetres of a light-yellow fluid. This was reduced to 8 cubic centi- metres by boiling ; before using, the fluid was again filtered. The filtrate was put in capsules, and after sealing their ends hermetically they were inserted into the subcutaneous connective tissue of animals with the same care as in the preceding experiments. The suppuration which followed the breaking of the glass capsule in these cases was again found to be limited to the space with the capsule, being caused by action of the preformed ptomaines on leucocytes and embryonal cells, which found their way into the interior of the glass capsule. The cadaverin and putrescin, two ptomaines prepared by Brieger, were next experimented with in the same manner. In preventing coagu- lation the results were even more striking than with the former sub- stances. These experiments leave no doubt that ptomaines derived from pyogenic bacteria produce a chemical action on leucocytes and embryonal cells b}^ which they are converted into pus-corpuscles. The suppuration thus produced, however, never extends beyond the tissues which are brought in contact with them, and, therefore, always remains circum- scribed. In this respect the results of the experiments just cited do not correspond with suppuration as we observe it in practice^ as here from the same causes, and apparently often under the same conditions, the process presents the greatest possible vaiHations in reference to its intensity and extent. In one case the suppuration remains circumscribed, result- ing in a furuncle ; in others the regional infection is more extensive, and a diffuse, phlegmonous inflammation is the result; while in the third class the local infection leads to general systemic invasion, and the patient dies of sep)sis or pyaemia. The clinical form of suppuration is noted for the progressive character of the infection, which is due to the reproduction of pus-microbes in the tissues and the production of ptomaines pro- portionate in amount to the number of microbes present, and, perhaps, also modified to a certain extent by the character of the soil. Practi- cally, the matter remains the same as before it was known that the ptomaines produced in the tissues b}^ the p3^ogenic micro-organisms could cause suppuration, as pus-microbes must be introduced into the organism, where they must also find an appropriate soil for their repro- duction, before ptomaines can be produced in suflficient quantity to account for the occurrence of the clinical forms of suppuration. To the practical surgeon it is immaterial to know whether the transformation of leucocytes and embryonal cells is brought about by the direct action of pus-microbes or by the ptomaines which they produce in the tissues. Description and Specific Action of the Different Pus-Microbes. — The microbes which, when present in sufficient number in the tissues, excite DIRECT CAUSES OF SUPPURATION. 201 suppurative inflammation are called pus-microbes. Their effect on the cellular elements of the inflammator}' product is a specific one, convert- ing them into pus-corpuscles. Onl}- such microbes will be described here which have been cultivated from pus, and the specific action of which has been demonstrated experimentall}'. 1. Staphylococcus Pyogenes Aureus. — The yellow staph} lococcus is the microbe most frequently present in acute abscesses. Under the microscope it cannot be distinguished from the staphylococcus pyogenes albus. It is easily cultivated upon gelatin, agar-agar, coagulated blood- serum, and potato. The culture liquefies gelatin. It grows best at a temperature approaching that of the blood, but can be cultivated at 30° C. It peptonizes albumen and coagulates milk. The culture grow\s in the track of the needle and upon the surface of the nutrient medium. The gold-yellow color of the culture appears onl}' if the colon}' is ex- posed to atmospheric air. Cultures upon gelatin or agar-agar retain their virulence for a year or more. This coccus is met i with frequently in acute circumscribed abscesses, osteo- '^l^i^ 2 myelitis, pyaemia, and ulcerative endocarditis. |^ ,;|J 2. Staphylococcus Pyogenes Albus. — This pus- *.s|50s°* ?}sf^ microbe can be distinguished from the yellow coccus p^^ 49.— micro- only by the color of the culture, which is white. Both of°stap?yloc'oc^ Passet and Klebs have observed in the white culture of ^^s. (Rosenbach.) 1, culture twenty-four this coccus small yellow dots, which, when isolated, Jj^^Jt^'g "' ™'""^« '"" lost their color. These authors, therefore, consider the yellow and white staph3'lococcus as varieties of the same kind of pus-microbes. As other experimenters have not been able to verily these observations, we must take it for granted that the staphylococcus pyogenes albus diflTers from the aureus in that it possesses no power to produce the same yellow color which characterizes the culture of the latter. Its pathogenic properties, both in man and animals, are some- what less than those of the aureus. Passet claims that the white coccus is more frequently found in the suppurative lesions in man than the yellow, while Rosenbach makes a contrarj^ assertion. The latter author seldom found it alone in pus, but more frequently associated with the aureus. The cultures of both the 3'ellow and white staphylococcus ui)on gelatin present an irregular surface, and the margins are dotted with minute globular projections. Both of these microbes liquefj' gelatin, but agar-agar and coagulated blood-serum are not similarly affected. 3. Staphylococcus Pyogenes Citreus. — Found by Passet in about 10 per cent, of acute abscesses examined. Like the aureus and albus, it liquefies gelatin. Cocci singly, or in [tairs, or zoogloea. If cultivated 202 PRINCIPLES OF SURGERY. on nutrient gelatin, or agar-agar, a sulphur or lemon-yellow growth develops after twenty-four hours, which at that time resembles the aureus, but later does not change into a gold-yellow color. Like the aureus, pigmentation only takes place if the culture is exposed to air. According to Passet, its virulence is somewhat less than that of the aureus andalbus. This statement has been confirmed by Cheyne. When a cul- ture of this pus-microbe is injected under the skin of mice, guinea-pigs, or rabbits, an abscess forms, from the pus of which a culture of the same lemon color can be obtained. 4. Staphylococcus Cereus Albus. — This microbe was first discovered by Passet in the pus of a periosteal abscess of a finger, as well as in an abscess of the heel. A culture upon gelatin is distinguished from that of other pus-microbes upon the same nutrient medium by its forming a white, slightly-shining layer, like drops of white wax, with a somewhat thickened, irregular edge. The needle-stab develops into a grayish- white, granular thread. In plate cultivations, on the first day, white points are observed, which spread themselves out on the surface to spots one-half a millimetre in diameter; when cultivated on blood-serum, a grayish-white, slightl3'-shining streak develoi)s ; and on potato the cocci form a layer which is similarly colored. This microbe is not pathogenic in rabbits. 5. Staphylococcus Cereus Flavus. — Passet cultivated this microbe from the pus of a case of chronic periostitis of the tibia. If cultivated on gelatin, the growth, which is at first white, becomes of a citron- yellow color, resembling somewhat yellow wax, considerably darker than the culture of staphylococcus pyogenes citreus. Both varieties of staph3'lococcus cereus are verj^ rarely met witli in abscesses, and inocula- tion experiments with them have usually proved harmless. Baumgarten thinks it possible that in cases where they were found in abscesses the}' were not the cause of suppuration, but occurred as an accidental inva- sion after thep3'0genic microbes had disappeared. 6. Staphyloooccus Flavescens. — This microbe was found in an abscess by Babes, and occupies an intermediate position between the staphylococcus pyogenes aureus and albus. On gelatin, the growth forms a colorless layer and causes liquefaction. It is fatal to mice, sometimes causing abscesses, and, in large doses, septicaemia. 7. MicPGOGOCUS Pyogenes Tenuis. — Rosenbach found this micro- organism in a large abscess which liad given rise to no general s^-mptoms. It is of rare occurrence. On agar-agar it forms an exceedingly' delicate, almost invisil)le, white film. The individual cocci are irregular in shape, and larger than the staphylococci. In all cases in which this microbe is tlie sole bacterial cause of sup- DIRECT CAUSES OF SUPPURATION. 203 puration, the process appears to have been unattended by any very severe inflammatory symptoms, and little or no general febrile disturbances. This microbe was not found by an3^ one else but Rosenbacli until February, 1888, when Raskina isolated it from the pus and organs in a case of scar- latina complicated with pyaemia, which resulted fatallj' on the eighteenth day after the beginning of the primary disease. At the necropsy mul- tiple miliary abscesses were found in the kidne3-s, at the junction of the cortex with the medullar}' portion. From the pus of these abscesses a pure culture of the micrococcns was obtained. Inoculation experiments made on rabbits gave only negative results, even though the coccus was present in the blood twenty-four hours after inoculation ; hence it is problematical as to its being a pyogenic microbe. Like the staphylo- coccus cereus, it probabl}^ belongs to the so-called metahiotic microbes of Garre, occurring secondarily after suppuration has been established by genuine pyogenic microbes. 8. Streptococcus Pyogenes. — Cocci, somewhat larger than staphy- lococci, alwaj's divide transversely, so that the}- arrange themselves in the form of chains, which are usually more or less curved. /r*'***^ •^ V,. Fig. 50.— Micrococctjs Pyogenes Tenuis, B'ig. 51.— Microscopic Picture of Strep- Cultivated FROM Pus IN A Case of tococcus Pyogenes. {Rosenbach.) Empyejia. i Rosenbach.) The cocci also appear singly or as diplococci. Cultures grow very slowly on ordinary nutrient media at summer temperature, but with great rapidity at the temperature of the body. Cultivated in a streak on the surface of gelatin on a glass plate, this microbe forms at first whitish, somewhat transparent, rounded spots, of the size of small grains of sand. On agar-agar it grows most luxuriant!}' at a temperature of 35° to 37° C. Even if the inoculation is made with the point of a needle in a continuous line, the culture appears in isolated, small points. In its further growth the culture is elevated in the centre, and presents a pale, brownish color, while the periphery is flattened, except at the extreme margin, which is again raised, and often with a spotted appear- ance. Still later, the periphery develops successive layers or terraces, which were pointed out by Rosenbach as chai'acteristic macroscopic:il features of the cultures of this microbe upon solid nutrient media. The growth is so slow that in two or three weeks the maximum width of the culture streak is about 2 or 3 millimetres. In a vacuum the strei)to- coccus eftects peptonization of albumen and beef. Subcutaneous inocu- 204 PRINCIPLES OF SURGERY. latioii in mice yields negative results in about 80 per cent. ; sometimes a sliglit suppuration follows at the seat of puncture, at times the animal dies without showing any particular pathological lesions, and no micro- organisms can be found in any of the internal organs. In the subcu- taneous tissue of rabbits in small quantities they cause hyperemia, red- ness, and slight swelling, which disappear in the course of two or three days ; when larger quantities are used, some authors claim that they produce small circumscribed abscesses. In healthy rabbits intra-venous injection of even a pure culture of the streptococcus causes no serious symptoms. If the animals are debilitated previously by injections of toxic substances, death was caused by rapid reproduction of the microbe in the tissues. If a pure culture is injected into a serous cavity, it causes, first, inflammation, and, later, effusion, which is again absorbed. In the pus from tlie human subject the streptococcus is found in about 40 to 60 per cent, of the specimens examined. This pus-microbe invades the tissues far in advance of suppuration. It is found most frequently in inflammations following the lymphatic channels. It is also found in >Su, Fig. 52.— Bacillus Pyogenes Fcetidus. Fig. 53.— Bacillus Pyocyaneus. X700. X790. {Fluegge.) (Fluegge.) grave affections, in progressive gangrene. In several cases of pyaemia cultures of the pus yielded a growth composed exclusively of the streptococcus. 9. Bacillus Pyogenes Fcetidus. — Passet found this micro-organism in the pus of a perirectal abscess. This bacillus possesses slow motion, its ends are rounded, and in cultures appears usually in pairs. In stained specimens each bacillus shows in its interior one or two spores. This bacillus grows on gelatin, forming a delicate white or grayish layer on the surface, but causes no liquefaction. When culti- vated on agar-agar and potato it has the appearance of a light-brown, glistening layer, which emits a very offensive odor. In mice traces of the culture do no harm ; the injection of several drops causes septicaemia. Injection of about 10 minims of the culture into guinea-pigs causes an abscess, in which the bacilli alone are found as pyogenic cause ; direct intra-venous injection causes sepsis. 10. Bacillus Pyocyaneus. — It has been known for a long time that the greenish-blue color of the pus, occasionally found in the pus of sup- purating wounds, is due to the presence of a color-producing microbe. PUS. 205 The investigations of Gessard and Charrin, Ernst, Fordos, and Ledder- hose have shown that this chromatogenous microbe is the bacillus pyoc3'aneus. In the pus and on solid culture media the bacilli appear in pairs, small groups, or, what is more common, large masses, or zodgloea. This bacillus grows upon gelatin, which liquefies and is stained a greenish blue. It also grows vigorously on agar-agar and potato, both of these substances being stamed a greenish hue. In milk it causes caseation, with subsequent peptonization of the casein and simultaneous appearance of ammonia, while the coloring material a^jpears on the surface in the form of greenish-j^ellow spots. Fordos and Gessard isolated the coloring material which this bacillus produces, and called it pyocj'anin. It is soluble in chloroform, and from a pure solution crystallizes in long, blue needles. Fluegge asserts that this bacillus is devoid of pj'ogenic properties, and appears only as a harmless settler upon wounds. Ledderhose, by cultivating this bacillus upon a large scale, obtained a considerable quantity of pyocyanin, and by chemical analysis determined its formula to be C14H14, NgC. In doses of 1 gramme, as muriate of pj-ocj'anin, injected into the circulation of different animals, he observed no toxic sj-mptoms. When a pure culture of the bacilli was injected, he produced suppurative inflammation, and attributes this result not to the presence of p3-ocyanin, but to other as yet unknown phlogistic and pyogenic substances elaborated by the bacillus in the tissues. IV. PUS. Pus is the liquefied product of suppurative inflammation. It can be defined as a dead or dying tissue composed of cells with a fluid inter- cellular substance. Pus is an opaque, creamy, j^ellowish-white or greenish-white fluid, which, in a recent state, shows a slightl3"-acid reaction, and, later, becomes alkaline b}- the formation of ammonia. If it is of a yellowish color, creamy consistence, and odorless, it is the pus bonuni vel laudabile of the old authors. If it is thin and intimatel}' mixed with blood it is called sanious or ichorous pus. If it contain but few pus-corpuscles and resemble serum, we speak of serous pus. Pus undergoing putrefaction from the presence of saproplu'tic bacteria is rendered fetid, and is then termed fetid pus. Pus mixed with the products of tubercular inflammation is designated tuberculous pus, and if mixed with the secretion of an inflamed mucous membrane it is defined as muco-pus. If pus is allowed to stand undisturbed for a number of hours in a test-tube, it separates into two parts ; the upper, the liquid portion, is the pus-serum, or liquor puris, while the lower represents the solid constituents of the pus, the pus-corpuscles. 206 PRINCIPLES OF SURGERY. Pus-serum. — The pus-serum contains albumen, a compound called pyine, regarded by Mulder as identical with tritoxide of protein, occa- sionally chondrin, glutin, and leucine, abundant fatty matter, and inor- ganic substances similar to those dissolved in the liquor sanguinis. Pus-serum contains no oxygen or hydrogen, or if present these gases are found only in minute quantities. On the other hand, it contains nitro- gen and carbonic acid in large amounts. It contains more potash and soda than blood-serum. Among the albuminous substances which it contains are paraglobin, albuminate of potash, serum, albumen, and my- osin. Pus-serum, in fact, is liquor sanguinis pZus soluble compounds which have developed during the inflammatory process ; hence it contains in solution the ptomaines elaborated by the pus-microbes. Fig. 54. {Koch.) 1, white corpuscles from normal blood ; 2. pus-corpuscles with cocci in their interior; 3, pus-corpuscles with bacilli in their interior. Pus-corpuscles. — The histological sources of pus-corpuscles are the leucocytes and embryonal cells. In acute inflammation the process is so rapid that the pus-corpuscles are derived almost exclusivel}^ from leuco- cytes. The conversion of a leucocyte into a pus-corpuscle in clinical suppuration is invariably accomplished by one or more kinds of pus- microbes which have been described. The pus-microbes constitute the most important morphological element of the product of suppurative in- flammation, being not only diffused between the cells, but also find their way into the interior of the cells. All pus-corpuscles show structural changes which indicate disinte- gration. The leucocytes present, as the first evidence of transformation into pus-corpuscles, fragmentation of the nucleus. Nuclear fragmentation is an entirely different process from karyo- PUS. 207 kinesis, as it is not, like the latter, an indication of cell reproduction, but of cell destruction. The nucleus breaks up into two to six or more fragments, the cell-body still retaining its original form. Fragmenta- tion of the nucleus is attended bj- other forms of intra-cellular disinte- gration. The protoplasmic strings, which form a living reticulum in the interior of the nucleus and cell-body, break up and disintegrate. The embryonal cells, which are converted into pus-corpuscles, undergo similar retrograde changes, as have been described in the leucocyte. Pus- corpuscles are not always of the same size and shape. Their size will depend on their histological source. Those derived from leucocytes are 0^ Fig. 55.— Fragmentation of Nucleus in Leucocytes undergoing Transformation INTO Pus-COKPUSCLES. Hartn. 8, Oc. iv. (Landerer.) somewhat uniform in size, while in subacute and chronic suppuration the fixed tissue-cells in a state of proliferation furnish a large percentage of the pus-corpuscles, and consequentlj- their size varies according to the tissue-cells which undergo this change. As long as the leucocytes or embryonal tissue-cells are not completely destro3-ed b}^ the pus-microbes or their ptomaines, they var}' greatly in their shape. The variation in shape in fresh pus-corpuscles which have not com- pletely succumbed to the pus-microbes is due to their amoeboid move- ments. If pus from an acute abscess is examined in a moist cliamber upon a warm slide, the amoeboid movements of the pus-corpuscles can be observed for hours, provided the slide is kept at a proper temperature. 208 PRINCIPLES OF SURGERY. Pus-corpuscles subjected to the action of acetic acid clear up and show their fragmented nucleus much plainer. If pus-corpuscles are mixed with w.ater they become larger and hydropic from inil)ibition of fluids. The round pus-corpuscles, according to Recklinghausen, are ^ -yfm^ FiQ.56.— Ptrs WITH Staphylococcus. X 800. (Fluegge.) Fig. 57 —Pus with Streptococcus. (Fluec/ge ) dead leucoc^ytes or embryonal cells which have lost their amoeboid move- ments. Liquor potassa dissolves the pus-corpuscles, and, if added to fluids containing pus, changes them into a gelatinous mass. In chronic abscesses the pus-coi'puscles undergo molecular degeneration, and such (0) Fig. 58. {Billroth-Winiwarter.) X 400. 1, dead pus-corpuseles ; 2, various forms which living pus-corpuscles assume by their amoeboid movements ; 3, pus-corpuscles acted upon by acetic acid ; 4, pus-corpuscles after addition of water. pus under the microscope shows no well-formed corpuscles, but a mass of granular detritus. If the serum is absorbed, we speak of inspissation of pus. If a wall of cicatricial tissue form around a collection of pus, we say that the pus has become encysted or encapsulated. CHAPTER IX. Suppuration {continued). CLINICAL FORMS OF SUPPURATION. In reference to the time required to transform tlie product of inflam- mation into pus, suppuration can be divided into acute, subacute, and chronic. I. Acute Suppuration. — In acute suppuration tliewallof the capillar}^ vessels is altered so seriously that emigration of the colorless corpuscles takes place with such rapidity that within a few hours the connective- tissue spaces are crowded with them, and in a few days the iuflammatory swelling- presents indications of approaching suppuration. The inflam- matory swelling is hard to the touch, and the tissues around it become oedematous from obstruction to the plasma circulation within and in the immediate vicinit}' of the inflamed tissues. Tlie hardness of the swell- ing is due to the infiltration of tiie connective tissue with leucocytes. In this form of suppuration a central ischsemic area is established by the rapid accumulation of leucocytes in the connective-tissue spaces, and, by pressure upon the inflamed and weakened capillar}' vessels, finally' leads to complete stasis. The pus-microbes and preformed ptomaines are present in such large quantities thnt liquefaction of the inflammatory product takes place within a few days. The first appearances of suppu- ration are observed among the cellular elements which appeared first, which corresponds to a point in the centre of the inflammatorj' swelling, because at this point tissue nutrition has suffered most, and the inflam- matory product has been exposed longest to the deleterious influences of the pus-microbes and their ptomaines. The direct causes of conver- sion of leucocytes into pus corpuscles are the pus-microbes and their ptomaines, the pathogenic action of which on the tissues results in puru- lent liquefaction of the inflammatory product. Softening in the centre of an inflammatory swelling is almost an unerring sign of approaching suppuration. The central suppurating focus increases in size by the ex- tension of the process of liquefaction in all directions, the leucocytes saturated with the ptomaines of the pus-microbes being rapidl}' trans- formed into pus-cor[)uscles. Acute suppuration is always accompanied by more or less necrosis of the flxed tissue-cells. The acute cell necrosis " (209) 210 PRINCIPLES OF StJRGERY. is the result of diminished blood-supply and the local toxic effect of the ptomaines of the pus-microbes. Necrosis occurring so constantly from tlie combined action of these two etiological factors in acute suppura- tive osteomyelitis furnishes a good illustration of this. In phlegmonous inflammation, from the smallest furuncle to the largest acute abscess, connective-tissue necrosis is a constant occurrence, following as an un- avoidable sequence of acute suppuration. Acute suppuration is almost without exception attended by a complexus of symptoms, indicating the entrance of phlogistic substances from the inflamed tissues into the general circulation, such as fever, headache, thirst, loss of appetite, which usually subside with the removal of the primary cause. Acute osteo- m3'elitis, acute suppurative inflammation of the large serous cavities and joints, and phlegmonous inflammation of different organs are excellent ex- amples of what is understood by acute suppuration, from an etiological, pathological, and clinical stand-point. 2. Subacute Suppuration. — As acute inflammation may pass into a subacute form, so suppuration may be delaj'ed in acute inflammation for days and weeks, if the indirect and direct causes which are concerned in the transformation of the cellular elements into pus-corpuscles are present, less in degree and intensity than in acute suppuration. The character and intensity of the primary microbic cause may determine a subacute type of inflammation from the beginning, and suppuration is correspond- ingly delayed. In subacute suppuration the tissues have more time to accommodate themselves to the presence of the inflammatory exudate, and hence tissue necrosis is a less constant occurrence, and, if present, it is less extensive. In subacute suppuration, at least, a part of the pus- corpuscles are derived from the fixed tissue-cells ; while in acute suppu- ration central liquefaction of tlie inflammatory^ product often takes place within three or four days, the same stage in the subacute form is often not attained in as many weeks. As a rule, the general sj^mptoms are also less severe. 3. Chronic Suppuration. — In acute and subacute suppuration the pus- corpuscles are derived, in the former almost exclusively, and in the latter largely, from the extravasated leucocytes. With few exceptions chronic suppuration occurs as the result of infection with pus-microbes of a pre- existing pathological product composed of granulation tissue. In such cases the embryonal tissue is the product of a specific infiammation caused by the presence of micro-organisms which possess no pyogenic properties, but which excite in the tissues a chronic inflammation, the product of which consists of granulation tissue. The bacillus of tuber- culosis, the microbe of syphilis, and the actinom3'Ces are good illustra- tions of this class of microbes. If a lesion caused by any of these CLINICAL FORMS OF SUPPURATION. 211 microbes become the seat of infection witli pus-microbes, tlie latter and tlieir ptomaines are brought in contact with cells which are readily con- verted into pus-corpuscles. In chronic suppuration the pus-corpuscles are derived mostlj^ from embryonal cells, and consequentl}^ they show a greater variety in size and shape than the pus-corpuscles found in an acute abscess. Purulent liquefaction of a mass of granulation tissue is the characteristic pathological feature of chronic suppuration. Embr3'- onal cells derived from a,ny of the fixed tissue-cells are converted into pus-corpuscles by the pus-microbes and their ptomaines in the same manner as the leucocytes in an acute abscess, only that this result is attained more slowh\ In the majorit}' of cases chronic suppuration is the result of infection with pus-microbes of a pre-existing granulating- focus, the liquefied portion of which constitutes the contents of the chronic abscess. While an acute abscess is often developed in the course of a few days, and a subacute in as many weeks, it maj^ require as manj^ months or years for the products of a specific inflammation to be trans- formed into a chronic abscess. Suppuration in Wounds. — Infection of a recent wound with a suffi- cient number of pus-microbes is followed b}' suppurative inflammation, which in its local and general manifestations resembles phlegmonous inflammation as it occurs without a wound. One of the earliest evi- dences that such infection has taken place is a profuse primarj- wound- secretion. This secretion is a mixture of blood and serum, and is secreted in excess on account of the inflamed capillaries being more permeable, and 3'ielding more readily to the intra-vascular pressure. It is also possible that under these circumstances closure of the lumen of divided capillaiy vessels does not take place as promptly nor as com- pletelj^ as in aseptic wounds. Suppurative inflammation, when it attacks a recent wound, commences upon its surface, with which the microbes have been brought in contact, and the products of coagulation necrosis furnish a favorable soil for their growth and reproduction. In such a wound the process of granulation is either impeded or completely sus- pended until the acute S3'mptoms have subsided, as the embr^'onal cells are converted into pus-corpuscles almost as soon as the}- are formed. From the surface of the wound the inflammation extends to the deeper tissues, the extension being usually along the connective tissue, fascia, and intermuscular septa. The parts in the immediate vicinity of the wound present the usual appearances of a phlegmonous inflammation. The pus wliich forms first contains dead leucocj'tes, while later the embr^'onal cells furnish an additional histological source for pus- corpuscles. Granulating wounds are usually considered exempt from infection with pus-microbes. While this may be true if the whole surface 212 PRINCIPLES OF SURGERY. is covered with an uninterrupted, intact layer of licalth}- granulations, it is certainly not tlie case if the granulations are in any way injured or diseased. A slight injur}', as probing, ma}' create an infection-atrium, through which pus-microbes enter the deeper tissues, where the}' may become the cause of a suppurative inflammation. Under unfavorable vascular conditions the granulations are rendered hydropic, become flabby and aufemic, — conditions which impair their resistance to the action of pus-microbes, — which then convert the layer of embryonal cells most remote from the blood-supply into pus-corpuscles. Tlie pre- formed ptomaines injure the subjacent cells, which in turn undergo the same fate, and thus an unhealthy, infected granulation surface becomes the cause of a secondary suppuration in wounds which indefinitely delays the healing process. If in a suppurating wound the pus-microbes attack a vein and produce a septic thrombo-phlebitis, the essential etiological condition for the occurrence of the most dangerous and intractable com- plication, pyjemia, has been established. SUPPURATIVE INFLAMMATION OF MUCOUS MEMBRANES. Suppurative inflammation of a mucous membrane is always preceded by a catarrhal stage, during which the amount of the physiological secretion is greatly increased. Proliferation of epithelial cells takes place with such great rapidity that the blood-supply becomes inadequate, when the most superficial embryonal cells readily succumb to the specific action of the pus-microbes and are exfoliated as pus-corpuscles, The ptomaines become diffused in advance of the microbic invasion, and, by injuring the protoplasm of the cells more deeply located, prepare the way for the pathogenic action of the pus-microbes, and suppuration ex- tends more deeply. In this way ulcers form, which may remain super- ficial, or which may also penetrate deeply and result in perforation. The products of coagulation necrosis which form upon the surface of an inflamed mucous membrane favor the occurrence and extension of sup- purative lesions, as they serve as a means of fixation and propagation of the pus-microbes. Pus from a suppurating mucous membrane, examined microscopically, will show pus-corpuscles derived from leucocytes and embryonal, epithelial, and connective-tissue cells which have become detached before they are converted into pus-cells. I. Abscess. — An abscess is a collection of pus in the tissues. A collection of pus in a preformed space, such as the pleura, pericardium. Fallopian tubes, pelves of kidneys, etc., although resulting from a sup- purative inflammation of the walls lining the space, is by general custom and usage not called an abscess, but the presence of pus in any of these organs is indicated by the prefix pyo, to which is added the anatomical SUPPURATIVE INFLAMMATION OF MUCOUS MEMBRANES. 213 localit}- — thus, pyo-thorax, pjo-pericarclium, pyo-salpinx, pyo-neplirosis. The formation of an abscess is always preceded by a circumscribed sup- purative inflammation. Tlie histological conditions which are present at the time pus formation commences are characterized by a richness of leucocytes in the connective tissue between the inflamed capillary ves- sels and compression of the pre-existing tissue-cells b}' them and the transuded serum. Suppuration commences at one or more points in the infiltrated area ; if the latter is the case, the different suppurating foci soon become confluent, forming an abscess-cavit}-, which increases in size in all direc- tions, both by the products of inflammation breaking down into pus and by tlic iii'.cli:inif:il jtressure of the exudation and transudation upon the Fig. -Infiltration of Connective Tissue of Cxttis, with Beginning Suppuration IN THE Centre. X 500. (Billroth-Winiwarter.) surrounding tissues. The size of the abscess is determined by the nature of the primary" cause of the inflammation, its location, and the degree of local and general resistance inherent in the tissues and the patient. The staphylococcus is found more frequently in circum- scribed abscesses, while the streptococcus is more prone to give rise to diffuse purulent inflltration. A suppurating focus near a surface is not so likel}- to result in a large abscess as when it is more deeply' located, as in the former case spontaneous evacuation in the direction offering the least resistance is an early occurrence, while in the latter instance such a termination is onl}' possible after the abscess has reached considerable dimensions. An abscess which develops in tissues debilitated by a con- tusion or some antecedent lesions usuall}' reaches greater dimensions than if it occur in otherwise healthy tissues. In patients whose strength 214 PRINCIPLES OF SUKGEKV. has been impaired by old age, improper or insufficient food, intemper- ance, mental anxiety, or some antecedent acute or chronic ailment, it is well known that acute supi)urative inflammation manifests a great tend- ency to rapid extension, while a vigorous, health}^ body offers the most lavorable conditions toward limitation of the suppurative inflammation. While liquefaction of the inflammatory product progresses from the centre toward its periphery, the outer zone of the inflamed area is in a condition of hj'pera'mia and active tissue proliferation. The leucocytes beyond the infected area are not converted into pus-corpuscles, and with the products of tissue proliferation constitute an impermeable wall, beyond which infection cannot extend. The limits of the abscess is an aseptic zone of inflltration, clinically readily recognized by its hardness Fig. 60.— Vessels (Artificially Ixjected) from Walls of an Abscess Arti- ficially Produced in the Tongue of a Dog. X 25. (Billroth- Winiwarter). to the sense of touch — the so-called abscess-wail. As many of the small vessels in the centre of the abscess are permanently destroj'ed, a collat- eral circulation is established in the abscess-wall and its immediate vicinity by the formation of new vessels, as is well shown in the above illustration. According to their contents, causes, and the time which elapsed between the commencement of the disease which caused them and their formation, abscesses are divided into acute and chronic. (a) Acute Abscess. — The acute or hot abscess is the usual termi- nation of acute circumscribed suppurative inflammation. Its favorite location is in the connective tissue. It is always caused by infection with pus-microbes, most frequently the staphylococcus. It contains the SUPPURATIVE INFLAMMATION OF MUCOUS MEMBRANES. '215 characteristic yellowish, cream}- pus, the jyus honum et laudabile of the old authors, and shreds of necrosed connective tissue. It appears within a few da3-s after the commencement of the inflammation and reaches its maximum size in a short time. It is attended by the typical local and general S3 mptoms which accompany acute suppurative inflam- mation. Acute abscess in the abdomen usuallj- develops after perfora- tion of the intestine or one of its appendages; thus, perforation of the gall-bladder often gives rise to circumscribed suppuration between the liver, stomach, and colon, and perforation of the appendix vermiformis in the right iliac region, where the circumscribed collection of pus is called a perityphlitic abscess. The loose connective tissue that surrounds the kidne}' is often the seat of an acute suppurative inflamma- tion, giving rise to a perinephritic abscess. The connective tissue in front of the bladder, the so-called cavum Hetzii, when it is infected with pus-microbes, occasionall}^ becomes the starting-point of an acute abscess. In three cases of abscess in this locality-, that came under my observation, the infection was caused b}' a perforation of an intestine, and in all of them, after incision, scraping, disinfection, and drainage, a fsecal fistula developed subsequently. Suppurative parametritis is another instance of acute abscess, and is usually caused by infection through the uterine cavity or the Fallopian tul)es. Perirectal abscesses following suppu- rative paraproctitis are frequently preceded hy localized rectal lesions, tlirough which infection of the connective tissue surrounding the rectum with pus-microbes takes place. The manyiei' of invasion often determines the location and character of the abscess. Thus, in suppurative mastitis, the abscesses which are caused b}- staphylococci always begin in the deeper part of the organ and extend toward the surface, while in infec- tion with streptococci of the same part the inflammation shoots from some superficial abrasion and first attacks the skin, whence the process extends in a central direction to the deeper portions of the gland, where suppuration takes place (Cheyne). This diflerence depends on the manner of invasion of the two microbes. The staphylococci enter the organism through the milk-ducts and act from their interior, whereas the streptococci, like the microbe of erysipelas, enter the tissues through the lymphatic vessels, and their pathogenic action is primarily observed at the surface. Bumm excised a portion of the wall of a commencing abscess of the breast, and was able to demonstrate the presence of staphy- lococci in the interior of the acini, and their penetration thence into the inter-acinous tissue. The phlegmonous inflammation of the breast caused by streptococci takes place along the course of the l3mphatics, and primarily involves the inter-acinous connective tissue. Diagnosis. — The recognition of an acute abscess is usuall}- not 216 PRINCIPLKS UF SUliGKKY. attended by any grc.it diflloulties. The history of Jin attfvck of acute suppurative iulhininiation is the first thing to be talven into considera- tion. Fever is usuall}^ present, but if tlie abscess has been caused by tlie micrococcus pyogenes tenuis it may be sliglit, or entirel}- absent. The kjcation of the abscess has also considerable inihience on the temperature. There is no doubt that the same kind and number of pus- microbes in some tissues produce either a larger quantit}' of phlogistic substances, or that these in some localities and certain tissues find a more ready entrance into the circulation. Pain is always present, but is variable in intensit}'^ according to the location of the abscess and the nature of its surroundings. It is severe if the abscess involves parts freel}' supplied with sensitive nerves, and where the iiifianimatory product gives rise to an unusual degree of tension. Thus, a small abscess under- neath the deep fascia of a finger will cause more suffering than a large abscess in loose connective tissue. A beginning abscess can usually be accurately located by ascertaining the exact point of tenderness, on making pressure with the tip of a finger. If the abscess is suflScientlj' near the surface, fluctuation can l)e felt as soon as central liquefaction has occurred. Redness of the skin and diffuse oedema over and around the abscess are important s3^mptoms, denoting the presence of pus. Remembering all the S3'mptoms which point to the existence of abscess, in doubtful cases an absolute diagnosis should not be made by rel3ung upon any one or all of them, as b}' doing so serious blunders have been and will be made in treatment. Aneurisms have been incised under the belief that they were abscesses, and the less serious mistake has been made of treating an abscess for an aneurism. The late Professor Gunn, who WHS "well known as a careful and clever diagnostician, incised a large angioma in the occipital region, having mistaken it for an abscess. An inflammatory sw^elling occurring in localities where anuerisms are liable to be met with — that is, in the course of large blood-vessels — should be examined with the utmost care before an incision is made. The most dfficult cases for diagnosis are the few instances where a suppurative inflammation occurs around an aneurismal sac. Fortunately, we are in possession of a very simple diagnostic expedient, which, if resorted to, as it should be, in all doubtful cases, will enable the surgeon, with infallible certaint}^, to ascertain the presence or absence of pus in an inflammatory swelling, and this is the use of the exploring syringe. An ordinary hj-podermic needle with a long point will answer the purpose, although every surgeon should be supplied with an exploring sj^ringe made for this special purpose. The needle must be rendered thoroughly aseptic by heating it in the flame of an alcohol-lamp. The surface where the i)unctui'e is to be made is thoroughl}' disinfected, and the needle is SUPPURATn'E INFLAMMATION OF MUCOUS MEMBRANES. 217 inserted somewluat obliquely toward the centre ol' the swelling and pushed boldly forward in this direction until resistance ceases, which is an indication that it has reached a cavity ; the piston of the syringe is now slowlj' withdrawn and the fluid aspirated is examined ; if it is pus the diagnosis is made and the needle is withdrawn. If no pus is found the exploration is carried deeper, and, if necessary, in ditlerent directions without removing the needle, by making aspiration at different points so as to explore the entire tracks made by the needle. If no positive diagnosis can be made it may become necessary to repeat this method of examination in a few days. A rapidly -growing sarcoma may simulate a suppurative inflammation so closely that great care is necessary to distinguish between these aflections before any operative procedure is advised or undertaken. In exploring for pus in deep-seated abscesses in the abdomen or pelvis, care should be exercised to insert the needle in such a direction, whenever this is possible, as not to penetrate the free peritoneal cavit}^ ; whenever this cannot be done it should be intro- duced in such a manner that, after its removal, the puncture is sufficiently oblique to prevent the escape of pus. In such cases, it is always advisa- ble to combine aspiration with exploration. If the tension in the abscess is diminished b}' removing a portion of its contents extravasation is less likeh' to occur. Treatment. — A correct diagnosis made, the old rule ubi j^us ibi evacuo is as applicable and wise to the treatment of an acute abscess at the present time as it was centuries ago. Nothing is gained by expect- ant treatment. The popular belief that an abscess should be drawn near the surface by the use of fllthy poultices before it should be opened is fallacious both in theory and practice. An abscess is ready to be opened as soon as a sufficient quantit}' of pus has formed to constitute an abscess sufficient in size to be recognized by the surgeon as such. Students have generally been taught that an abscess should be evacuated by a free incision. This advice dates back to the time when antiseptics were not known and tubular drainage had never been heard of. The lajnng open of an acute abscess by an extensive incision is no longer necessar}-. The indications in the surgical treatment of an acute abscess are to open it in such a manner as to secure perfect evacuation and to resort to such means as will prevent re-accumulation of pus. These indica- tions can be fulfilled much better by making multiple small incisions and establishing free drainage by the insertion of tubular drains, than by making a single long incision ; at the same time, such treatment will leave the parts in better condition for rapid healing than by the old- fashioned incisions. The incisions need never be more than an inch in length, through which a rubber drainage-tube the size of the little 218 PRINCIPLES OF SURGERY. finger can be readily introduced. Abscesses uj) to the size of an orange do not require more than one incision. Abscesses larger than this should be treated by through drainage wherever this is possible. In deep-seated abscesses the first incision is made at a point wliere fiuctua- tion is most distinct, or in the direction of the track of the needle of the exploring syringe, if the pus has been located b^' the use of this instrument. Instead of incising the abscess with one stroke of the knife, I always incise the skin and fascia to the extent of an inch, and then wiLli a pair of sharp-pointed and hseinostatic forceps I tunnel the intervening tissues. As soon as the point of the instrument has reached the abscess-cavity, pus will escape along the side of the instrument; the handles of the forceps are now locked and the blades separated suf- ficiently so that upon the withdrawal of the instrument the opening is enlarged sufficiently to introduce a drainage-tube of requisite diameter. If counter-openings are to be made, the same forceps is carried across the abscess-cavity and pushed from within outward at a point where drainage is most required, the skin over the point is cut with a knife, the opening dilated, and a drainage-tube drawn through. The surface over the abscess and a considerable distance beyond it should be shaved and disinfected before the abscess is opened. After incision and drainage the abscess-cavity is washed out with a weak antiseptic solution until the fluid returns clear, when an absorbent antiseptic dressing is applied. After twenty-four or forty-eight hours the dressing is removed, the drain shortened, or, if through drainage has been made, the drain is cut through in the middle and each opening is drained separately. If sup- puration has not ceased the cavity is again irrigated. It is seldom that an abscess-cavity' heals without further suppuration after it has been incised and drained, even under the strictest antiseptic precautions. The inner lining of the walls of the abscess remains infected with pus- microbes, and a limited suppuration, even in the most favorable cases, continues, at least until after the second dressing. The dressings should be so applied as to make equable compression, for the purpose of keep- ing the surfaces of the abscess-cavity in accurate apposition. The drainage-tubes are removed as soon as suppuration has ceased, when healing of the aseptic cavity takes place by granulation, in the manner described in the healing of wounds. An important element in the treat- ment of abscesses is to secure absolute rest for the part affected. Pa- tients suff"ering from large abscesses should be kept in bed, and in the treatment of similar attections of one of the extremities rest is secured by the application of a well-padded splint, which will not only prove an efficient means of mitigating pain, but will keep the parts in a condition most conducive to rapid healing. SUPPURATIVE INFLAMMATION OF MUCOUS MEMBRANES. 219 (b) Chronic Abscess. — Clironic, conjestion, cold, or, as it is some- times called, migrating abscess can most alwa3^s be traced to some specific clironic inflammation, most frequently of a tubercular nature. What has been called a chronic abscess is very often no abscess at all. In tuberculous processes the product of tissue proliferation undergoes coagulation necrosis and disintegrates into a granular mass, which, when mixed with a sufficient quantity of serum, forms an emulsion that macroscopically resembles pus, but under the microscope shows none of the histological elements which are found in true pus. An abscess can only be called such if it contain pus. A true chronic abscess can origi- nate in a tubercular actinomycotic or syphilitic lesion when the granula- tion tissue is secondarily infected by the localization of pus-microbes^ which convert the embryonal cells into 'pus-corpuscles. Occasionally' secondary infection with pus-microbes of such a granulating focus is followed b}- an acute phlegmonous inflammation, which extends rapidl}^ to the surrounding tissues ; but usually the suppurating process pro- gresses slowly-, and is not attended by any of the symptoms of acute inflammation. What has been desci'ibed as a cold abscess is a cavity con- taining the debris of the product of a tubercular inflammation, and is in communication icilh the p)rimary lesion. Such abscesses frequently appear at a distance from the primary seat of the disease. Thus, tuber- culosis of the vertebrffi gives rise to a lumbar abscess if the swelling appear in the lumbar region. It is called a psoas abscess if the tuber- cular product gravitate along the course of the psoas muscle and appear as an abscess underneath Poupart's ligament. Abscesses originating in tlie hip-joint often, make their first appearance over the outer or inner aspect of the thigh, some distance below the joint. Abscesses originat- ing in the shoulder-joint often wander a considerable distance awa}' from the joint, along the course of the biceps or triceps muscle. . Bacteriological examination of the contents of such abscesses will show conclusively whether they are true pus-containing abscesses, or whether they are pseudo-abscesses. If cultivations are made with their contents, pus-microbes will grow upon proper nutrient media, if it is a true media, while from the contents of a pseudo-abscess onlj- the microbes of the primary infection can be cultivated. The information obtained 1)3- the discover}' of the essential cause can be confirmed by inoculation experiments. Cold abscesses, as a rule, are painless, not tender to the touch, and give rise to little or no febrile disturbances. Diagnosis. — The diagnosis of a chronic abscess is based not so much upon the location, size, and characteristic features of the swelling as a careful consideration of the symptoms of the local lesion from which it started. Tubercular affections of the spine and hip-joints are accompanied 220 PRINCIPLES OF SURGERY. by such well-defined symptoms fit the stage when abscesses form that the primary lesion can be located without much difIicult3^ A chronic paranephric abscess often develops in the course of a tubercular pyelo-nephritis. A tubercular pelvic abscess is frequentl}^ associated with primary tuberculosis of the Fallopian tube. A chronic abscess often arises around a tubercular gland and appears, in consequence of infection with pus-microbes, as a chronic suppurative periadenitis. In such cases the gland itself has undergone caseation, and is often found extensively separated from the surrounding tissues by the suppurative process. In reference to the nature of the swelling and the character of its contents, an exploratorj^ puncture will furnish positive diagnostic information. Treatment. — The indications for early surgical interference in the treatment of chronic abscess are not so urgent as in tlie acute variet}'. These abscesses appear months and often years after the commencement of the primary disease. While an acute abscess should alwa^'s be opened under antiseptic precautions, it becomes a matter of duty and conscience to deal with a chronic abscess in a surgical way, on!}- under the strictest and most elaborate antiseptic precautions. It is a well-known clinical fact that when such an abscess oi^ens spontaneously, or is incised in a careless way, profuse suppuration and hectic fever follow, with onl}'^ too often a speedy fatal result from septic infection. Additional infection with pus-microbes results in the destruction of the granulations which line the cavit}', and the patient dies from septic infection. Unless the surroundings of the patient admit of carrying out the antiseptic treat- ment to its fullest and most perfect extent, a chronic. abscess should not be evacuated by incision. A number of German surgeons have recently advocated the treatment of such abscesses b^^ aspiration and iodoform injections in preference to incision and drainage. One great difficult}^ in evacuating a tubercular abscess b}' aspiration is the blocking of the needle or trocar b3- shreds of necrosed tissue, which often interferes with complete evacuation. A chronic abscess should always be treated b\^ in- cision, if by such procedure the primary lesion can be made accessible to direct treatment. If such a course is adopted, the incision is made large enough so that the whole cavity can be thoroughly scraped out and all of the infected tissues removed. After thoroughly curetting the cavity is cleansed and disinfected, and after drying it is iodoformized. The wound is then sutured, drained, and treated on the same principles as a recent wound. The treatment of special forms of chronic abscess will be considered more in detail in the chapter on Surgical Tubercu- losis. 2. Phlegmonous Inflammation, with Suppuration. — Phlegmonous in- SUPPURATIVE INFLAMMATION OF MUCOUS MEMBRANES. 221 flammation with suppuration is clinically cliaraeterizecl b}^ rapid exten- sion of the disease without leading to a circumscribed collection of pus or abscess. From the pus of this form of infection the streptococcus can be cultivated more frequently than the staphylococcus, and in some cases both of these microbes are found in the same pus. The inflamma- tion affects the connective tissue, and extends rapidly' along intermus- cular septa, fascia, and tendon sheaths. This form of suppurative inflammation is prone to follow compound fractures, railroad and other crushing injuries, and all injuries attended by extensive contusion of connective tissue. The first s3"mptoms usually appear within four days after the injury. The general symptoms are ushered in b_y a chill, fol- lowed by high temperature and rapid pulse. The first local symptoms ai'e a copious, sanious discharge from the wound, and a rapidl3'-spreading oedema. The tissues are infiltrated with the same kind of fluid, and if life is prolonged sufficiently long a diffuse suppuration is inevitable. The symptoms of sepsis in this affection predominate because the pus- microbes have invaded an extensive area of tissue, and are reproduced with great rapidity and gain entrance into the general circulation at an early stage ; at the same time the necrosed tissues, saturated with the blood}^ serum, furnish a good soil for the growth of putrefactive bacteria. In most of these cases the septic cellulitis is accompanied by lymphangitis, the parts presenting an erysipelatous appearance. Treatment. — Phlegmonous inflammation of the t3pe just described calls for early and energetic treatment before suppuration has appeared. The pus-microbes are present in such quantities that the connective tissue partially devitalized by an injur^^ becomes necrosed from the local toxic action of the ptomaines of the pus-microbes. To render such wounds aseptic is one of the most difficult tasks in surgery. Small in- cisions and drainage will not accomplish the desired object. The in- fected tissues must be freely exposed b}' as many incisions as ma}' be required. The secondary disinfection in such a case must be regarded in the light of a capital oi)eration. The patient should be placed under the influence of an anjesthetic, the limb shaved and disinfected, and b}' large incisions the infected tissues must be rendered accessible to direct means of disinfection. Before undertaking the operation the limb should be rendered bloodless by applying Esmarch's constrictor. In compound fractures the tissues immediately over the fragments should be incised sufficiently so that the fractured ends can be turned out. The infected medullary tissue should be scooped out with a sharp spoon, and all clots and necrosed tissue removed; the parts are then thoroughl}^ irrigated with corrosive sublimate (1 to 1000), or carbolic acid (I to 20), after which the whole surface is dried and brushed over 222 TRINCIPLES OF SURGERY. ■with a lO-pov-ccMit. solution of cliloride of zino. Pockets luul sinuses which cannot be reached with the sharp spoon can be rendered aseptic 1>3' pouring in peroxide of hydrogen, whicli, in such cases, is a remedy of great vaUie. Tlie bones are then placed in proper position, a numlier of counter-oi)enings made, and a sufficient numl)er of tubular drains in- troduced; after which a copious antiseptic dressing is ai)plied and the limb properly immobilized, great care being taken to prevent decubitus or gangrene from pressure by protecting the parts exposed to pressure witii antiseptic cotton. During the subsequent treatment such a limb should be slightly elevated and suspended. If after such treatment the temperature is not lowered within six hours and the remaining symi)toms are not improved, it is evident that the secondary disinfection has not succeeded in obtain- ing an aseptic condition of the wound. If amputation does not appear to be indicated at this time, another effort should be made to secure nsepticit}' b}- resorting to pormnnent irrigation. Tlie antiseptic dressing- is removed and not re-applied. The parts are covered with a compress wrung out of a ^-per-cent. solution of acetate of aluminum, and constant irrigation made with the same solution. The simplest arrangement for constant irrigation is a reservoir holding the warm solution suspended over the patient's ])ed, and connected with the principal drainage-tube by means of a rubber tubing and a glass tip. By siphon action the fluid is conducted from the vessel to every part of the wound. The amount of fluid flowing through the tube can be regulated hy compressing the tube to the desired extent with a clothes-pin. The limb being suspended, the fluid is conducted away from it into a vessel b}^ means of a sheet of rubber cloth, macintosh, or gutta-percha. Constant irrigation with a harmless, non-toxic, yet efficient germi- cidal solution in these cases is of the gi'eatest value, as the wound-secre- tion is constantly washed away, and, as no accumulation can take place, the danger of sepsis from products of putrefaction is greatly diminished; at tlie same time the tissues are kept constantl^^ saturated with the solution, which at last will exert a potent inliibitory influence upon the action and multiplication of pus-microbes in the living tissues. Should a faithful attempt at obtaining an aseptic condition by this method of treatment prove inefficient after a fair trial, the question of sacrificing a limb, to save, if possible, a life, will present itself. In the absence of recognizable secondary foci in distant organs, the surgeon will not be able to ascertain whether a fatal form of general infection exists in a special case, and it is therefore alwa^^s justifia1)le in resorting to a mutilating operation as a last resort, provided the patient's strength warrants such a procedure. As in cases of progressive gan- SUPPURATIVE INFLAMMATION OF MUCOUS MEMBRANES. '223 grene, so in cases of progressive plilegmonous inflammation, it is ex- ceedingly difficult to decide upon the exact location where the amputa- tion should be made, as a distinct line of demarcation between healthy and infected tissues is never present. The only rule to go by in tlie selection of the site of amputation is to secure healthy skin-flaps, and to make the circular section of the muscular tissue above the tissues pre- senting macroscopical evidences of infection. The condition of the deep connective tissue furnishes important information concerning this question. The infection is sure to extend as far as an}^ undermining or sloughing of connective tissue has taken place ; hence, amputation should be done above these limits. The general treatment of phlegmonous inflammation is considered upon the same principles as the treatment of sepsis from other causes. 3. Progressive Purulent Infiltration. — This is the purulent oedema of Pirogoft'. It is a more advanced stage of what has just been described as progressive phlegmonous inflammation with suppuration. Purulent infiltration follows upon the heels of phlegmonous inflammation, and is, consequently, clinically also noted for its progressive character. The infiltration is often very extensive, involving, in many cases, an entire extremit}'. It is always attended b}' extensive connective-tissue necrosis. The pus burrows deeply among the muscles and detaches the skin over a large surface. The external appearances seldom indicate the extent of the disease. If the skin is incised freely the parts beneath, the muscles, vessels, and nerves, appear as plainly- as in a dissection made to show the relations of these parts. Purulent infiltration following progressive phlegmonous inflammation has often been mistaken for erysipelas, and has been called phlegmonous er3'sipelas. If purulent infilti-ation com- plicate erysipelas, it occurs in consequence of secondary infection with pus-microhes, and not as a result of the action of the streptococcus of erysipelas. The gravit}' of this disease depends largel}' upon the extent of the tissues involved. If it alfect an entire limb the danger to life is great. Death may occur from pyaemia or exhaustion. Treatment. — The surgical treatment is the same as in abscess, only that tlie incisions should be made longer, two or three inches in length, in order to enable the operator to remove the necrosed connective tissue and to insert large tubular drains. After the first incision is made a long, curved, Pean forceps is introduced, the cavity explored, and counter-openings made upon the point of the instrument in places where drainage will be most effective. The cavity must be drained at different points from one end to the other If the forceps is not long enough to reach both extremities it is removed and inserted again into the second opening, and so on until the cavity is thoroughly drained. It is advisable 224 PRINCIPLES OF SURGERY. to bring each drainage-tube out of two openings and secure each end with a safetj'-pin. In eases of purulent infiltration of an entire lower ex- tremity, I have often made as man}' as twelve incisions and inserted half as many drainage-tubes. After the cavity has been thoroughly drained, it is washed out with one of the milder antiseptic solutions. An excellent solution for this purpose is iodinized water. This can be readily prepared b}^ adding tincture of iodine to sterilized water until the solu- tion has the color of sherry wine. A solution of this strength is a valu- able antiseptic, and can be used repeatedly and in large quantities without fear of causing intoxication. I have never succeeded in rendering such a large suppurative cavity aseptic Avith one irrigation, and have conse- quently abandoned the occlusive antiseptic dressings in these cases. It is much better to apply a compress wrung out of Avarni salicylated water or a 1-per-cent. solution of acetate of aluminum, wiiich can be removed and re-applied every time the cavity is irrigated, which at first should be done every four to six hours. The warmth and moisture of the com- press can be maintained by covering it with gutta-percha tissue or mac- intosh cloth. As burrowing of pus often does not stop even after efRcient drainage has been established, the case should be watched with great care, and any attempt at ])urrowing should be promptly met by free incision and additional provision for drainage. It is always advisable to support the limb in proper position upon some kind of a suspension splint, both for the purpose of securing rest and to prevent contractures. As soon as suppuration has nearly ceased the drains are shortened and irrigations made less frequently. It is a consolation to know that such patients, especially if they are not advanced in years, and free from any other disease, often rally and make an excellent recovery after their strength has been reduced to a dangerous extent and their bodies re- duced to a skeleton by the prolonged suppuration and septic fever. If suppuration is not controlled by drainage and antiseptic irrigation, and especially if the temperature and pulse indicate a continuance of absorp- tion of septic material, amputation may become an unavoidable necessity. If amputation is decided upon, tlie deep incision must be made beyond the limits of the suppurating area. If the suppuration has extended as far as tlie hip-joint it may become necessary to utilize for flaps the skin which has been undermined, in order to secure a covering for the stump. If such a procedure become necessary, the internal siirface of the skin- flaps must be rendered aseptic by using the sharp spoon and scissors in freeing it from infected tissue. During the whole course of the disease, which gives rise to purulent infiltration, the patient's strength must be supported by stimul.ints and tonics and a concentrated nutritious diet. 4. Suppurative Tendo-Vaginitis. — Another form of rapidly-spreading SUPPURATIVE INFLAMMATION OF MUCOUS MEMBRANES. 225 inflannufttion is suppurative teiido-vaginitis. As the name implies, it is ail acute inflammation of tendon sheaths terminating in suppuration. It occurs most frequentl}' in the tendon sheaths of the fingers, hand, and forearm. It develops usually from an infected wound of tlie finger or hand, or as a complication in the different forms of paronychia. The inflammation travels along the course of the tendon, starting, perhaps, from one of tlie tendons of a finger, extends to the palm of the hand underneath the annular ligament to the flexor muscles of the forearm, where it often produces a phlegmonous inflammation which, in the course of time, may involve the wliole forearm. The tendons are often destroj'ed, and can be pulled out after a few weeks, — an occurrence Avhich is always followed b}" permanent functional impairment of the affected finger or of the whole hand. Not infrequentl}' suppurative inflammation of a tendon sheath extends to one or more joints over which the tendon passes, caus- ing a complication, which often necessitates amputation. This affection is always attended by severe pain, and, if extensive, b}^ grave constitu- tional disturbances. The extent of the disease can be ascertained, ap- proximatel}', at least, by the external swelling, and especially' b}' tlie tenderness along the course of the tendon. Frequently the inflammation attacks adjacent tendon sheaths and the pus undermines the entire palmar fascia. Treatment. — The surgical treatment of suppurative tendo-vaginitis must be thorough if it shall be eflficient. If it follow in the course of a wound, the tendon in the wound is exposed ; if it develop during an attack of paronychia, it is laid bare by a free incision. Along the course of the tendon a curved forceps is passed, another incision is made down upon the point of the instrument, and a drainnge-tube is drawn through. If the end of the suppurating cavity h;is not been reached the forceps is again introduced through the second incision down to the tendon, a third incision made higher up, and another drainage-tube draAvn through. These manoeuvres are repeated until the upper extremity of the suppurating cavity is reached. Taking it for granted that the suppurative tendo-vaginitis commenced in the distal portion of the middle finger, and has reached as far as the muscles of the forearm, the first drain should reach as far as the metacarpo-phalangeal joint, the second from here to the middle of the palm of the hand, the third from here to above the annular ligament, and the fourth as far as the middle of the forearm, and if suppuration has extended farther it will become necessar}^ to extend drainage higher up by another drain. If the whole palmar fascia is undermined, a drain should be placed transversely across the hand. If the suppuration has extended to adjacent tendon sheaths, more extensive provision for drainage will be required. The subsequent 226 PRINCIPLES OF SURGERY. treatment is the same as in cases of purulent infiltration. Necrosed tendons separate verj^ slowl}', but it is better to leave their elimination to the gi-anulating process, as it is ditlicult to decide how mucli of the tendon should be removed, and its operative removal would often require large incisions, which would heal at best only slowly, and the large cicatrix would onl}' add to the functional impairment of the member. From time to time traction can be made upon the tendon where it is exposed, so as to remove it as soon as it has become partially or com- pletely detached. Passive motion and massage must be instituted as soon as the abscess has healed, so as to restore the function of the limb as far as compatible with the existing condition, as not only the affected finger but the whole hand often will be found to have suffered seriously from the attack. If one of the principal tendons of a finger has sloughed, and motion cannot be restored, it is advisable to immobilize the finger in a slightly-flexed position, as a curved finger is more serviceable than a straight one. Suppurative arthritis occurring in the course of an attack of tendo-vaginitis often necessitates amputation, more especially if it involve more than one joint of a finger, 5. Paronychia. — Paron3chia, felon, whitlow, are terms used to designate an abscess of a finger. All of these terms should be abolished, and abscesses of the finger, like of other parts, should be called in ac- cordance with the primary disease which caused them. Hueter made a classification upon a strictly pathological basis. The abscess may be located in the skin, and is then a furuncle ; it may involve the connective tissue, and is then the product of a phlegmonous inflammation ; it may form after an attack of periostitis or osteomj-elitis, or, finally, it may com- mence in a joint, and is then from the beginning a suppurative arthritis. A suppurative tendo-vaginitis, as a primary affection of a tendon sheath, has often been mistaken for an ordinar}' felon, and treated as such, with most disastrous results. Suppurative tendo-vaginitis is frequently met with as a secondary aflTection of the different pathological conditions which give rise to abscess of the fingers. All of the conditions which have been enumerated as causes of abscess of the fingers are attended b}' excruciating pain, as the anatomical conditions necessary for the produc- tion of this symptom — tension and abundant supply of sensitive nerves — :ire pre-eminent in inflammator}' aflTections of the fingers. The pain is of a throbbing character, and is always aggravated by placing the hand in a dependent position, as the venous congestion produced b}- this position inerenses the swelling, and consequentl}- the tension, in the inflamed part. Treatment. — Volumes have been written on the abortive treatment of paron3'chia, — the surest indication that none of the various means sug- gested have proved successful. Abscesses of the fingers, as in any other SUPPURATIVE INFLAMMATION OF MUCOUS MEMBRANES. 227 part of the bod}', result onl}' from infection with pus-raierobes; hence, an}^ measure which falls short of effecting complete sterilization at the primary focus of infection must necessarily' fail in accomplishing the desired object. The onl}- rational treatment consists in the emplo3'ment of such measures as will limit the extension of the suppuration. One of the most important elements in the earl}' treatment of a felon is to diminish the blood-supply to the inflamed part by placing the limb in an elevated position, and by the continued application of cold. The use of ic6 in such a superficial inflammation will not onlj^ tend to diminish the congestion, but at the same time it has a positive influence in retarding the reproduction in the tissues of the primary cause — the pus-microbes. Poultices should never be emplo^'ed. If position and the use of cold do not afford relief, moist, hot, antiseptic compresses should be applied. As soon as pus has formed it must be liberated by incision. The centre of the inflammatory focus is accurately located by marking out by pressure the area of tenderness, and the incision is made at this point parallel to the long axis of the finger. Scrupulous care must be exercised in ren- dering the whole surface of the finger aseptic before the incision is made. It is not good practice to make the incision invarial)l3' down to the bone, as the inflammation may not extend to this depth. Tlie incision is only carried down to, but not beyond, the suppurating focus ; hence, it is made down to the bone only if the abscess has originated in a joint, or has followed an osteomyelitis or periostitis of a phalanx. As the wound gaps, free drainage is not required. The abscess is washed out with an antiseptic solution, and the finger dressed antiseptically. Suppurative arthritis is treated by through drainage. In osteomyelitis followed bj' necrosis the sequestrum is allowed to separate and is then extracted, which can usually be done after three or four weeks. Excellent results are obtained after the loss of a complete phalanx, as the bone is often reproduced almost to perfection by the periosteal sheath. Amputation only becomes necessar}' in cases of osteomyelitis aftecting more than one phalanx, complicated by suppurative arthritis of the adjacent parts. 6. Furuncle. — A furuncle is a small abscess of the skin. The centre of a furuncle is always occupied by a plug of necrosed connective tissue, vulgarly called a core. Longard has made a careful microscopico- baeteriological examination of 9 cases of furunculosis in young children. In 4 of these cases he found the staphylococcus p3^ogenes albus alone, in 5 cases in combination with the staphylococcus p3'0genes aureus. The identity of these microbes with those described b}' Rosenbach was demonstrated b3' cultivation and experiments on rabbits. The microbes were not found in the ftecal discharges of the patients, but were discov- ered, in small numbers, in the diapers of healthj'^, unclean children, as 228 PRINCIPLES OF SURGERY. well as in the diapers of those suliering from suppurative folliculitis. He believes that the pus-microbes are the direct and sole cause of the affection, and that infection takes place through the sweat-glands, as the microbes were found in abundance upon the inner surface of the mem- brana projnna of these glands. As soon as the microbes reach the subcutaneous connective tissue they produce suppurative inflammation. Experiments on dogs and rabbits, bj^ cutaneous inoculations with pus- microbes cultivated from the furuncles, produced a slight swelling and redness, and, in some instances, the formation of small pustules. The result of these inoculations was always the same, whether the cultures were made from the pus of a furuncle, a suppurating wound that healed without fever, or from a i)y8emic patient. The inoculation experiments of Garrfe, Brockhart, and Bumm, upon themselves, have been previousl}' referred to, and they prove that many of the circumscribed suppurative affections of the skin (among them furuncle) are caused by the direct inoculation with pus-microbes, which enter the connective tissue either through a slight abrasion or through the glands of the skin. Furuncles often appear multiple, either in the same region or widely separated from each other over different parts of the body. In such cases the successive appearance of furuncles would tend to prove the reproduction and diffu- sion of the primary cause, the pus-microbes, over the surface of the bod3\ Treatment. — The prophjdactic treatment consists in securing for the skin a healthy condition. B\' the free use of hot water and potash-soap the openings of the glands of the skin are cleared of accumulation of pus-microbes and of materials which might serve as culture substances. In patients suffering from furuncle, the slightest abrasions should be treated with care, in order to guard against infection. If the general health has been impaired, dietetic and medical treatment should be insti- tuted to correct the fault}- nutrition. We have no special internal remedies to correct a supposed suppurative diathesis which does not exist. Sulphide of calcium, whicli has been recommended in such strong terms, has no influence either in the prevention or cure of furuncles. With the first appearance of a furuncle, the skin over and considerablj'^ beyond it should be disinfected, and a compress saturated with a weak antiseptic solution applied. As soon as pus appears it is evacuated through a small incision, and if the necrosed tissue in its centre has become detached it is extracted. The interior of the small abscess is then disinfected and a small antiseptic dressing applied. A furuncle is an insignificant lesion, but its proper treatment should not be neglected, as numerous cases have been reported where thrombo-phlebitis, p3^8emia, and acute suppurative osteomyelitis could be traced to infection from a furuncle. SUPPURATIVE INFLAMMATION OF MUCOUS MEMBRANES. 229 7. Carbuncle. — A great deal of confusion has been created in the minds of students in reference to what is really meant by a carbuncle. This confusion has been brought about b^' the teachings of some of our text-books, both old and recent, which assert that carbuncle is alwaj-s caused by infection with the bacillus of anthrax, while others speak of a less malignant form of carbuncle caused by suppurative inflammation. Malignant carbuncle, or malignant pustule, is the anthracic form of carbuncle, which always starts from a single centre of infection, and is ajways attended by necrosis of the overlj'ing skin. The ordinary carbuncle, which is under consideration now, is caused by infection with pus-microbes, and diflers from a furuncle onh* in so far that it is made up of a number of foci of suppuration, which develop simultaneously or in rapid succession, and usually become confluent. A carbuncle of this kind is in realit}' nothing else, etiologicall}'^ and pathologically, but a group of furuncles. A section through a carbuncle, before extensive liquefaction has occurred, will show a number of foci of suppuration and necrosis, each one of which, taken separately, would represent a furuncle. On account of the more extensive area of infection in carbuncle than in furuncle, the local s3'mptoms are much more severe. The tissues at an early stage become so extensively in filtrated that the carbuncle feels as hard as cartilage. The pain, as a rule, is very great. In size, a carbuncle varies greatly ; it is sometimes not larger than a 25-cent piece, and it may attain a circumference fully as large as an ordinary soup-plate. The inflammation, which first attacks the skin and subcutaneous tissue, in unfavorable cases, extends to the deeper tissues and also travels in a peripheral direction. If the carbuncle is large, the skin covering it becomes gangrenous and extensive sloughing takes place. If the car- buncle is small, composed of onl}- three to four centres of suppuration, the skin is not destroyed, with the exception, perhaps, of a very small portion, corresponding to the apex of each furuncular focus. Central necrosis of the connective tissue in each suppurating focus invariably occurs, and if the inflammation is very severe and extensive the whole carbuncle becomes a necrotic mass. In mild cases the tissues between the suppurating foci are preserved, and after the elimination of the necrosed tissue the part presents a cribriform appearance, each depres- sion indicating the exact position of the former focus of infection. Carbuncle is met with more frequently in persons advanced in 3'ears, and attacks in preference such parts as are most exposed to infection from without, as the neck, face, and hands. The dangers to life connected with carbuncle are exhaustion and septicaemia, in the progressive form, while thrombo-phlebitis and p^'semia may occur as fatal complications, even if the disease is circumscribed and the local symptoms not severe. 230 PRINCIPLES OF SURGERY. Diagnosis. — Tlie differential diagnosis consists in separating car- buncle frona furuncle and malignant pustule, or antbracic pustule. A furuncle presents only one centre of suppuration, is more circumscribed, more superficial, and not attended by such marked infiltration as car- buncle. Malignant pustule is primarily not a suppurating lesion, as it is caused by infection witli the bacillus of anthrax, and develops from one point of infection and gives rise to necrosis of the skin at an early age. Carbuncle starts, simultaneously or in rapid succession, from three to a dozen or more suppurating foci, is attended by a hard induration of the surrounding connective tissue, and gives rise always to multiple foci of necrosis of the subcutaneous connective tissue. Treatment. — The different methods advised at various times to a])ort a carbuncle have not proved more successful than the means suggested to check the growth of a furuncle. Very recently Beau- quinque has made the assertion that a carbuncle can be aborted by appl^'ing to the part antiseptics dissolved in alcohol. He claims to have succeeded in three cases by applying tincture of iodine. While we have no right to question the correctness of his diagnosis, or the truth of his assertions, it is well known that the same treatment has not been attended bj^ the same satisfactory results in the hands of other surgeons. It is difficult to conceive how the external application of tincture of iodine or any other antiseptic alcoholic solution should have the power to destroy the pus-microbes or prevent their reproduction when so deeply buried in the tissues. The most potent agent to limit the extension of the inflammation is the continued application of ice. As soon as pus has formed, the different foci of suppuration should be exposed to direct means of disinfection b}' incising the carbuncle under strict antiseptic precautions. The old-fashioned conical incision answers an excellent purpose. The necrosed and infected tissues are removed with a sharp spoon, and the surface is disinfected by irrigation with a solution of carbolic acid or sublimate ; after which the scraped sur- face is dried and touched with a 10-per-cent. solution of chloride of zinc and the part covered with an antiseptic moist compress or dressed on strict antiseptic principles. If the primary disinfection does not arrest further extension of the disease, the whole surface shonld be deeply cauterized with the knife-point of Paquelin's cauter3\ After cauteri- zation a compress saturated with a weak solution of corrosive sublimate is to be applied. With the cessation of suppuration granulations appear, when the same treatment is to be followed as in the management of granulating wounds. Septic tlirombo-phlebitis is announced b}^ a well- marked chill, followed b}- the usual grave s3'mptoms which attend ])ya?mia. If the thrombosed A'ein can be located in such cases it should be removed by excision, with a faint hope that by an early recourse to this expedient a fatal form of pysemia may possibly be prevented. CHAPTER X. Suppurative Osteomyelitis. Suppurative inflammation of the marrow of bone is an exceed- ingly frequent affection in children and 3-oung adults. As a primary disease it is seldom met with after the skeleton has become fully de- veloped. The form of osteom3'elitis that will be considered here is the so-called spontaneous variety, which occurs without direct exposure of the medulla to infective micro-organisms from without. HISTORY. Traumatic osteomyelitis following amputation, compound fractures, or gunshot injuries of the bones has been recognized for a long time as a distinct and serious wound complication, but osteomyelitis occurring without such injuries Avas not understood until quite recentl}'. We find no mention of this acute affection of bone until 1705, when J. L. Petit gave a description of an acute disease of the long bones which corresponds with what we now understand by osteom3'^elitis. Similar allusions have been made to it by Gooch, Pott, Cheselden, Hey, and Abernethy, some of their descriptions being sufficientl}^ accurate to enable us to recognize the character of the lesion. In 1831, M. Renaud published a paper " On Inflammation of the Medullarv Tissue of the Long Bones," in which he gives a report of 5 cases occurring after amputation, all having terminated fatally. Cruveilhier alludes to the remote consequence of this affection when he saj's, " The phlebitis of the bones is one of the most frequent causes of vjsceral abscesses following wounds or surgical operations in which the bones are involved." Roux credits Nelaton with having devised the term osteoni3'elitis in 1834, and having published a brief account of it in 1844. In 1849, Mr. Stanley, in his excellent monograph, " On Diseases of the Bones," gave an accurate account of the spontaneous varietN' under the title, " Suppuration in Bone." In 1855, Chassaignac applied the term osteom3'elitis for the first time to the spontaneous variet3', re- porting at the same time 4 cases that came under his own observation. Among the surgeons who have increased our knowledge of the traumatic variet3', the names of Vallette, M. Roux, Jules Roux, Larre3'', Pirogoff, Lidell, and Allen deserve well-merited mention. In 18G5. Y. Roser gave (231) 232 PRINCIPLES OF SUKGERY. a coiiii)Iete resume^ in tliirt}' propositions, of what was tlien known con- cerning tlio spontaneous variety. On account of tlie multiplicity of the bone ali'ection, and the frequency with which the joints are involved, he called the disease " pseudo-rheumatism." The infectious origin of trau- matic osteomyelitis has been recognized for a long time, but the sponta- neous form was believed to be purely inflammatory until Luecke first called attention to its infectious character. Demme, Yolkmann, Schede, and Hueter have added valuable contril)utions to the modern literature of non-traumatic acute suppurative osteom3'elitis. Pasteur detected in osteo- m^elitic pus a mici'obe which he claimed was identical with the microbe found in furuncles ; hence he spoke of osteoni3-elitis as " furuncle of bone." The bacteriological and experimental researches of Koclier, Rosenbach, Passet, Krause, and Kraske have established the fact that non-traumatic osteomyelitis, like the traumatic form, is a suppurative inflammation of the medullary tissue, caused invariably by infection with pus-microbes. Primary suppuration in hone begins in the medullary tissue ; hence it is not correct to syeak of a suppurative ostitis, as is so frequently the case among English and American authors. Primary suppurative j)eriostitis is an exceedingly rare affection; consequently, osteomyelitis must be considered- as the most frequent of all inflammatory diseases of bone. BACTERIOLOGICAL AND EXPERIMENTAL INVESTIGATIONS. Active suppurative inflammation in bone, when it occurs independ- ently of an external wound, and consequently of direct infection, fur- nishes one of the most interesting, and, thanks to the patient and persevering investigations of a number of the foremost pathologists, one of the best-known forms of purulent infection. For years it has been contended, by some who made the etiology of acute osteomyelitis the subject of experimentation, that it is caused hy a specific microbe not found in other forms of suppuration. Convincing evidence, however, has accumulated, which seems to leave no further doubt that the ordinary microbes of suppuration are the cause of this form of suppurative in- flammation, and that the gravity of the symptoms which attended the disease, as compared with other suppurative processes, is owing to the anatomical location and structure of the inflamed tissues, rather than to any difference in the microbic cause. Even before the microbic cause of acute osteomyelitis was understood, Kocher believed that infection, in some cases at least, occurred through the intestinal canal, and made some experiments to prove this point. He produced subcutaneous fractures artificially in dogs, and then fed the animals large quantities of putrid materia], and, in some cases, succeeded in causing suppuration at the seat of injury. In his clinical experience he also observed that in many BACTERIOLOGICAL AND EXPERIMENTAL INVESTIGATIONS. 233 cases of acute suppurative osteom3'elitis the premonitory symptoms pointed to the gastro-intestinal canal as the portio invasionis. Rosenbach cultivated the staphylococcus from osteomyelitic pus as early as 1881. In one case the yellow and the white staphylococcus were found together, in another case the staph3'lococcus alone, while in a third case the aureus and the streptococcus pj'ogenes were cultivated from the same pus. Rosenbach produced the same result in his experi- ments b}' injection of a pure culture of pus-microbes from a furuncle of the lip, as Struck did with cultivations from the pus of osteomyelitis, and witii osteomyelitic pus injected into the subcutaneous connective tissue he produced an ordinarj- abscess. Recurrent attacks of osteo- myelitis, years after the primary disease had been apparently cured, Rosenbach explains b}- assuming that after the first attack some of the microbes remain in the tissues in a latent condition until, at some subse- quent time, local conditions are created which enable them again to dis- play their pathogenic properties. Struck obtained from the pus of an acute case of osteom3-elitis, upon gelatin, an orange-yellow culture; the identity' of this culture with the staphjdococcus pj'ogenes aureus was soon generall}' recognized. B3- injecting a pure culture into the circula- tion of animals whicii had been subjected, a few da^-s before, to injury of bone, as contusion or fracture, he produced a suppurative inflamma- tion at the seat of the trauma. Krause cultivated from osteomyelitic pus the staphjdococcus pyogenes aureus and albus, which he also found in the effusion of joints, when this occurred as a complication of the disease. Injection of a pure culture of tliese cocci into the peritoneal cavity of animals caused suppurative peritonitis. Intra-venous injections, with or without previous fracture, were followed most frequentl}^ by suppuration in joints and muscles. If a bone was fractured subcnta- neouslv before tlie injection was made, he frequentlj^ observed suppura- tion at the seat of fracture, and from the pus the staphylococcus could again be cultivated. Foci in the kidne3"s were alwa3-s present in all of these experiments. Miiller succeeded in cultivating the staph3dococcus P3'0genes aureus from the 3-ellow granulations in cases of acute epiphys- ear}- osteomvelitis. Rodet succeeded in producing in animals suppura- tive osteonu'elitis l)v intra-venous injections of pus-microbes, witliout inflicting an osseous injury. The suppuration, whicli was generally circumscribed, was usually located near the epiphysis; it seldom involved any considerable portion of the shaft. lu man3' cases separa- tion of the epiphysis and suppurative arthritis of tiie adjacent joint occurred. In the most acute cases, the animal died Avithin twenty-four hours, without any appreciable changes in the bones being demonstrable at the necrops3'. Young animals proved more susceptible to inoculations. 284 PRINCIPLES OF SURGERY. Rodet believes that primaiy localization of the pus-microbes takes place in the medullary tissue at a point close to the epiphyseal cartilage. When separation of the epiph3'sis occurred, the pathological fracture was-always found on the side of the diaphysis. Rinne, who failed in producing metastatic abscesses with pure cultures of pus-microbes, rendered four rabbits p3^semic by injecting osteomyelitic pus directly into the venous circulation. He used the pus taken from a case of acute osteomyelitis with grave symptoms, and diluted it with distilled water, and of such a mixture he injected a Pravaz syringeful into one of the auricular veins of four rabbits. One died in twent^'-four hours, with S3'mptoms of toxaemia, and the autopsy showed nothing but a beginning pneumonia of left lung. The other three animals died seven to ten days after the injection, and in all of them suppurating foci were found in the kidneys and the muscles of the heart. No abscess in muscles or suppuration in joints. The plate cultures made from the pus used for the experiments showed the staphylococcus pyogenes aureus and albus and the bacillus pyocyaneus. With the exception of the albus, all of the microbes were also cultivated from the pus of the metas- tatic abscesses. In a later communication the same author expresses the opinion tliat the indirect causes of suppurative osteomyelitis are changes brought about in the medullary tissue by the microbes and their ptomaines of general febrile diseases, such as typhus, scarlatina, diph- theria, etc., which prepare the soil for the action of pus-microbes, or the disease is produced by the direct extension from a localized suppurative lesion, as a furuncle, through the l3anphatic vessels, or along vessel- or nerve- sheaths to the medullary tissue. Kraske has studied, from a clinical stand-point, the manner of infec- tion in cases of acute osteomyelitis. In one case he could trace the infection distinctlj' to a furuncle of the lip; but, as a rule, he thinks that infection takes place through a wound or abrasion of the skin. In- fection through the intestinal canal he considers possible, but not proven ; more frequently it takes place through the respirator}- organs, and in one case he could locate the infection through this route with certainty. He asserts that recurring attacks should not alwaj's be looked upon as the result of former infection, but as a consequence of a new infection of the old site. CAUSES. The essential exciting cause of suppurative osteom3-elitis,both acute and chronic, is the presence of one or more varieties of pus-microbes. Direct extension of a suppurative lesion through the medium of lym- pliatic vessel- or nerve- sheaths, as Rinne suggests, may be possible, but such a direct connection between a peripheral suppurating focus and a, CAUSES. 235 central osseous lesion of a similar nature can seldom be demonstrated. Infection in most instances takes place by pus-viicrohes^ which have found their way into the circulation from a suppurating wound or through the respiratory or intestinal mucous membrane, and which localize in the medullary tissue prejjared for their reception by anatomical peculiarities of the cap)illary vessels, or by a locus minoris resistentise, created by an injury or some antecedent pathological condition. A number of well- authenticated cases have been reported where a subcutaneous fracture became the starting-point of an attack of osteomj^elitis in patients who suftered at the same time from a suppurating wound in a part distant from the fracture. In such cases it is reasonable and logical to assume that pus-microbes enter tJie circulation and are conveyed by the blood-cur- rent to the seat of fracture, ichere they are arrested and find a favorable soil for their reproduction and the exercise of their pathogenic properties. Such cases are simpl}' the counterpart of what has been accomplished b}^ experimentation. Clinical experieiice and experimental research, have shown that pus-microbes localize in preference near the epiiphy seal line of the long bones. During the growth of bone this region is supplied with new, growing, and imperfectl3"-developed capillar}' vessels, — a condition which cannot fail in favoring localization of floating micro-organisms in this localit}-. Xeumann has also called attention to a peculiarity of the capillary vessels in the medullar}' tissue, their calibre being four times greater than that of the arterial branches that supply them, — another im- portant anatomical condition which predisposes to localization of microbes in this tissue. Histological investigation has also shown that the small blood-vessels in the medullar}- tissue are devoid of a proper vessel-wall, and appear more like channels or excavations than blood-vessels, — another condition wliicli must yield a potent influence in determining congestion in these vessels and mural implantation of infected leucocj-tes under the action of an exciting cause or causes. As Luecke has shown, and as Rinne again asserts, the medullar}' tissue is prepared for the action of pus-microbes by the causes which precipitate an attack of some acute febrile affection, as variola, typhoid fever, scarlatina, rubeola, and diph- theria. Children and young adults who have passed through an attack of any one of these infectious diseases are strongly predisposed to an attack of acute suppurative osteomyelitis. Excluding all such influ- ences, there is still left a large number of cases where osteomyelitis attacks persons otherwise apparently in perfect health. My own obser- vations induce me to attribute to exposure to cold an important role as an exciting cause. I do not wish it to be understood that exposure to cold alone could ever result in an attack of acute suppuration of the medul- lary tissue. Pus-microbes inhabit persons in perfect health, and they 236 PRINCIPLES OF SURGERY. do not cause disease as long as the circulation remains normal, as locali- zation does not take place in the absence of a proper soil. If, however, in such a person the circulation in the medullary tissue is disturbed sud- denly, in conse(inence of a sudden or prolonged chilling of the surface of the body-congestion, mural implantation and localization of the floating pus-microbes occur in a locality which olfers the least resistance in such an emergency, and a suppurative inflammation is established in the medullary tissue. I have repeatedly observed cases of osteomyelitis in bo3's who, after active exercise, suddenly became chilled b}' bathing in cold water, or who, after an exciting game of base-ball, stretched them- selves out on the cold ground to rest. A disturbance of the equilibrium of the circulation from an}' cause is an important factor not only in precipitating an attack of acute osteomyelitis, but many other local infective processes in persons already infected with the essential cause. SYMPTOMS. Acute suppurative osteomyelitis is usually ushered in by a chill and other symptoms indicative of the commencement of an acute suppura- tive affection. In some cases, even during the earliest stages, the gen- eral symptoms are out of all proportion to the local lesion, presenting a clinical picture characteristic of intense septic intoxication. I have observed several cases of multiple osteomyelitis, where the patients passed into a t^-phoid condition, muttering delirium, dry tongue, diar- rhoea, and a continued form of fever, with a high temperature and rapid pulse, who died within a week, before the local disease had made any con- siderable progress. In one of these cases the patient was a young lady, 18 3'ears of age, in whom the disease affected both tibiae, 1 femur, both humeri, 1 clavicle, and several ribs from the very beginning, and the dis- ease proved fatal on the sixth day. In such cases the prominent general symptoms are those of a malignant form of progressive sepsis. It is possible that the ptomaines produced by the pus-microbes in the medul- lar}'^ tissue mny be more virulent, or that they are produced in larger quantities than in suppurative inflammation of other organs. Again, the ptomaines gain here more ready entrance into the circulation, as, at least in part, they are produced within the blood-vessels, and the extra-vascular products are forced rapidly into the circulation on account of the unyield- ing nature of the tissues around the primary focus of inflammation. In some cases of acute osteomyelitis the actual development of the disease is preceded by premonitory symptoms, which indicate the route tlirough which infection has probably taken place. A preceding bronchial ca- tarrh would indicate the possibility that infection had occurred through the mucous membrane of the respiratory organs, while infection through SYMPTOMS. 237 the intestinal canal would give rise to diarrhoea as a premonitor}- symp- tom. The local symptoms will be considered separately, as a correct early diagnosis can onl}' be made by a careful stud}' of these, individually and collective!}'. Pain.— Pain is one of the earliest and constant symptoms of acute osteomyelitis. It may be absent in multiple osteomyelitis, where the patient passes into a condition of stupor almost from the beginning. The pain is described by the patient as being excruciating, of a boring, tearing, or throbbing character. It is not limited to the area involved by the disease, but is often diffuse, extending to the adjacent joint and over a considerable portion of the shaft. It is caused b}- the great tension resulting from tlie pressure of the inflammatory product in a tissue surrounded by an un3Melding case of compact bone. Pain in- creases as the exudation becomes more abundant, and is diminished or subsides almost completely with the escape of the inflammatory product from the interior of the bone into the surrounding soft tissues. Sudden diminution of pain is almost a certain indication that perforation of the bone has occurred, and that the pus has escaped into the paraperiosteal tissues. The location of pain sliould be carefull}' inquired into, as in multiple osteom^'elitis this symptom will locate, at an early time, the number and location of bones affected. In multiple osteom^-elitis the disease ma}^ appear simultaneousl}^ in several bones far apart, or the disease appears in one bone first, and other bones are attacked later successivelv. The appearance of pain in a new locality is generally an indication that another bone has become involved. Tenderness. — The patient is very seldom able to locate accuratel}^ the primary focus of the disease in an inflamed bone, as the pain is diffuse, but the pain caused b}^ pressure will enable the surgeon to locate the primary focus within the bone with accuracy, even before an}' ex- ternal swelling has appeared. During the first few days the area of tenderness will correspond to the extent of the disease in the interior of the hone, and the centre of this area will correspond to the primary focus of the inflammation. Tenderness is most acute where the disease has approached nearest the surface of the bone, and by this means the sur- geon locates the site for early operation. Tenderness is caused by the secondary periostitis. In osteomyelitis of the long bones this symptom appears first near one of the epiphyses, and extends later toward the shaft of the bone as the periostitis ascends or descends in that direction. Swelling. — The absence of external swelling during the first few days of an attack of acute osteomyelitis has often given rise to mistakes in diagnosis. As the primary inflammation is located in the interior of 238 PRINCIPLES OF SURGERY. a bone, external swelling is absent until the inflammation has extended to the surrounding soft tissues. With the appearance of the secondary periostitis swelling occurs, which at first can be felt as a hard induration, soon followed b}^ oedema and deep-seated fluctuation. The rapid local diflTusion of the process is largely due to the unyielding nature of the tissues around the primary focns, and to the fact that the blood-vessels are directly' concerned in the extension of the process by becoming the channels for the dill'usion of the septic infection, their contents forming a nutrient medium for the pus-microbes, Thrombo-phlebitis is a con- stant and early condition in every case of acute osteomjelitis. The oedema of the soft parts is caused, in part at least, by the deep-seated venous obstruction. The external swelling seldom appears before the end of the first week, but when it once shows itself it increases very rapidly. The secondary suppurative periostitis results in extensive denudation of the bone of this membrane, a large portion of the shaft being surrounded by pus. As soon as the suppurative inflammation extends to the soft tissues, dilT'ase burrowing of pus takes place between the bone and the periosteum and among the muscles. Within a few days an immense abscess, or a very extensive purulent infiltration, develops in this manner. Redness. — The skin over the aflTected bone presents a pale, normal appearance until the pus reaches the subcutaneous tissue, when it presents a red or brownish-red discoloration. The superficial veins are always dilated and turgid, — a reliable indication of the existence of a deep-seated thrombo-phlebitis. Synovitis. — Inflammation of joints situated in close proximit}- to osteomyelitic foci is the rule. Catarrhal synovitis appears during the first few weeks, while suppurative synovitis usually occurs later as a complication of acute suppurative osteomj^elitis. If the effusion into the joint is of a serous character, it occurs not as a result of infection with pus-microbes, but in consequence of vascular distui-bances outside the limits of the area of infection. The serous effusion appears rapidly, gives rise to pain and contraction of the joint, but, as a rule, disappears spontaneously after the evacuation of pus. Suppurative synovitis follows infection of a joint with the same microbes that caused the osteomyelitis, which reach the joint either directly, through some patho- logical defect of the epiphysis, or through the lymphatics or blood- vessels. The occurrence of an attack of suppurative sjniovitis greatly aggravates the general symptoms, and is attended b}^ more serious local disturbances than is the case if the eff"usion is of a non-septic character. If any doubt exist in reference to the character of the efl"usion an exploratory puncture will furnish the necessary information. «. DIAGNOSIS. 239 Epiphyseolysis.' — Separation of an epiphj-sis from the diaphysis in the epipb3-seal line is not an infrequent accident in cases of osteomyelitis of the long bones. It is a pathological fracture which occurs in conse- quence of necrosis, inflammator}' osteoporosis, or molecular disintegra- tion of bone in the epiphyseal line. It is readily recognized b}^ the existence of a false point of motion and the displacements which usually attend fractures in such a localit}^ Epiphyseol3'sis seldom occurs before the end of the fourth or sixtli week from the beginning of the attack. Loss of Function. — In a limb the seat of an acute osteomyelitis all functions are usuall}' completely suspended. It is as useless as though one of the principal bones had been fractured. The patient is unable to raise it, or to move the nearest joint. The limb is not onl}- useless, but the patient complains of a sensation as though it would break on its being lifted or otherwise manipulated. DIAGNOSIS. Mr. Holmes has well said that acute suppurative osteomyelitis is more frequently recognized at post-mortem examinations than at the bedside of the sick. It has often been mistaken and treated for other affections, as periostitis, ostitis, inflammation of joints, rheumatism, typhoid fever, erysipelas, and even phlegmonous inflammation of the soft parts. When we remember that periostitis, ostitis, synovitis, and cellulitis are secondary lesions, intimately associated in the clinical history of every case of osteomyelitis, and, furthermore, that the fever attending it closely resembles tj'phoid fever, it is not surprising that mistakes in the early diagnosis of this disease are not infrequent, even in the practice of experienced surgeons. A careful consideration of everj' feature of the clinical picture presented b}^ each case can only enable us to arrive at correct diagnostic conclusions. There is no single pathognomonic sj^mptom that would infallibly lead us to a correct diag- nosis. The presence of fat-globules in the pus was regarded as diagnostic by Chassaignac and Roser. Fat-globules are often found in osteo- myelitic pus, but the}' are not invariably present, and may also occur in the pus of a phlegmonous inflammation. An important element in differ- ential diagnosis is the absence of external swelling for the first few days, regardless of the severity of other symptoms ; also, its rapid diffusion after it has once made its appearance. In periostitis and phlegmonous inflammation of the connective tissue, swelling is one of the earliest S3^mptoms. In osteomyelitis the superficial swelling is at first oedema- tous, extends S3-mmetrically around the entire bone, and gradually diminishes at a point where the morbid process in the interior of the bone has become arrested. In acute cases, fluctuation appears about the 240 PRINCIPLES OF SURGERY. end of the first or during the second week. A consecutive inflammation of proximal joints usually makes its aj)i)earance al)out from the end of the first to the fourth week. The time of its ai)pearance, as well as its character, is determined l)y the causes which i)roduce the synovitis. While joint affections are almost constant in osteomyelitis, they are seldom associated with periostitis, or plastic osteomyelitis. The char- acter of the fever which accompanies grave attacks of osteom^^elitis sometimes obscures the local symptoms to such :in extent as to lead the attendant to the belief that the patient is suffering from an attack of typhoid fever. Goltdammer has reported a typical case of this kind. The general symptoms simulated typhoid fever so closely that the patient, after an illness of ten da3's, was sent to the medical wards as a severe case of typhoid fever. The pulse ranged between 110 and 120; temperature, 40° to 41° C. Tympanites, dry tongue, enlargement of spleen, bronchitis, rapid respiration, and delirium. On close examina- tion, a slight swelling was found over the lower part of the right tibia, with tenderness on pressure, — symptoms which finally enabled the attend- ing physician to make a correct diagnosis. During the progress of the case, pleuritis, parotitis duplex, and synovitis of the right shoulder-joint made their appearance. The patient died eight days after admission, or eighteen days from the beginning of the disease. The necropsy revealed the existence of acute osteomyelitis of the tibia and pyaemia. Many such cases have been recorded where the differential diagnosis between acute osteomyelitis and tj'phoid fever was difficult, if not impossible, until the local sj'mptoms became more prominent. The premonitory sj'mptoms in tj^phoid fever are moi'e constant and prominent than in osteomyelitis. In the latter affection the bronchial or intestinal catarrh which occasionally precedes the attack constitutes the only premonitory s3'mptoms which have been observed, and, as a rule, the disease com- mences abruptly without any such warnings. Chassaignac believes that diarrhoea is present in almost all cases in the beginning, but it is a more constant symptom after septicaemia or P3'aemia have made their appear- ance. The temperature, as a rule, shows less variation in osteom3^elitis tlian in t3'phoid fever. After the initial chill and the usual S3'mptoms attending the subsequent fever, the first symptom that points to osteo- m3-elitis is pain. This is generall3" severe, deep-seated, constant, boring, tearing, or throbbing in character, and referred to the primar3' focus of the disease, usually in the vicinity of the epiph3'seal line. Patients old enough to describe their sensations complain of a feeling as if the bone Avas being broken. They object to moving or handling of the limb on account of fear of an aggravation of this distressing sensation. E. von Wahl makes the statement that fluctuation is at first circumscribed in PROGNOSIS. 241 phlegmonous inflammation of the connective tissue, while it is diffuse from the beginning in osteomjelitis. This distinction is a good one. The importance of searching for points of tenderness in the diagnosis and location of the disease has already been alluded to. The differential diagnosis ])et\veen rheiimatisn!, gonorrhceal arthritis, and osteomyelitis is not difficult, as in the former diseases the joint affections occur as a primary disease, while in osteomyelitis they appear as complications. PROGNOSIS. Modern aggressive surgery has greatl}- diminished the mortalit}^ of acute osteomyelitis. Under the old, expectant, non-antiseptic treatment it was great. Thus, Demme lost 4 out of 17 cases; Luecke, 11 out of 24 ; Kocher, 9 out of 26 ; and Schede, 3 out of 23 cases. Multiple osteomye- litis, with grave sj^mptoms of septicaemia from the beginning, almost with- out exception proves fatal in less than two weeks. Death in such cases is caused b}- progressive sepsis resulting from the entrance of large quan- tities of pus-microbes into the circulation. After death no character- istic macroscopical lesions can be found in distant organs, and micro- scopical examination reveals onl}' the minute changes in the capillary vessels typical of acute septicaemia. If the patient escape this, the first source of danger to life, he is still exposed during the duration of the acute symptoms to the more remote risks incident to the presence of septic thrombo-phlebitis. If any of the thrombi undergo softening and disintegration, fragments reach the general circulation and constitute infected emboli, which establish in distant organs, notably the lungs and kidneys, independent centres of suppuration, — the so-called metastatic or pytemic abscesses. The accession of this fatal complication is announced by recurring chills, an intermittent form of fever, and is followed within a short time b}- death from sepsis or exhaustion. Another fatal accident which maj" occur is fat-embolism. The medullar}- tissue is liquefied by the suppurative inflammation, and some of the free fat-globules may be forced into the circulation b}' the intra-osseous pressure, and death is preceded b}- rapid, shallow breathing; cyanosis; small, rapid pulse, — S3'mptoms which point to the existence of an obstruction to the passage of the blood from the right to the left side of the heart. Extensive destruction of the medullar}^ tissue is always followed by marked anaemia, and this condition is a prominent sj-mptom in all cases of osteo- m3-elitis, as tliis disease seriously impairs the function of one of the important l)lood-producing organs. Schede has seen, in cases of acute osteomyelitis, tlie })roportion of the white to tlie red blood-corpuscles increased to 1:100. The clinical thermometer is an important prognostic aid in this as well as in many other acute infective processes. If the 16 242 PRINCIPLES OF SURGERY. morning and evening temperature remain continuously high, — that is to sa^', ranges between 40° to 40.5° C. during tlie first week, — it indicates a severe case. The more the general symptoms resemble a severe case of typhoid fever, the graver tlie prognosis. The occurrence of decubitus is always an unfavorable sign. In regard to the function of the limb after an attack of acute osteomyelitis, a few words are necessary. Necrosis of the bone to a greater or less extent is the rule. The extent of perios- teal detachment during the acute stage is no indication of the area of subsequent sequestration, as the greater part of the denuded bone ma^' receive an adequate blood-supply from the vessels within the bone, and soon becomes covered with granulations, and later unites with the peri- osteum or the paraperiosteal tissues. Joint affections and partial or complete separation of one or more epiphyses are frequent complica- tions. A catarrhal effusion is generally removed b^' absorption, after the subsidence of the acute sjnnptoms, and the functions of the joints are restored completely. If the effusion is sei*o-purulent and the articu- lar cartilages remain intact, aspiration, with subsequent washing out of the joint with an antiseptic solution, may be sufficient to remove the effusion and restore the usefulness of the limb. Stiffness of the joint and malposition of the articular surfaces of the bones are events that cannot be avoided in all cases, even by the most skillful and attentive treatment. If the articular cartilages are destroyed by suppurative arthritis, the best result that can be hoped for is a useful but ankylosed joint. Pathological fractures through the sliaft of a bone or epiphj'seo- lysis are complications which greatly tax the duties of the attending surgeon, but from which the patients frequentl}^ recover with a useful limb. PATHOLOGICAL ANATOMY. Acute osteomyelitis is essentiall}^ a phlegmonous inflammation of the marrow of bone. This disease attacks, preferably, the long bones, although the scapula, clavicle, ribs, and ilium are also frequently affected, especially in cases of multiple osteomyelitis. Of the long bones the femur is most frequentl3^ affected. Seventy-three per cent, of all of Demme's cases involved this bone. In the femur the disease manifests a special predilection for the lower epiphyseal region, while in the tibia the order of frequency is reversed. The great frequency with which the extremities of the shaft of the long bones are affected receives a plausible explanation from the activity of the physiological changes during the growth of bone, and perhaps to a lesser extent b}' the greater frequency of traumatism in these localities. Englisch claimed that the extremity of the shaft and epiphysis, toward which the nutrient artery is directed, is alwa^'s primarily alTected, on account of the greater blood- PATHOLOGICAL ANATOMY. 243 pressure in that locality. Clinical experience lias proved the contrar}-. As acute osteom^-elitis, without direct exposure of the marrow, is caused 1)3' infection with pus-microbes, which reach the tissue through the circulation, the inflammatory process must commence in the capillaries from mural implantation of microbes or leucocytes containing them. The cause of the inflammation is primarily' endo-A-ascular, and reaches the medullary tissue with the leucoc3-tes. Intense alteration of the capillary wall is always present in these cases, giving rise to rhexis. Pus from acute osteomj-elitis almost alwa3's presents a reddish appear- ance, which is owing to the presence of extravasated blood. The inflam- mation extends rapidl3' to the larger veins, which become blocked b3- the formation of a thrombus. If pus-microbes enter the thrombosed veins in sufficient quantit3^ to cause liquefaction of the coagulated blood, pyaemia results from transportation of fragments of such infected thrombi to the distant circulation. Extensive thrombo-phlebitis results in arrest of circulation in portions of the bone, or perhaps of the entire shaft, which is followed b3' the usual consequences of such a condition — necrosis. Xecrosis is undoubtedl3' also caused b3- the local toxic effect of the ptomaines of the pus-microbes upon the tissues and the pressure resulting from the presence of the inflamniator3' exudate in a tissue not capable of distention. The central medullar3' cavit3' is rapidh* trans- formed into an abscess-cavit3'. The pus occupies either the entire cavit3', a certain section of it, or in the form of multiple circumscribed abscesses or infiltration. The infection from the central focus extends along the blood-vessels and soon reaches the periosteum, which becomes the seat of an inflammation which resembles, pathologicall3', the medul- lar3' lesion in ever3- respect primar3^ The secondar3' periostitis in ever3' case of acute osteomyelitis alwa3's assumes a suppurative t3'pe. Pus accumulates between the periosteum and bone, causing often extensive denudation of the bone. The periosteum at some points is destro3'ed when the pus reaches the surrounding connective tissue, which then becomes the seat of a phlegmonous inflammation. The periosteal defects are not restored subsequentl3', and at these points openings remain later in the new bone, called cloacae. After the active S3'mptoms have sub- sided the suppurative periostitis gives wa3^ to a process of repair, during which the periosteum forms a case of new bone arouud the necrosed portion, which, in technical language is called an involuo'um. The abscess in the soft parts heals, and one or more fistulous communica- tions between the surface of the skin and the dead bone in the interior of the involucrum remain. The external openings are often quite distant from the cloacae, and in such cases it is difficult, if not impossible, to discover the dead bone b3' probing. The necrosed bone is called a 24:4: PRINCIPLES OF SURGERY. sequestrum. If necrosis has occurred :it diflVront points several sequestra will be included by the involucruni. Separation of a sequestrum, like the elimination of necrosed soft tissues, is accomplished either b}- suppu- ration or, what is more common, by granulation. Such pieces of bone always show an irregular or deutated outline, which is due either to the original shape of the sequestrum or to the action of tlie granulations, v,liieh diminish the size of the detached bone after its separation, Necrosis is said to be central if the sequestrum is composed of tissue ■rom the interior of the Ijone, complete if it represent the entire thick- r.e^s of the bone, and cortical if it is composed of the external compact layer only. In complete necrosis a pathological fracture necessarily takes place if separation occur before a firm involucrum has formed. In such cases restoration of the continuity of the bone is effected by the new bone. In central necrosis the dead bone is always encased in an iiivolucrum. In cortical necrosis spontaneous elimination of the seques- tnnn frequently occurs if the bone separate before an involucrum forms around it, or, if an involucrum does not form, on account of destruction of a corresponding portion of the periosteum. The medullary canal in the new bone, after central or total necrosis, is seldom restored to perfection. The new bone is harder and heavier than normal bone (osteosclerosis), but in exceptional cases it remains porous and soft (osteoporosis), — a condition described by Yolkmann and Schede, which ma}' become the cause of various degrees of deformity, from bending of the shaft. Separation of a sequestrum will take place in from four weeks to three months, according to the age of the patient and the location and extent of the necrosis. TREATMENT. An early and correct diagnosis is of the greatest importance in the treatment of acute osteomyelitis. As the gastro-intestinal canal is undoubtedl}' more frequentl}' the route through wdiich infection takes place than is generall}' supposed, and as nature's resources often attemp/t elimination of the pathogenic micro-organisms in this direction, it would appear rational to administer a brisk cathartic soon after the appearance of the first symptoms, as such treatment might prove of great value in arresting further infection from this source. A large dose of calomel, administered for the same purpose and in the same manner as advised during the early stage of typhoid fever, could not fail to produce a salu- tary effect. Kocher has advised the internal use of salicylate of soda, giving from 6 to 24 grammes in divided doses during twenty-four hours. In such doses this remedy would also have some effect in reducing the temperature, which is constantly high in all acute cases. Opium must TREATMENT. 245 be given in sufficient doses to alleviate pain. The affected limb should be placed in a slightly -elevated position. Demme, Billroth, and Yolkmann recommend vesication by frequently- repeated applications of the strong tincture of iodine. It is doubtful if such treatment has an}' influence in arresting or even retarding the further development of the disease. The use of the ice-bag is rational, and often relieves pain. In multiple osteom^-elitis, with pronounced symptoms of progressive sepsis almost from the beginning of the attack, it is doubtful whether an}- surgical treatment will have an}- effect in pi-eventing a fatal termination. In such cases general infection occurs almost from the very beginning, and at the necrops}- verj' little, if an}-, pus is found in the inflamed medullary tissue. The indicatio vitalis in these cases calls for the use of stimulants. In regard to the propriety of making early incisions, the greatest diversity of opinion has prevailed in the past. Previous to the researches of Demnie, early and free incisions were practiced very generally. As the results following the treatment were frequently disastrous, Demme was led to adopt a more conservative treatment. He advised an expec- tant plan to be pursued until the disease should exhaust itself, as it were, as indicated by reduction of temperature and cessation of the active symptoms of the inflammation, and then he argued the propriety of making large incisions. For the purpose of affording an outlet for the pus, Klose made early and small incisions at the junction of the epiphysis with the diaphysis. Oilier advocntes early incision, combined with trephining of the bone. In a communication, read before the Academy of Paris, he claims that trephining is applicable to all forms of osteo- myelitis with severe general symptoms. He maintains that trephining, even in the most diffuse form, will arrest the intense pain by relieving pressure; and where the disease is circumscribed it affords prompt and decided relief In the acute form, he claims, trephining will often pre- vent external necrosis and fatal symptoms, while in the subacute and chronic forms it removes the most distressing symptom — pain. In 8 out of 19 cases of early trephining he found pus ; and in 10 cases the marrow presented different, diverse, morbid appearances; v.liile in the last case, a case of acute osteomyelitis of the femur, a large quantity of fluid blood escaped. Two of the 19 cases died of pyaemia. Since osteomyelitis has been recognized as a microbic disease at- tempts have been made to arrest the disease by intraosseous injections of germicidal solutions. Hueter has employed parenchymatous injections of solutions of carbolic acid with decided benefit in the treatment of other inflammatory affections of bones and soft tissues. Kocher recom- mended that the soft tissues around the infected bone should be disin- 246 PRINCIPLES OF SUUGEKY. fected b}' saturating them with a solution of carbolic acid, thrown in with an ordinary hypodermic syringe. Later, the same autlior suggested the propriety of making intra-osseous injections after penetrating the bone witli a small perforation and injecting carbolized water, thus reach- ing the primary focus of the disease. Theoretically, the suggestion appears valuable; practically, intra-osseous injections in the treatment of acute suppurative osteomyelitis have proved a foilure. If it is next to impossible to al)ort even a small circumscribed suppurative inflamma- tion in the soft tissues with antiseptic parenchymatous injections, it is not surprising to learn that the same treatment has invariably failed in arresting suppuration in the interior of bones. Intra-osseous injections are no longer used in the treatment of acute suppurative osteomyelitis. Antiseptic surgery has revolutionized the treatment of acute suppu- rative osteomyelitis. The diseased medulla is now attacked with the same impunity as the soft tissues outside of the bones. The objections to large incisions increasing the danger from sepsis and pyaemia are no longer well-founded, as incisions made under antiseptic precautions for the evacuation of pus, instead of increasing the risks of death from sepsis or pyfpmia, are now considered the best means to prevent these fatal complications. It can now be laid down as an axiom in surgery that the medullary cavity, in every case of acute suppurative osteomyelitis, should be freely exposed and submitted to direct and most thorough antiseptic treatment as soon as a positive diagnosis can he made. It would be a serious and unjustifiable mistake to open a health}^ medullar}^ cavity; but, on the other hand, it would also be next to criminal negligence to wait for fluctuation before resorting to operative treatment in a case of acute osteomyelitis. The bone should be opened, the infected medulla removed, and the cavity disinfected before suppuration has extended to the peri- osteum and the surrounding soft tissues. The intelligence and moral courage of a surgeon can be nowhere better tested and gauged than when he is confronted by a recent case of acute osteom3'elitis. He must be sure of his diagnosis, and this often requires no ordinar}' erudition and diagnostic skill. A positive diagnosis made, he must possess enough courage to face the popular prejudice against early operation under circumstances where success is not alwa3^s attainable. Impressed with the imperative necessitj^ of operative interference from his knowledge of a case, a conscientious surgeon will not flinch from his duty, even under the most unpromising circumstances. If the respon- sibilities and risks are great, he will do well to fortify his course by calling into consultation one or more of his colleagues, to protect himself against unmerited criticism in the future, or, perchance, a suit for mal- TREATMENT. 247 practice. An earl}' radical operation for osteomyelitis (and the author means by this an operation done as soon as a positive diagnosis can be made, and before any external swelling has appeared) accomplishes the following most desirable results : 1. It removes pain. 2. It enables the surgeon to remove the local cause of the disease completel}^ or in part. 3. It prevents extensive necrosis. 4. It is the best proph3'lactic measure against fatal septicaemia and p3ajmia. 5. It prevents extensive destruc- tion of the periosteum and other contiguous soft parts. 6. It cuts short the attack and expedites recovery. As we have seen, the pain which attends osteom3'elitis is caused by the intra-osseous tension and by the secondary periostitis. If the medullar}' cavity is opened freely before suppurative periostitis has developed, the operation removes the conditions which cause the pain, and will therefore accomplish at once what anodynes and external appli- cations can do but imperfecth". The removal of the infected tissues fulfills the etiological indications of the disease, the removal of the pus- microbes completely- or in part, which, with thorough disinfection of the cavity, prevents the further extension of the disease. Necrosis takes place from the action of the pus-microbes and their ptomaines on the tissues, intrn-osseous tension, and vascular obstruction, all of which causes are either removed or, at least, favorably modified b}' an early radical operation. Limitation of necrosis is one of the most marked results of all early antiseptic operations for acute osteom^^elitis. Progres- sive sepsis is caused In' the introduction of pus-microbes and their ptomaines from the osteomyelitic focus into the general circulation ; hence, there is no better way in which this fatal complication can be pre- vented than by the removal of the infected tissues and subsequent disinfection of the cavity, followed b}- efficient drainage and strict anti- septic treatment of the wound. As pyaemia is always caused by septic thrombo-phlebitis, no surer way of guarding against it could be devised than the early removal of the infected tissues, which maj- include the vessels with a beginning thrombo-phlebitis. If the interior of an osteo- myelitic bone is rendered accessible to direct means of disinfection, such treatment will often, if not invariabl}', prevent the extension of the sup- purative inflammation to the periosteum and surrounding connective tissue, which constantly occurs when the patients are treated upon the expectant plan. An early radical operation, b}' limiting the necrosis and extension of the inflammation to the surrounding soft tissues, shortens the attack, and is conducive toward establishing at an earlj'time a repar- ative process in place of one of destruction. Pathological fractures will become less frequent complications in acute osteomyelitis as soon as earl}' radical operations are more generally adopted. Earl}' operations 248 PRINCIPLKS OF SURGERY. under antiseptic precautions, in short, are life-saving operations ; at the same time, thoy will leave the parts in a more satisfactory- condition for ra[)id and satisfactory repair. An earl)' operation I should call one done l)efore secondary suppurative periostitis has aj)peared. An intermediate operation for acute osteom3elitis is one performed after suppuration has occurred around the bone first affected, and late operations are under- taken for the removal of necrosed bone. Early Operations. — The surface of the limb is prepared in the same manner as for other antiseptic operations. The primary focus of the disease, usually in the vicinity of an epiphyseal line, is accurately located by searching for the most tender point. Over this point, or as near to it as the nature of the soft parts will permit, an incision is made down to the bone. As the operation is to be done below Esmarch's constrictor, the soft tissues can be carefully examined during every step of the operation, and their exact condition ascertained. The skin and under- lying fascia are cut through with one stroke of the knife, when the knife should be laid aside and the remaining tissues, down to the bone, are carefully separated with the finger, which can be readil}^ done by follow- ing the intermuscular sei)ta. The periosteum, even at an earl}' stage, will be found vascular and easily separated from the bone. This structure is then reflected with the soft tissues on each side, and held out of the way with retractors. The bone is then opened with a small, round chisel. The trephine should never be used, as it is, to say the least, a bungling and inefflcient instrument, while the chisel is an instru- ment of precision. For the first or exploratory opening a semicircular chisel should be used ; in the further steps of the operation ordinary chisels, such as are used b}^ carpenters, answer an excellent purpose. As the first opening will probably be made near an epiphyseal extremity, at a point where the compacta is verj' thin, the chiseling is attended by no diflSculties. The opening is made directly toward the centre of the bone. If no pus has formed the osteomyelitic focus is recognized b}'^ the softness and great vascularity of the tissues and the escape of bloody serum. If pus is found it will probably appear at this time as an infil- tration. The object of the operation is not only to open the bone, but to remove all of the infected tissues. The opening in the bone is, there- fore, enlarged in the direction of the shaft to the extent of the disease in its interior. If the suppurative inflammation is extensive, involving- half of the bone, or, perhaps, the entire shaft, it is advisable to make several incisions over the bone in the same line instead of one large incision, thus avoiding a large wound and, perhaps, injur}^ of important structures; at the same time the interior of the bone is rendered accessible to direct treatment by opening the bone at the corresponding points and TREATMENT. 249 scraping out the medullaiy tissue contained in tlie intervening sections witli a sliarp spoon, tlie handle of which can be bent at an}^ desirable angle. After the whole cavity has been thoroughly curetted it is dis- infected by irrigating it with a solution of corrosive sublimate (1 to 1000), and then dried and mopiied out with a 10-per-cent. solution of chloride of zinc. Peroxide of hydrogen is also an excellent remedy for disin- fecting the bone-cavity after curetting. The cavity is then packed with iodoform gauze, which is brought out of the wouijd or wounds to serve the purposes of a capillary drain. A copious antiseptic dressing is applied, and the limb immobilized in proper position upon a splint. A fall in the temperature, and otlier signs of improvement soon after the operation, are indicative tluit the desired object, primary disinfection of the osteomyelitic focus, has been attained. If on the following da}' the temperature shows no reduction, the dressings are removed, antiseptic irrigations are again employed, and the limb is dressed antiseptically. Should, in spite of the early operation and careful antiseptic after-treat- ment, the suppurative inflammation extend to the periosteum and the connective tissue, the antiseptic occlusive dressing should give way to warm compresses kept saturated with one of the mild antiseptic solu- tions. Frequent irrigations Avith a 2-per-ceiit. boracic-acid solution, a ^ to 1-per-cent. solution of acetate of aluminum, or a weak aqueous solu- tion of tincture of iodine should be made, and the limb confined upon a suspension splint. Intermediate Operations. — If a case of acute osteomyelitis come imder treatment after purulent infiltration has occurred around the affected bone, no time should be lost in evacuating the pus by incision and drainage. Multiple incisions and numerous tubular drains are often required to effect complete evacuation and secure free drainage. In these cases operations on the bone itself should be limited to making smaller openings in the exposed portion of the bone, for the purpose of reaching its interior with antiseptic irrigations. Large openings, under these circumstances, might lead to pathological fractures. The subse- quent treatment is conducted on the same principles as a case of phlegmonous inflammation and pundent inflammation of the soft parts. As in the early treatment of osteomyelitis by radical operation, the limb must be supported in a desirable position by some kind of a splint. The use of a i)ioper splint in the treatment of acute osteomyelitis is in- dispensable. A well-fitting posterior splint, or the anterior suspension splint of R. N. Smith, secures rest for the limb, i)revents contractures and sul)lux;iti(iu of joints, and finall}' diminishes the frequency of patho- logical fractures. Catarrhal synovitis is treated by aspiration, and sup- purative synovitis by incision, drainage, and antiseptic irrigations. During 250 PRINCIPLES OF SURGERY. the ncnU> stngc of suppurative osteomj^elitis the removal of an entire shaft of a long bone should be limited to one bone of the forearm or leg, as the removal of the entire shaft of the humerus or femur before the formation of an involucriim of suflicient tirmness to act as an efficient sup[)ort would greatly complicate the mechanical part of the after-treat- ment, and tlie procedure might result in imperfect restoration of the bone removed. Where the greater portion or the entire shaft of a bone has become necrosed and has separated at one or botli epiphyseal junctions, it m.'i}^ become necessar}' to remove it during the acute stage to avert death from exhaustion from profuse discharges and septic fever inci- dent to the presence of such a large septic foreign body. It has been argued against such a procedure that the bone would not be regenerated after its removal. This fear, however, is not supported by facts, as when the periosteum and the epiph3^sis remain a good, if not perfect, substitute is reproduced. Duplay, Holmes, McDougal, Lefort, Giraldes, Spence, Petrequin, Wilms, Cheever, Ropes, and Gay have each reported cases where almost complete reproduction followed the removal of tlie entire shaft. It is very important, especially in children, to preserve both epipli3-ses, to prevent subsequent shortening and other deformities of the limb. Where the continuity of a bone has been destroj'ed, either by a pathological fracture or the removal of a part or an entire diaphysis, which has separated before the involucrum has become sufficiently firm to serve the purpose of an efficient mechanical support, a suitable me- chanical support must be applied for a long time to guard against short- ening and bending of the new bone. During the septic stage of acute osteom3'elitis with suppurative synovitis amputation ma}- become neces- sar}' to save the life of the patient. In exceptional cases the same sad alternative ma\' become a necessity after the acute symptoms have sub- sided, for the purpose of removing the source of exhausting suppurative discharges. Our present means of treating abscesses, diffuse purulent infiltrations, and suppurative diseases of joints are, fortunately, so perfect and efficient that even severe cases can be treated on a more conservative plan, and amputation should be restricted to extreme cases as a dernier ressort. Should signs of p3-8eraia arise, our main reliance must be placed on the administration of large doses of quinine and alcohol. Luecke has obtained the best results from large doses of alcoholic stimulants. Instances have been reported where two pint-bottles of cognac were given during twenty-four hours with decided benefit. Osteom3'elitic patients should be surrounded b}' the most favorable hygienic influ- ences, as fresh air, equable temperature, light, and an abundance of plain, nutritious food. As soon as the acute symptoms have subsided, iron, especially tinctura ferri chloridi, should be freely administered. If TREATMENT. 251 osteomyelitis is complicated by the co-existence of other diseases, siicli as syphilis, tuberculosis, rachitis, etc., the treatment of the latter should receive appro})riate attention. Late Operations. — As late operations will be considered the operative removal of sequestra. The operation for the removal of detached dead bone is called necrotomy or sequestrotomy. The operative removal of a sequestrum should always be postponed until complete separation has taken place and the involucrum is strong enough to furnish the neces- sary mechanical support. If an operation is undertaken at an earlier time there is danger of unnecessarily removing a portion of health}- bone or of leaving a part of the sequestrum. Necrosis is not a disease, but always a result of a destructive inflammation. It is not always easy to determine whether separation of the sequestrum has taken place in a given case. The sinus leading down to the dead bone ma}' be so tortu- ous that it is impossible to introduce a probe into the interior of the involucrum. Again, if the sequestrum is felt with the probe it is often impossible, by any kind of manipulations, to ascertain in this manner its mobility, as it is often firmly encased in a bed of granulations. The time required in separation of the sequestrum varies greatly, — a whole pha- lanx of a finger may be separated completely in four weeks, a cortical sequestrum of a long bone may become detached in six weeks to two months, while the separation of half or an entire shaft of the large, long l)ones, as the femur or humerus, ma}- require from three to six months. If the patient's general health is improving there is no need of haste in the removal of a sequestrum, as there is notliing lost and a great deal gained by waiting until sufficient time has elapsed for separation to take place. Sequestrotomy, if properly performed, is one of the most grateful of all operations, as it is attended by little or no danger to life, and is usually followed by a favorable result. Its performance has been greatly simplified by the use of angesthetics and Esmarch's constrictor. Since Esmarch taught us how to obtain, by a very simple appliance, a bloodless condition of the limb during the operation, the surgeon can make the necessary dissection with the same degree of accuracy as in the dissecting-room, thus avoiding injury of important vessels and nerves, which formerly occurred quite frequently even in the hands of the most accomplished surgeons. Before the operation the entire limb is disinfected and rendered bloodless by elevating it for a few minutes, W'hen an Esmarch constrictor is applied on the proximal side and some distance from the seat of operation. I have met, in my practice, with 2 cases of paralysis of the musciilo-spiral nerve from the use of Esmarch's constrictor, which was applied about the middle of the arm, and, although both patients recovered perfect use of the limb in the course 252 I'KINCIPLES OF SURGEKY. of two to four months, I have since taken the precaution to guard against such a perplexing accident by appl3'ing the constrictor over the middle of the deltoids, and over several thicknesses of a towel in order to protect the nerves against undue pressure. Since I have made use of these precautions I have had no further accidents from elastic constric- tion. In an operation for extensive necrosis of the tibia the constrictor was applied just above the knee, and as soon as the patient recovered consciousness it became evident that the constriction had resulted in paralysis of the i)eroneal nerve. More than four months elapsed before function was completely restored. Since that time I always apply the constrictor higher up, where the nerves are protected by a thick cushion of muscular tissue, and have seen no more evil elfects from elastic con- striction of the lower extremity. Wherever it is safe to make the incision in the line of one or more fistulous openings this should be done, but when these are in localities w^here there would be danger of wounding important vessels, muscles, or nerves, another location must be chosen. In operations upon the humerus the exact location of the musculo-spiral nerve must be remembered, and if the incision necessarily comes close to this structure the dissection is made slowly and with the use of blunt instruments until the nerve is found, when it can be held out of the way. In operations upon the lower end of the femur, even if the fistulous opening should be in the popliteal space, the incision down to the bone should be made in the course of the intermuscular septum, on the outer or inner side, as the posterior surface of the femur can be made accessible from either side by making the incision large and by keeping close to the bone, separating the soft tissues well and keeping them out of the way by the use of retractors. Where the bone is cov- ered by thick layers of muscles the incision is made in the direction of the muscles, and at a point corresponding to an intermuscular septum. The external incision should always be large, so as to aftord plenty of space. As soon as the intermuscular septum is reached the scalpel should be laid aside and the parts carefully separated down to the bone by using the fingers or blunt instruments. When the bone is reached the periosteum is incised and reflected with the soft tissues attached to it. The opening of the involucrum is done with the chisel. In old- standing cases the involucrum is as dense as ivory and the chiseling is an exceedingly slow and laborious process, as only very small chii)s cnn be removed with each cut of the chisel. The brittleness of the new bone should wai-n the surgeon to chisel with care, as, otherwise, a frac- ture might result. If the chiseling is done at the site of a former open- ing, this opening is enlarged until the sequestrum is reached and can be extracted. Extraction of the sequestrum was the sole object of opera- TREATMENT. 253 tions in the past ; hence the dead bone was removed through a compara- tivel}' small opening in the bone, either in toto or after fragmentation. Modern surgery not only seeks to remove the dead bone, but to place the cavity in the best possible position for rapid healing. The first indica- tion to be fulfilled in securing a favorable reparative process after the operation is to obtain an aseptic condition of the cavity. This can only be done by exposing the interior of the entire cavitj'. Chiseling is con- tinued until both ends of the cavity are reached, when the sequestrum can be lifted out and the granulations lining the cavit}' are scraped out with a sharp spoon. Spoons of different sizes should be at hand, as the interior of such cavities usually' present depressions and sinuses, which can be only dealt with successfully by keeping on hand different-sized spoons. After the mechanical removal of the infected tissues the cavity is washed out with a solution of corrosive sublimate (1 to 1000) and rubbed out and dried with an antiseptic sponge. It is evident that the healing of such a cavity, by unaided resources of nature, would be a slow process. Various attempts have been made to overcome the diffi- culties in the healing of cavities with unjielding walls. D. J. Hamilton suggested sponge-grafting. Neuber made flaps of the skin from each side, which he fastened to the floor of the cavity with bone nails. Schede utilized the blood, which he allow^ed to accumulate in the cavity after suturing the external parts, and obtained some excellent results with this treatment. Recently, E. Hahn advised to detach the skin on each side to within an inch, at the posterior surface of the limb, for the purpose of better immobilization of the flaps, which are to be mitted over the centre of the gutter by suturing. For some years the author has been experimenting on animals with decalcified bone in the healing of aseptic bone-cavities, and the experimental as well as the clinical results obtained so far exceed all expectations. The decalcified bone-chips are i)reserved in an alcoholic solution of corrosive sublimate (1 to 500) or a solution of iodoform in sulphuric ether. The most essen- tial condition for success, in the treatment of bone defects b}' implanta- tion of decalcified bone, is a perfectly aseptic condition of the tissue to be brought in contact with the implanted bone. This condition is easily procured in operations on bones for lesions other than those caused b}' infection with pus-microbes, such as tumors, echinococcous c^'sts, and tuberculous and syphilitic affections uncomplicated by suppuration. In the surgical treatment of these affections, after the removal of the dis- eased tissue the seat of operation must be aseptic, if the ordinary- pre- cautions in the prevention of infection from without have been observed. In sucli cases speedy healing of the external wound and the earl}- partial or complete reproduction of the lost bone are assured. The next most 254 PRINCIPLES OF SURGERY. favorable cases for this procedure ure circumscribed osteomyelitic proc- esses in the epipbj^seal extremities of the long bones, as we observe them in cases of primary circumscribed epiphyseal osteomyelitis, or in the form of a recurring attack in the same i)lace, perliaps years after a diffuse osteom^-elitis of the entire shaft. This method of treating bone-cavities is also applicable after operations for necrosis resulting from a previous attack of acute suppurative osteomyelitis. The cavity must be prepared for tlie implantation of decalcified bone in tlie manner described above. The implantation is made before the removal of the constrictor, in order that, after this is done, sullicient blood will escape to fill the spaces be- tween the chips, and thus serve the nseful purpose of a temporary cement- substance. After the cavity has been dusted over lightly with iodoform, the chips, which have been washed previously in an antiseptic solution, are dried upon a gauze compress, and are then poured into the cavit}' until this is packed with them as far as the periosteum. The first advan- tage derived from this method of bone-packing is that the chips serve as an antiseptic tampon which arrests the free oozing from the surface of the bone, which alwa3's takes place after the removal of the constrictor. Some blood escapes between the bone-chips and coagulates at once, thus forming a desirable and useful cement-substance which permeates the entire packing, and temporarily glues, as it were, the chips together and the entire mass to the surrounding tissues. The periosteum should be carefully preserved in exposing the bone, and, after implantation, is sutured over the surface of the bone-chips with absorbable aseptic buried sutures. If the bone is deeply located, it may become necessary to apply a second and third row of buried sutures in bringing into accurate apposition other soft parts. The skin is finally sutured with silk. It is of the greatest importance to secure accurate apposition of the divided soft parts, in order to preserve for the subjacent bone all of its natural coverings. In some instances it w^ould be, undoubtedly, superfluous to secure any form of drainage, as, when the cavit}' is perfectly aseptic and haemorrhage is not in excess of requirements, healing of the entire wound would be accomplished under one dressing. Experience, however, has taught me that tension arising from extravasation of blood often exerts an injurious influence upon the process of healing, and should be care- full}' avoided. As it is desirable to heal as much of the wound as possi- ble without interfering with drainage, an absorbable capillar}' drain should be inserted in the lower angle of the wound. A string of catgut twisted into a small cord answers an admirable purpose. The wound is covered with a strip of aseptic protective silk, over which a few layers of iodoform gauze are applied. Over this a cushion of sublimated moss is placed, with a thick layer of salicylated cotton along its margins for TREATMENT. 255 the purpose of guarding more securel}- agiiinst the entrance of unfiltered air. The whole of the dressing is retained by a circular gauze bandage, evenly and smoothly applied. For the purpose of securing absolute rest for the limb, it is placed upon a posterior splint and kept in a slightl}^ elevated position. If no indications arise, the first dressing is not removed for two weeks, when the entire wound will usually be found healed, except a few granulations at the place where the catgut drain was inserted. A smaller antiseptic compress is applied and the limb dressed in a similar manner. It is prudent to enforce rest, — not only till the external wound has healed, but until the process of repair in the interior of the bone has been completed, which embraces a period var^ iug from four weeks to three months, according to the size of the cavity and the age of the patient. If an operation for necrosis with implantation of decalcified antiseptic bone-chips is followed by suppuration, it is an evi- dence that antisepsis was imperfect, and such cases must be treated upon the same principles as suppuration in other localities. If suppuration take place soon after the operation, and is profuse, it is probable that all of the bone-chips will have to be removed in order to facilitate the dis- infection of the cavity. If it develop after granulation tissue has had time to form, and the discharge of pus is moderate in quantity, the pros- pects are that the bone will remain and serve its purpose as a nidus for the granulation tissue. In such cases an antiseptic irrigation should be made everj^ three or four days until suppuration has ceased. If the bone-chips are lost b}' suppuration, or have to be removed for the pur- pose of a more thorough disinfection of the cavity, no attempt should be made at re-implantation until suppuration has been arrested ; or, in other words, until the cavity has become lined with granulations, and is in a comparatively^ aseptic condition (when the time for secondary im- plantation has arrived). After the cavit}' has been irrigated with a strong- antiseptic solution the superficial granulations are removed with a sharp spoon, and it is packed with bone-chips, which are implanted in the same manner as in the treatment of a recent cavit^y. Complete closure of the external wound under these circumstances is seldom obtainable, and the surface of the exposed portion of the cavity should be provided with a thin layer of Schede's moist blood-clot. I have resorted to implantation of decalcified antiseptic bone-chips in the treatment of bone-cavities, after necrotomy and operations for tuber- culosis of bone, in at least 25 cases, and have had the satisfaction of healing large defects without a drop of pus under one or two dressings in from two to four weeks. Only in a small percentage of the cases was it found necessary to remove the packing, and in most of these secondary implantation proved successful. Schede's blood-clot does not possess 256 pHiNnrLKS of surgery. :uiy niitiseptic properties, like the Ijoiie-cliips, and is not as permanent a structure. Operntions b^- Neuber's method are often followed by necrosis of tlie (laps, and even if successful the lost bone is not restored. Implantation of decalcified antiseptic bone-chips, in the treatment of aseptic bone-cavities, is preferable to the use of viable grafts, as the substance used is not onl}' absolutely aseptic, but possesses also valuable antise[)tic properties, which must be looked upon as a valua])le and important quality in the treatment of such cases. Reproduction of bone follows almost to perfection in everj^ case where antisepsis proves successful ; hence they serve the same purpose as viable grafts, as far as the restoration of lost tissue is concerned. I have chiseled a wide gutter in the humerus and tibia almost from one epiphysis to the other, for the removal of large sequestra, and have seen such enormous defects restored after implantation with bone-chips in a few weeks. The contour of the bone is restored to such perfection that after a few months it would be difficult to tell where the operation was performed. The bone-chips serve as a temporary scaffolding for the granulations springing from all sides of the bone-cavity, and as the}' are removed by absorption their place is occupied by living permanent tissue ; first by embryonal cells, "which are later converted into bone. CHRONIC CIRCUMSCRIBED SUPPURATIVE OSTEOMYELITIS. This is the bone-abscess of the older authors. The etiology of this form of suppurative inflammation is the same as in the diffuse variety. Clinicall}', two kinds can be distinguished : 1. Primarj- epiphyseal circumscribed osteomyelitis. 2. Secondary circumscribed osteomyelitis. The first kind is occasionally met with as a multiple affection, and is then attended by more or less constitutional disturliances and maj^ result in epiph3'seol3'sis. The secondar}' form occurs in bones that have been the seat of an attack of dittuse suppurative osteomyelitis, the patient apparently having recovered completel}' from the primary attack years before. It is still a question under discussion, if in these cases the infection is caused b}' microbes which have remained in the tissues in a latent state since the primary attack, or whether it is caused by localiza- tion of pus-microbes in the tissues weakened by the first attack. Rosen- bach is of the opinion that recurring attacks of osteomyelitis in the same bone are caused b}' pus-microbes which have remained in the tissues, and which again become pathogenic when the tissues around them are rendered susceptible to their action by subsequent causes. I am strongl}^ inclined to the same opinion. I have seen numerous cases where, in persons from 16 to 25 years of age, repeated attacks of circum- scribed osteomyelitis occurred in a bone which, during childhood, had CHRONIC CIRCUMSCRIBED SUPPURATIVE OSTEOMYELITIS. 257 passed through an attack of acute osteomj-elitis. The tibia, femur, and humerus are the bones which are most frequentl}' attacked b}' recurrent osteom3elitis. The secondary attacks occur either in the centre of the sclerosed bone, the former site of the infected medullary cavity, or near one of the epiphyseal lines. I have no doubt that secondarj- osteo- myelitis will be of less frequent occurrence after earl}' operations for osteomjelitis, and that antiseptic sequestrotomy will be more generally practiced. Symptoms. — The most important symptoms of circumscribed central suppuration in bone are pain and tenderness. The pain is deep-seated, intense, of a boring or gnawing character, and is generally more severe after active exercise and during the night. It is often intermittent, and lias frequently' been wronglj- interpreted as neuralgia of bone. The tenderness is circumscribed, and corresponds to the location of the suppurating focus. It is due to a circumscribed secondary plastic periostitis. The external swelling is slight, and often completely' wanting. Usually neither redness nor oedema are present. Pathological Anatomy. — Limited suppurative osteom3elitis gives rise to a circumscribed abscess, which varies in size from a pea to a walnut. Necrosis of bone seldom takes place; if it does, the sequestra are small and composed exclusively' of cancellated tissue. If the abscess is situated in an epipln'sis it ma}' open into the adjacent joint and become the cause of a secondar}' suppurative arthritis. Thrombo-phlebitis, sepsis, and pyaemia rarely occur. The periostitis which attends chronic suppuration in bone always assumes a plastic type, as the periosteum is beyond the reach of pus-microbes. Epiphyseal osteomyelitis is often associated with chondritis and osteoporosis, — conditions which may result in pathological fracture. If in this form of osteomyelitis the sii[)iiuration extend to the periosteum, a circumscribed suppurative periostitis occurs, which is followed by the formation of small abscesses in the epiphyseal region. Limited necrosis in these cases is of frequent occurrence. Treatment. — Circumscribed osteomvelitic processes in the epiphyseal extremities of the long bones, as we observe them in cases of primary circumscribed suppuration in the epiphyseal region, or in the form of a recurring attack in the same place or in the sclerosed shaft, perhaps years after a diffuse osteomyelitis of the entire shaft, are favorable cases for implantation of decalcified antiseptic bone-chips, as an aseptic con- dition of the cavity can be readily procured after the operative removal of the infected tissues. The inflammatory focus can be located externally with accurac}' by the presence of a circumscribed area of tenderness, and the centre of the tender spot constitutes the guide in the search for the abscess. The operation is performed under strict antiseptic precau- 258 PRINCIPLES OF SURGERY. tions, and by the bloodless method. The chiseling is done in the direc- tion of the centre of the bone by making a track perhaps an inch sqnare. If the abscess is not fonnd at a certain depth the surrounding tissue is explored with a small drill, in difl'erent directions from the track, until it is discovered, when further excavation is again made with the chisel. As soon as the abscess has been full}- exposed the pus is washed out, and the size of the cavity ascertained by probing. As the abscess is often surrounded by a zone of tissne infiltrated with pus, all of the infected tissues arc scraped ont thoroughly with a sharp spoon ; after which the cavity is prepared for the implantation of the bone-chips in the same manner as in operations for necrosis. lodoformization of the cavit}^ and the implantation of antiseptic bone-chips are measures which are well calculated to resist the pathogenic action of pus-microbes which might still remain, and in the majority of cases will secure an aseptic healing of the wound. I have repeatedly seen cavities the size of a small orange, in the head of the tibia, heal under two dressings, wnth perfect restoration of the bone removed by this method of treatment. The means resorted to to obtain an aseptic condition of the cavity will often result in increase to twice its original size, but the loss of tissue is not to be taken into consideration when a method of treatment is to be employed which requires perfect asepsis in order to be successful in placing the parts in a condition where perfect restoration will be accomplished with almost unfailing certaint3\ CHAPTER XI. Suppuration in Large Cavities ; Abscess of Internal Organs. The suppurative afl'ections of the ditl'erent large cavities in the body present so nianv features common to all of them that they will be con- sidered together in this chapter. Suppurative inflammation of a mem- brane, synovial or serous, lining a closed cavity, is characterized b}- the rapidit}^ with which the inflammatory process spreads over the entire surface, and the retention of the products of inflammation in a preformed closed space. Abscesses of internal organs result from infection by the extension of a suppurative lesion from the surface along the course of blood-vessels, lymphatics, nerve-sheaths, or b}'^ localization of pus- microbes floating in the blood in a locus minoris resistentise of an organ. suppurative arthritis. Suppurative inflammation in an intact joint is alwaj^s caused by localization of pus-microbes in the sj^novial membrane, conveyed to this structure by the blood, which results in suppurative synovitis, and, by the extension of the infection to the other structures of the joint, is often followed by complete disorganization of the joint. In this manner metastatic suppurative synovitis is caused, as it occurs, in p3'aemia, gonorrhoea, and in some of the general infective diseases. Bacteriological Researches. — In animals susceptible to the action of pus-microbes, the injection into a joint of a pure culture is nsuall}^ followed by acute suppuration, and, not infrequently, by the formation of extensive para-articular abscesses. Hoffa, Kranzfeld, and Krause have studied, with special care, the microbic origin of suppurative S3^no- vitis, and all of them found in the pus one or more varieties of the microbe of suppuration. Krause found, in the pus of suppurating joints in small children, a streptococcus, the identity of which with the one described b}^ Rosenbach was proved by cultivation experiments. In one case the same microbe was also found in the products of a purulent meningitis, which followed in the course of the joint disease. The same streptococcus was found by Heuber and Bahrdt in pus from a suppurat- ing joint, and in the diphtheritic membranes of a scarlet-fever patient. The so-called gonorrhoeal rheumatism is a suppurative S3'novitis, but opinions are divided in reference to the p^-ogenic properties of the (259) 260 PRINCIPLES OF SURGERY. gonococcus. This microbe was discovered in gonorrhoeal pus hy Neisser, in 1879. Its direct etiological relation to gonorrhoea has been sufficiently demonstrated by experimental research and clinical observation. The gonococcus always occurs in pairs, and is, therefore, a diplococcus. The cocci appear as hemispherical bodies, with their flattened sur- faces in apposition, which imparts to the microbe the characteristic biscuit-shaped appearance. They are found in clusters upon, or, what is more probable, as Biimni asserts, within the pus-corpuscles of gonor- rhoeal pus. Their intra-cellular location was shown b}- Bumm, b^^ exam- ining pus-corpuscles in water ; when, after imbibition of fluid, the cells became swollen, the cocci could be seen between the molecular granules of the protoplasm. The microbes within the corpuscles ma}^ become so numerous as to fill the entire space, with the exception of the nucleus. It can be cultivated upon solidified blood-serum, or agar-agar-meat peptone. Its pus-producing property in specific inflammation of the mucous membrane of the urinary organs and conjunctiva is well known, Fig. 61.— Gonococcus. {Bumm.) A. From a pure culture. B. From a blennorrhceic conjunctival secretion ; an epithelial cell covered with cocci; a pus-corpuscle with cocci in the protoplasm; a pus-corpusele completely filled with cocci; a free mass of cocci in close proximity to a pus-corpuscle. C. Development of gonococci. and at present is not attributed to its direct efl'ect on the tissues, but to the action of ptomaines, which it produces. A number of cases have been reported which appear to show that under certain circumstances the microbe enters the circulation and becomes the cause of metastatic suppuration, especialljMn joints. Schwarz asserts that the gonococcus is constantly found in the eff"usion of joints in gonorrhoeal rheumatism, in other abscesses caused by gonorrhoea, and in the glands of Bartholin, in women who have passed through an attack of gonorrhoea. Petrone detected the gonococcus in the effusion of joints and in the blood, in two patients suffering from gonorrhoeal rheumatism. He regards the joint complications as metn static processes caused by the gonorrhoeal infection. Other authors found metastatic abscesses in gonorrhoeal patients, cultivated from the pus-microbes of suppuration, and on this account regard them as the result of a secondary- or mixed infection. If gonococci can transform epithelial cells of the urethra or conjunctiva into pus-corpuscles, there is no renson to doubt that under favorable SUPPURATIVE ARTHRITIS. 261 circumstances they can exercise the same pathogenic eftect on other tissues, particularly the synovial membrane of joints. Symptoms and Diagnosis. — Suppurative arthritis is usuall}- attended b}' a great deal of pain. This symptom is a prominent one in this affec- tion on account of the intensity of the inflammation, and also because the pus accumulates with great rapidit}^ in the joint, causing tension, x^octurnal exacerbations are common. The pain is greatly aggravated bj- passive motion, and any attempt on the part of the patient to use the joint vastl}" increases the suffering. Flexion of the joint is an early symptom, and increases in degree with the progress of the disease. In suppurative inflammation of the hip- and knee-joint it is not uncommon to find the limb flexed at right angles. In advanced cases of suppura- tive gonitis the tibia becomes partially dislocated backward and rotated outward. The swelling, as long as it is caused In' the effusion into the joint, is proportionate to the amount of fluid contained in the joint. In the knee-joint the patella is raised from the condyles of the femur, the depressions on each side of it are effaced, and the upper recesses of the sj-novial sac become prominent. After perforation of the capsule, the pus escapes into the loose para-articular connective tissue, where it causes a rapidly-spreading phlegmonous inflammation. In \evy acute cases rupture of the capsule and an extensive para-articular abscess may appear in less than a week. With the rupture of the capsule of the joint the pain is diminished, but the general symptoms are aggravated. The parts around a suppurating joint usuall}- present an oedematous appear- ance. The clinical history is often of great value in arriving at a con- clusion in reference to the character of the synovitis. If an arthritis develop insidioush* in connection with a suppurating lesion, attended by grave general sj-mptoms, it is an evidence which renders a diagnosis of pyaemia more than probable. In p^'aemia the joint affections appear often, either simultaneousl}- or in rapid succession, as multiple afl^ections. An obstinate joint affection, appearing in the course of an attack of gonorrhoea, is generally either a sero-purulent or suppurative s3'novitis. Gonorrhoeal synovitis develops most frequently' from the second to the fourth week after the appearance of the primary disease. If anj' doubt exist as to the character of the effusion into a joint, this can be readily dispelled bv making an exploratory- puncture with an ordinary' hypo- dermic needle. Treatment. — Tlie only form of suppurative sj-novitis amenable to any other treatment, short of free incision, drainage, and antiseptic irri- gation, is the sero-iMirulent effusion complicating gonorrhoea. In such cases aspiration, followed b}- compression of the joint and fixation of the limb in an immovable dressing, is usuall}' successful in permanently 262 PRINCIPLES OF SURGERY. removing the effusion. The absorption of the products of inflammation and return of function are hastened by massage and liot and cold douches. If a joint contain pus, temporizing measures should be abandoned, and the pus should be evacuated either by aspiration followed by washing out with an antiseptic solution, which should be repeated until the fluid returns clear, or, wliat is preferable in the vast majority of cases, the joint is treated from the beginning as an ordinary abscess. For irriga- tion of asuppurating joint with the aspirator, a ^-per-cent. (.5 per cent.) solution of acetate of aluminum should be \ised. The greatest care must be exercised not to inject atmospheric air into the joint, as, aside from the danger of increasing the infection b}^ the admission of air, such acci- dents have been followed b}' immediate death from air embolism. The most eflficient treatment in cases of suppurative arthritis is incision and drainage under strictest antiseptic precautions. As in the treatment of acute abscesses, the incisions must be made in places where drainage is most required. A long pair of haemostatic forceps is an indispensable instrument in draining a joint. In draining the knee-joint three trans- verse tubular drains should be inserted, one beneath the tendon of the patella, one under the patella, and one across the upper recess of the joint. The fourth drain should be passed directly through the joint between the condyles of the femur, reaching from one side of the patella into the popliteal space. This would require eight incisions, each from ^ to 1 inch in length ; half of them serve as openings into the joint for the forceps, while in making the remaining incisions only the skin and fascia are cut to the requisite extent over the point of the forceps. In tunneling the soft tissues in tlie popliteal space, with the forceps, from within outward, the opening is to be made to one side of the large vessels and nerves. Such an operation requires the administration of an anaes- thetic and the use of elastic constriction of the limb. As soon as all the drains are inserted the joint is washed out in different directions with one of the stronger antiseptic solutions, after which a copious antiseptic dressing is applied and the limb is immobil- ized upon a splint. If on the following day the fever has not subsided, or as soon as the dressing has become saturated with the discharges, it is removed, and the irrigation repeated as before. As soon as suppura- tion diminishes, through drainage is dispensed with and the drains are shortened from time to time, to be entireh' removed with the disappear- ance of the swelling and the cessation of suppuration. The elboAv-joint can be efficiently drained by passing a drain transversel}' through the joint, between the articular surfaces of the humerus, radius, and ulna. In draining the ankle-joint, a small incision is made down into the joint, at a point corresponding to the anterior margin of the external malleolus, ENDOCRANIAL SUPPURATION. 263 through which a haemostatic forceps is introduced and pushed in a backward direction, along the upper surface of the astragalus, until its point can be felt posteriorly under the skin, to the outer side of the tendo Achillis. The skin is then incised, the opening enlarged by un- locking the forceps and separating its blades, and a fenestrated rubber drain drawn through. If, as it so often happens, the posterior portion of the capsule of the joint bulge considerably, this can be drained b}' a drain inserted transversely underneath the tendo Achillis, near its attach- ment to the OS calcis. Through drainage of the shoulder-joint in an antero-posterior direction can be established in the same manner without much difficult}-. Drainage of the hip-joint is alwa3S difficult and never efficient. The best plan to follow is to open the joint from behind through an incision tliree or four inches in length, and then to pass a long pair of Peau's or polypus forceps between the capsule and the neck of the femur, either along the upper or lower border, in the direction of the groin, and to make a counter-incision upon the point of the instrument, and to draw a tubular drain through the whole length of the track. The wrist-joint can be drained transversel}' and antero-posteriorly, without fear of injuring any important structures. If suppuration continue, in spite of free drainage and careful antiseptic after-treatment, threatening the life of the patient from exhaustion or sepsis, more aggressive measures are indicated. Under such circumstances, it becomes often an exceed- ingly difficult matter to decide which one of the operative procedures should be adopted, — arthrectomy, excision, or amputation. If the pa- tient's strength is so much reduced that artlirectomy or excision offer no prospects of a successful issue, amputation should be performed. This alternative becomes an unavoidable necessity if the suppurative arthritis is complicated by extensive burrowing of pus among the muscles, ten- dons, and para-articular tissues. If the patient's strength warrant an arthrectomy, this operation should be done if the disease is limited to the synovial membrane of the joint. Tj'pical or at3'pical resection is to be restricted to cases where the articular cartilages and bone itself are found diseased. In resection of joints for suppurative affections, the surgeon must aim to remove onl}- infected tissues; hence incomplete atypical are more frequently indicated than complete or tyi)ical resections. All cases of suppurative inflammation of joints should be treated from the beginning b}- immobilization of the limb and by the use of an ai)pro- priate mechanical support, both for the purpose of securing rest and to prevent deformities. ENDOCRANIAL SUPPURATION. (a) Suppurative Pachymeningitis. — Suppurative inHamnmtion of the dura mater occurs either as a circumscribed or diffuse affection. It is 201 PRINCIPLES OF SURGERY. caused b}' direct or indirect iiilection with pus-microhes. Direct infec- tion occurs when the membrane is in communication witli an infected penetrating wound of tlie skull. Traumatism, without infection, never results in suppurative inflammation of the envelopes of the brain ; nor does the presence of an aseptic foreign body produce it. Aseptic injuries of the brain and its envelopes are productive of circumscribed, degenerative, or plastic lesions, but no suppuration. Septic inflamma- tion of these structures, on the other hand, is noted for its tendenc}^ to become diffuse and to extend from one tissue to another, both b}' con- tinuity and contiguit}'. Thus, in cases of pachymeningitis with loss of continuity of the dura mater, in cases of compound fractures of the skull, resulting from infection with pus-microbes from without, the in- flammation commences npon the outer surface of the membrane, and if the pus-microbes do not penetrate the tissues the suppurative process remains superficial ; but, as is more frequently the case, the microbes wander deeper into the tissues, until the entire thickness of the dura has become infected, and when the inner surface is affected, the underlying membranes, the arachnoid and pia mater, as well as the surface of the brain itself, are liable to become involved, step b}^ step, b}' the extension of the infection from meml)rane to membrane and surface to surface. Suppurative pach3'meningitis may remain as a circumscribed affection, and, if the internal surface of tlie dura is the seat of suppuration, it results in the formation of a subdural abscess. In circumscribed sub- dural suppuration, the diffusion of the pus between the dura mater and the arachnoid is prevented b}- a plastic exudation, which cements the two membranes together. In suppurative pach^'meningitis, affecting only the inner surface of the dura, w^e often find a subcranial abscess, the outer wall of which is formed by the skull and the inner by the dura mater. The mechanical effect of the presence of pus in either locality will give rise to the same group of cerebral symptoms. Indirect infection of the dura mater with pus-microbes occurs in cases of suppu- ration in the epicranial tissues and in suppurative osteom3^elitis of the cranial bones, bj- extension of the infection along the course of blood- vessels. In this way an insignificant peripheral suppurative lesion of the coverings of the skull is often followed by a grave form of endo- crnnial suppurntion. Symptoms and Diagnosis. — Diffuse septic pach^-mcningitis is alwa3%s attended by inflammation of the arachnoid, pia mater, and cortex of the brain, and the symptoms point more toward a cortical encephalitis than a pachjMneningitis. Localized suppurative pachj'meningitis gives rise to sj'mptoms which indicate the presence of a phlegmonous inflammation, modified in this instance by symptoms arising from mechanical disturb- ENDOCRANIAL SUPPURATION. 265 ances, caused by the presence of inflamuiator}' exudation, or the partici- pation of the surface of the brain in the suppurative process. In the acute septic form, following a compound fracture of the skull, the first S3-mptoms are observed, usually, during the second or third day after the injur}-, and rapidly increase in intensity' from the progressive exten- sion of the infection. In the circumscribed form the symptoms are more localized. The headache is often severe, especially if the inflam- mation is located upon the inner surface of an intact dura, and involves a corresponding extent of the subjacent membranes and cortex of the brain. The earl^' symptoms are those of irritation, to be followed, as the accumulation of pus increases, by evidences of compression. B}^ means of focal symptoms it is often possible to locate the seat of the inflammatory product in the interior of an intact skull with sufficient accuracy to enable the surgeon to evacuate the pus by operative measures. Acute suppuration between the surface of the brain and the inner sur- face of the skull is alwaj's attended by a rise in the temperature. The pulse is accelerated, at first full and bounding, to become slower and slower as compression increases. If the pulse, in a case of endocranial inflammation, has been gradualh' reduced from 120 to 35 or 40, it is a sign that cerebral compression has reached the maximum extent com- patible with life, and when it again reaches its former frequency it is an indication that dissolution is near at hand. The condition of the dura mater in subdural suppuration is of great importance in determining the presence or absence of accumulation of pus. In compound fractures, with loss of bone-substance, the existence of a subdural abscess is indi- cated by bulging of the dura into the opening of the skull and absence of cerebral pulsations. In trephining the skull for a supposed endo- cranial abscess, the surgeon's duty is to explore the subdural space, or to incise the dura mater, if this membrane appear tense or bulge into the opening, and if cerebral pulsations cannot be seen or felt. Treatment. — The successful prevention of endocranial infection by rigid antisejitic precautions in compound fractures of the skull and endo- cranial operations is one of tlie best arguments in support of the value of the antiseptic treatment of wounds. Intentional opening of the skull under strict antiseptic precautions is seldom followed by suppura- tive endocranial inflammation. Compound fractures of the skull without fatal injur}' to the brain, if treated by strict antiseptic measures soon after the receipt of the injury, generally result in recovery of the patient. The most important indication in the treatment of these cases is to prevent infection of the wound, and thus guard most effectively against the occurrence of endocranial suppuration. In the treatment of compound fractures of the skull, correction of 26() PRINCIPLES OF SURGEKV. mechanical difficulties is nothing compared with the importance of carry- ing out full antiseptic precautious to prevent the fatal complications. Suppurative pachymeningitis is i)revented by the same treatment wliich secures an ideal aseptic healing in wounds of other parts. The prophy- lactic treatment aims at obtaining for the external wound, the fractured bones, and the exposed spaces underneath them a perfectly aseptic con- dition. Tlie entire head should be shaved and tlie scalp rendered aseptic, by washing it with warm water and i)otash-soap, to be followed with a solution of corrosive sublimate (1 to 1000), and, lastly, with sul- phuric ether or alcohol. The wound of the i)ericranial tissues is en- larged sufficiently to admit of thorougli disinfection of the crevices between the fragments. Blood-clots and otlier foreign substances are to be sought for and removed, as infection is often traceable to imperfect treatment in this regard. Loose fragments are removed and kept in a, warm solution of corrosive sublimate until they are re-implanted. De- pressed fragments are elevated, and the space between the bone and the dura disinfected. If the dura has been lacerated the disinfection is carried farther. Detached and contused brain-tissue is removed. All haemorrhage is carefully arrested, and after the final irrigation the dura is sutured, and, if necessary, a capillar}^ drain of aseptic catgut or horse-hair inserted. In the majorit}' of cases it is advisable to drain the external wound by the insertion of a tubular drain at the most dependent point. Re- tention of the antiseptic dressing is secured best by applying a few turns of a plaster-of-Paris bandage. If, in spite of thorough primary disin- fection, asepsis is not secured, secondary disinfection is to be instituted at once. This requires that tlie superficial sutures are removed. De- tached bone is not to be re-implanted a second time, for fear of renewed infection. The whole surface is now disinfected by filling every sinus and depression with peroxide of hydrogen After effervescence has ceased the fluid is washed away by irrigation with the ordinary anti- septic solutions. Tlie peroxide of hydrogen will reach parts of the infected surface inaccessible to other antiseptic solutions. If any evidences, local or general, point to the existence of a beginning inflam- mation of the dura mater and the subjacent membranes, the deepest portions of the wound are subjected to thorough disinfection and tubular subdural drainage is established. If secondary disinfection prove un- successful the antiseptic dressing is to be removed and the moist anti- septic compress substituted, which is removed from time to time, when the deeper portions of the wound are cleansed by irrigation with an antiseptic solution. An external supimrsitive pacli^'meiiiiigitis is treated in the same wa}' ENDOCRANIAL SUPPURATION. 267 as an infected compound fracture of the skull. If it follow a com- pound fracture, loose, detached bones are removed, and the whole sup- purating surface is disinfected ; after which, tubular drainage is estab- lished. If it follow a fissured fracture, a sufficiently large opening is made in the skull, to permit of free disinfection, and the accumulation of pus is prevented by the insertion of a tubular drain. Suppuration between the dura mater and the cranial vault in an intact skull is treated by making one or more openings in the skull for disinfection and drain- age. A subdural abscess without fracture of the skull is to be accu- ratelj' located by a s3-stematic and accurate stud}' of the clinical histor}' of the case, and bj- reference to tlie etiology of the suppurative process, and the information thus obtained can usualty be corroborated by focal s^-mptoms which point to the exact location of the disease. The skull is opened with the chisel over the point where the abscess is suspected. If the dura bulge into the opening, is tense, and the pulsations of the brain cannot be felt, the surgeon ma}' be almost sure that a subdural abscess is present, and confirms his suspicion by an exploratory punc- tui'e. If pus is found, the dura mater is incised, the cavity washed out with an antiseptic solution, and a tubular drain is inserted. A daily change of the dressing and washing out of the cavity with antiseptic solution are necessar}' until suppuration lias nearly ceased ; then the dressing is removed less frequentl}', and the drain is shortened as the cavit}' diminishes in size. If at the point where the abscess was local- ized the dura present no indications of subdural, intracranial pressure, but the surgeon feels sure otherwise of his diagnosis, it is justifiable to make a number of small exploratory punctures until he succeeds in locating the suppurating focus. If the abscess-cavit}' is large, and the first opening has been made at a point UTifavorable to efficient drainage, it is advisable to imitate the example of Macewan, to make a counter- opening in the skull and dura at the most dependent point, and to main- tain through draiuiige until suppuration ceases. A localized suppura- tive pachj'meningitis, recognized in time, and located with sufficient accuracy to admit of radical treatment b}' operative measures, is an attection which the modern surgeon treats with ever}^ assurance of success. (b) Suppurative Leptomeningitis. — Inflammatiou of the arachnoid, without implication of the pia mater and surface of the brain, never occurs, and on this account we no longer speak of inflammation of au}' of these structures as separate lesions, but substitute the term lej^to- meningifis, by which is meant inflammation of the two inner envelopes of the bniin. (•(tinbiiuMl with coiiic;!! cneeijhalitis. The surface of the brain is su[)[)li('d in [)art with Itluod-vessels from tlie pia mater, and this 268 PRINCIPLES OF SURGERY. intimate vascular connection establishes an equally intimate pathological relationshi[) between these two structures. A septic leptomeningitis is a diffuse inflammation of the arachnoid, pia mater, and cortex of the brain, caused by infection with pus-microbes, and which, in the absence of all tendencies to localization, proves fatal before well-marked suppu- ration has occurred. Etiologically and pathologically it resembles diffuse septic peritonitis. Examination of the contents of the skull reveals great vascularity, more or less serous transudation, and softening of the gray matter of the brain. Microscopical examination shows only a moderate emigration of the colorless corpuscles and the minute changes in the capillar3' vessels, which are characteristic of acute septic inflammation. Suppurative leptomeningitis is characterized by the presence of pus between and upon the membranes and upon the surface of the brain. Septic leptomeningitis alwa3's terminates in suppuration, if the life of the patient is sufficiently prolonged for emigration of leuco- cj'tes and their transformation into pus-corpuscles to occur. Septic leptomeningitis sometimes appears within a few hours after a perforating wound of the skull. Bergmann relates the case of a child where a convex meningitis could be diagnosticated four hours after an injury of the skull. Konig reports a case that came under his observation where woll-mnrked s^ymptoms of leptomeningitis followed ten hours after perforation of the skull with the point of a sword. The wound was examined outside of the hospital with instruments that had not been dis- infected. Ten hours after the injury the patient commenced vomiting, and had a temperature of 39° C. The following day, wild delirium, strabismus divergens, and a temperature of 40° C. The second day, coma, rapid pulse, and death. The necropsy revealed diffuse septic leptomeningitis. The inflammatory product is found most abundant in the subarachnoid space. The effusion in this space is sometimes clear, raising the arachnoid ; it contains, also, fibrin in flakes and membranes, or it presents the consistence and color of pus. Pus first appears along the course of blood-vessels in the pia in the shape of yellow streaks, which, when the}^ become confluent, tend to considerable inflammatory thickening of the membrane. Pus may also appear in the ventricles by wa}' of communication with the subarachnoideal spaces. On account of the absence of connective-tissue spaces, the inflammation of the surface of the brain remains superficial. If pus form here, it appears as small abscesses, which later ma}' become confluent, causing superficial destruc- tion of the brain-substance. If the surface of the brain is the seat of a contusion, sujipurative encephalitis is more diffuse, and ma}' lead to a diffuse acute abscess underneath the infected envelopes. Besides wounds communicating with the atmosphere through which ENDOCRANIAL SUPPURATION. 269 infection takes place, suppurative leptomeningitis, like pachymeningitis, can be caused by peripheral suppurative lesions, as phlegmonous inflam- mation of the soft tissues covering the skull, suppurative osteomyelitis of the cranial bones, and suppurative inflammation of the middle ear. In fractures at the base of the skull, infection frequentl}^ occurs through a ruptured tympanum, or through a wound of the soft parts in the naso- pharynx conimuuicating directly with the meninges. Symptoms and Diagnosis. — Tlie surgeon should be versed in the symptomatology of suppurative leptomeningitis, rather for the purpose of knowing when not to interfere, by operative procedure, in cases of endocranial su})purative lesions, than to risk his reputation in a fruitless attempt in operating for an incurable disease. Diffuse septic and suppu- rative leptomeningitis are fatal diseases, and the surgical treatments will in all probability always remain of a purely prophylactic character. The S3'mptoms of leptomeningitis are always those of cortical encepha- litis, from which it cannot be distinguished during life. The disease is often initiated by a chill, like phlegmonous inflammation in other locali- ties, followed by high fever and other sj-mptoms of septic intoxication. In other cases the chill is absent and the fever develops more insidiously'. The rise of temperature, which is usuall}' abrupt, — the thermometer after a few hours shows an increase to 39° or 40° C, and as a rule presents but slight variations, — is caused by the absorption of septic material from the infected and inflamed tissues. The intra-cranial pressure and fever give rise at once to symptoms which indicate the presence of cere- bral irritation. Headache, morbid sensitiveness to external impressions, sleeplessness, restlessness, and psychical perturbation are some of the most constant and conspicuous early S3anptoms. If the patient fall into a short nap he starts up suddenl}^ and behaves like a maniac. The pupils are usuall}^ contracted at first, but dilate as other symptoms of compression appear. Often they are unequal in size and respond only shiggishl}' to light. Localized general convulsions frequently attend the stage of irritation. Vomiting and constipation are among the early symptoms. Paralysis of definite muscular groups, according to Berg- mann, indicates extension of the disease to the region of motor centres. The face is suff'tised, the conjunctivae injected, and the pulsations of the carotid arteries increased. The pulse, at first increased in frequencj', bounding and firm, becomes slower as cerebral compression advances. If, after its frequenc}' has been reduced to 40 or 50 beats per minute, it again becomes rapid, it is a sure indication of approaching death. If the disease develop in the course of a perforating wound of the skull, the increased intra-cranial pressure is manifested by bulging of the dura mater into the wound, or if the envelopes of the brain have 270 PRINCIPLES OK SURGERY. been lacenited, by hernia of the biiiui. Tlie prohipsed portion of the brain often sloughs, when putrefaction of tlie dead tissue occurs as an unavoidable result, and death from sepsis is hastened b}^ such an occur- rence. Bergniann has recently called the attention of the profession to the fact that leptomeningitis, affecting the convex surface of the brain, leads at once to paralj'sis of one extremity, or hemiplegia, by the exten- sion of the disease to motor centres. Indications pointing to localized symptoms of central irritation can l)e explained by the same theory. Leptomeningitis at the base of the ])rain is not attended b}' any definite localized focal symptoms, and the retraction of the head takes place in consequence of the extension of the inflammation to the meninges of the spinal cord. Basilar meningitis in its advanced stage gives rise to a peculiar disturbance of respiration, — the Cheyne-Stokes phenomenon. With the appearance of compression of the brain the symptoms of cen- tral irritation subside and give place to the paralytic stage. The patient passes from a condition of listlessness gradually into a stupor, and finall}' into complete coma. With the appearance of monoplegia and hemiplegia some centres may be still in a condition of irritation, so that symptoms of irritation and paralysis may be manifested at the same time. During the paralytic stage the suffusion of the face disappears, the face is pallid, and the whole surface of the bodj- covered with a clammy, cold perspiration ; the pupils dilate and no longer respond to light ; the pulse becomes small and rapid, and death is preceded bj'" relaxation of all sphincter muscles. Treatment. — The proph^dactic treatment has for its object the pre- vention of infection through wounds communicating with the contents of the skull. Rigid antiseptic treatment of all compound fractures of the skull must be carried out in the most pedantic manner. Fractures of the base of the skull, communicating with the atmospheric air through a ruptured tympanum or through a lacerated wound in the naso-pharyn- geal region, should be treated upon the same principles as a compound fracture of the vault of the cranium. If the tympanum has been rup- tured the external meatus is thoroughly disinfected and packed loosely with iodoform gauze, over which a filter of salicylated cotton is applied. If the fracture communicate with a wound of the naso-phar^'ngeal region, disinfection is aimed at by using an antiseptic nasal douche and plugging the posterior nares with tampons of iodoform gauze, which are to be removed daily, and, after using the nasal douche, are to be replaced by new ones. The prophylactic treatment of leptomeningitis, caused by suppurating foci in the coverings of the skull, the internal ear, or in the cranial bones, can be carried out most successfully by early and rational treatment of the primary diseases. With the first appearance of the BRAIN-ABSCESS. 271 sj'mptoms of leptomeningitis, the surgeon should lose no time in render- ing the wound or primary suppurating depot aseptic by operative measures, combined with most rigid antiseptic precautions, with a faint hope that such measures maj', in exceptional cases at least, lead to a successful issue by limiting the extension of the infection. As soon as the disease has become diffuse the prospects of a favorable termination are almost nil. It may be possible that multiple openings in the skull, with subaracluioid drainage and frequent antiseptie irrigations or per- manent irrigation, will in the future become an established and feasible method of treatment in such cases. From a surgical stand-point such heroic treatment appears the only rational course to pursue in a class of patients otherwise doomed to certain death. The multiple perforations would have a potent influence in diminishing the intra-cranial pressure, and drainage, combined with frequent or permanent irrigation, might, at least in a small percentage of cases, succeed in sterilizing the extensive area of infection. BRAIN-ABSCESS. The term abscess of the brain should be limited to circumscribed collections of pus surrounded on all sides by brain-tissue. Suppuration occurring between the brain and its envelopes, from a circumscribed suppurative leptomeningitis, is not a brain-abscess, A brain-abscess is the result of a circumscribed suppurative encephalitis. The acute form occurs when a contused portion of the brain becomes infected through a wound communicating with the atmospheric air, but, as this form will seldom, if ever, become the subject of successful operative treatment, our remarks will apply to abscess of the brain proper, or chronic abscess. A chronic circumscribed encephalitis may originate in a contused area of the brain, without any external wound or direct route of infection, from localization of pus-microbes in the locus mmoris resistentiae. Such cases have been frequently observed where, weeks and months after the subsidence of the symptoms resulting from the immediate effects of a head injury, remote s^-mptoms pointed to a central suppurating focus in the brain. The occurrence of such grave remote consequences renders the prognosis, even after slight injuries to the skull, always more or less doubtful. In other instances an abscess forms around a foreign body that has lodged in the brain, and has remained for a long time without having given rise to any local or general disturbance. Infected pene- trating wounds of the skull may heal, and the patient apparently recover perfect health, when at some remote time, and in direct causal connec- tion with the previous infection, a chronic abscess develops, perhaps, some distance from the primary seat of infection. Most frequently such abscesses ai'e caused b}' suppurative inflammation of the internal ear, 27*2 PRINCIPLES OF SURGERY. :ind suppurative osteomyelitis of the cranial bones. In size they vary from that of a pea to that of an entire hemisphere. They ma}' remain stationary for twenty years, but the period of latency may pass into activity at any time. A large abscess in the white substance of a hemi- sphere may give rise to no functional disturbances wiiatever, and can only be recognized by the terminal S3'mptoms. In other cases the abscess can not only be diagnosticated during life, but its location accurately determined by symptoms which point to destruction of a particular part of the brain. Symptoms and Diagnosis. — The first symptoms are insidious in their onset, and often of a very indefinite nature. The first thing noticed is, frequently, a hypersensitiveness and irritable temper of the patient, with more or less severe headache. Early loss of memory is often noticed, and the patient becomes dull, sullen, unconcerned, and reckless in his business transactions. If the abscess involve any of the motor centres, or a considei-able portion of fibres originating from them, mono- spasm or hemispasm, or monoplegia or hemiplegia follow as peripheral evidences of the central lesion. General convulsions, Avhich sometimes occur at this stage, have less diagnostic value than localized focal symp- toms. Abscess of the brain seldom causes fever; on the other hand, the temperature is often subnormal. A sudden rise in temperature indicates that the abscess has reached the surface of the brain, and that a terminal leptomeningitis has developed. Rupture of an abscess into one of the ventricles is followed by general convulsions, paral^'sis, and death. Prominence of the dura over the abscess and absence or diminution of cerebral pulsation are important diagnostic signs, especiall}' in cases where the abscess is located near the surface of the brain. Examination of the exposed brain by palpation may elicit evidences of deep-seated fluctuation. In exceptional cases the portion of brain covering the abscess is firmer than normal from inflammatory infiltration (Rose). Gussenbauer states that in some cases the presence of the abscess can be ascertained by the existence of fluctuation. Prognosis. — An abscess in the brain is always an imminent source of danger to life. A considerable nccumulation of pus in the brain, like in any other organ, is never removed by absorption. If the abscess remain in the active stage it gradually increases in size until it ruptures into one of the ventricles or reaches the surface of the brain, in either event resulting in complications which lead to a rapidly- fatal termination. It may remain in a latent condition for an indefinite period of time, but the life of the patient is alwa3'S in jeopardy, as acute exacerbations may come on at any time. If an abscess form after a perforating injury of the skull, and the pus finds an exit through a permanent fistulous open- BRAIN-ABSCESS. 273 ing, the general lieulth may remain sufficiently good to enable the patient to follow his occupation. A ease came recently' under my observation where I could introduce the probe to a distance of four inches into the brain, and ^-et the general health remained unimi)aired, although this condition had existed for years. Tiie brain-abscess in this case deA'el- oped in connection with purulent intlammation of the middle ear. I have knowledge of another ease, where a young man received a perfo- rating wound of the skull, which was followed by tlie formation of an abscess of the brain that discharged externally. The patient filled, in a creditable manner, a responsible and important government position for thirty 3'ears, and died from another cause. The necrops}' showed an abscess-cavity the size of an orange, located in the anterior right lobe of the brain, which communicated with the external surface through a fistulous opening in the skull. A few cases are reported where recovery followed the spontaneous discharge of the contents of the abscess through the ear or nose, but ordinarily such an occurrence is followed by putrefiiction of the remaining contents of the abscess-cavitv and death from sepsis. Treatment. — All eflorts to cure an abscess of the Itrain b}' external applications, or internal medication, will be worse than useless in effect- ing removal of the i)us b^' absorption. All expectant treatment is worse than useless. Brain-abscess must be treated on the same principles as abscess in any other organ, by incision and drainage. The great difficulty in these cases is to make a sufficiently accurate diagnosis in regard to the exact location of the abscess. Before an3thing was known in refer- ence to tlie subject of cerebral localization, Dupu^'tren plunged a bistoury deeplj' into the brain, and was fortunate enough to hit an abscess which he suspected, and his patient recovered. The same bold treatment has been frequently followed since, but not with the same brilliant result, as, in the majority- of cases, either no abscess existed or the incision was made, not into, but aside of, the abscess. Renz cnred an abscess of the brain b}' repeated aspirations through a fissure in the skull. The average surgeon, at the present time, would not undertake to incise a brain for abscess unless he had previously located the abscess bj^ a careful stud}' of focal symptoms, and b}' a resort to exploratory punctures. Bergmann condemns the nse of the exploring-sj-ringe for this purpose, but in the hands of those less skilled in cerebral localization than this eminent surgeon the exploring-needle will alwaj's be regarded as a welcome and useful instrument of exact diagnosis. Cerebral Localization. — As the peripheral symptoms upon which the surgeon relies in locating an abscess in the brain are caused b}' irritation or destruction of the motor tracts or centres, it is absolutely necessary 274 PRINCIPLES OF SURGERY. for him to become familiar with the topography of the motor centres. A. W. Hare gives a very practical instruction on cerebral localization in a paper published in tlie London Lancet^ March 3, 1888, from which I will quote below: — " In the parietal region, grouped around the fissure of Rolando, are the areas associated with movements of the extremities of the opposite side of the body, and, at the lower end of the fissure, those related to movements of the mouth and tongue. In the accompanying diagram (Fig. 62) the motor areas have been mnrketl in their anatomical relations to the other structures of a normal head, dissected for the purpose, show- ing the brain in its natural position. The areas associated with move- ments in neighboring regions of the body have been shaded alike in the figure. Thus, the areas A, B, C, and D, bounding the fissure of Rolando Fig. 62.— Motor Areas. posteriorly, and 5 and 6, in front of the fissure, together with 2, 3, and 4, at its upper end, are those in functional connection with the upper extremity; A, B, C, and D being concerned in the movements of the fingers, head, and wrist, 5 in a forward movement of the arm, 6 in pro- nation and supination of the forearm, and 2, 3, and 4 in co-ordinated movements of the whole upper extremity'. The areas 7, 8, 9, 10, and 11, indicated as having a common region of motor representation, are re- lated to movements of the tongue and of the muscles around the mouth. Area 1 represents in part movements of the lower extremity. In the same way areas of representation of general and of special sensation are located by Terrier around the horizontal limb of the fissure of S3'lvius. It must not be overlooked that this mapping out of areas has an absolute exactitude onl}' in the case of the species of ape upon which the experi- ments were performed. Its bearing in the human subject is one of great BRAIN-ABSCESS. 275 relative importance, but it must not be louivcd upon as a final statement of fact, in the case of man, until each area can be shown to be correctly placed, as it is b}' the accumulation of a sufficient number of clinical and of post-mortem observations directly confirming the method employed. "In the stud}' of cranio-cerebral topography the surgeon has to rely on four primarj' landmarks in establishing a system of measurements. These are the glabella, or root of the nose, which bears a definite relation to the anterior limit of the cranial cavity, and the occipital protuberance, or inion, which bears a similar relation to its posterior end, correspond- ing to the junction of the falx with the tentorium. The whole mass of the cerebrum is disposed between these two points, and the}' bear definite relations to its cortical matter, uninfluenced by the structure and contour of the bones forming the vault. The third constant landmark is the external angular process of the frontal bone, which bears a relation to the lateral expansion of the frontal lobes, similar to that borne hy the two prominences already mentioned, to the anterior and posterior ex- tremities of the cerebrum. It has also a uniform relation to the fissure of Sylvius. Lastl}', the parietal eminence is of value, since it marks tlie greatest lateral expansion of the substance of the hemisphere, and, as Turner has shown, bears a special relation to the submarginal convolu- tion. To find the upper end of the fissure of Rolando by the use of these data, the surface measurement in the middle line of the head should be taken over the scalp from the glabella to the occipital protuberance. In ordinar}- adult heads this will var}- from 11 to 13 inches; measured along this line from before backward, the distance from the glabella to the top of the fissure will be 55.7 per cent, of the total distance from the glabella to the occipital protuberance. The following scale shows the distance from the glabella to the top of the fissure in all ordinar}'- heads : — When the distance from the glabella to the The distance from the glabella to the upper occipital protuberance is end of the fissure of Rolando is 11 inches, 6^ inches. iij " el " 12 " 6| " 12^ " 7 " 13 " 7J " To find the top of the Rolandic fissui'c, Thane halves the distance fiom the glabella to the occipital protuberance, and, having thus de- fined the middle point of the vertex, takes a point half an inch behind it as the location of the upper end of the fissure. Having thus ascertained the upper end of the fissure, it is desirable to determine its length and direction. The scalp measurement corresponding to its length is 2T6 PRINCIPLES OF SURGERY. 3| inches. It runs from above downward and forward, its axis making an angle of 67 degrees with tlie middle line. " Wilson's cyrtometer is an exceedingly useful aid in locating the fissure of Rolando. It consists of three strips of flexible metal and a tape for securing it in situ. The method of its application is illustrated by Fig. 64. " The broadest, transverse strip passes coronally around the forehead, corresponding with the glabella and external angular process ; the narrower, longitudinal strip passes backward from the glabella in the middle line to the occiput. This strip is marked with two scales of R Fig. 63.— Wilson's Cyrtometer. Fig. 64 —Wilson's Cyrtom- eter Applied. G. glabella ; E A P, external angular process : R, fissure of Rolando, its posi- tion and direction marked by the lateral strip of metal. letters, — capitals in its posterior fourth, and small letters about the middle of the strip. These two scales bear a relation to one another, calculated to aid in the application of the instrument to an ordinary head. Measured from the glabella backward, the distance to any given small letter is 55.7 per cent, of tlie distance from the glabella to the corresponding capital letter; thus, when any capital letter will co- incide with the top of the fissure, a third narrow, reversible strip strikes on the longitudinal strip of metal, marking an angle of 67 degrees, opening forward and marked at 3f inches from its attached end, thus giving the length and direction of the fissure on the surface of the head. To de- termine the exact location and direction of the fissure, a line is drawn BRAIN-ABSCESS. 271 from the external angular process of the frontal bone backward to the occipital protuberance, taking the shortest route between these points. Such a line drops a little toAvard the external auditory meatus, avoiding the greater convexit}' of the skull, which lies in the course of a hori- zontal line between the bou}- prominences. It usually passes about i inch above the meatus, and thus closely corresponds to the floor of the middle fossa, and behind runs parallel to and nearly in the same course with the attachment of the tentorium and the posterior half of the lateral sinus. A measurement of 1| inches along this line, backward POF. O.P. Fig. 65.— Head, Sktill, and Cerebral Fissures. {Adapted from Marshall.) O p. occipital protuberance ; E A P, extern.al anpilar process ; S F, Sylvian fissure : A, its ascending limb; F R. fissure of Rolando; P E, parietal eminence ; M M A, middle meningeal artery T S, tip of temporo-sphenoidal lobe ; B, Broca's convolution. from the external angular process, marks the lower end of the fissure of Sylvius. From this point a straight line drawn to the centre of the parietal eminence accuratel}" marks the course of the posterior limb of tlie fissure. The main line of the fissure follows the line of the squamo-parielal suture to its highest point, whence it continues its course to tlie parietal eminence. The middle meningeal arter}', after grooving the inner surface of the great wing of the sphenoid, passes on to the ante- rior angle of the parietal bone, and is distributed to the dura mater lining the anterior and superior half of the bone. If the surgeon desire to ex- pose the tip of the temporo-sphenoidal lobe, he should open the skull 278 PRINCIPLES OF SURGERY. behind the upper extreniit}' of the great wing of the sphenoid ; if to expose Broca's convolution, immediately in front of the same bony peninsula. The sites of the two operations are shown in Fig. 65." Opening of the Skull. — The operative treatment of abscess of the brain i)resupposes an accurate diagnosis by means of cerebral localiza- tion and a careful study of the clinical and etiological aspects of the case. If symptoms of abscess of the brain arise, after a compound frac- ture of the skull, before the continuity of the skull has been restored, exploration can be done with a fine needle through a fissure, or at some point where fragments have been removed ; and, if pus is found, a closed hemostatic forceps can be pushed along the side of the needle into the abscess, and the track enlarged by separating the blades before withdrawing the instruments. Into this track a drainage-tube is intro- duced, the abscess-cavity gently irrigated, and the wound disinfected and dressed antisepticall}' ; or, a small qnantit}' of peroxide of hydrogen can be injected into the abscess-cavity through the drainage-tube, which will not only force out the contents, but will also sterilize the walls of the abscess more thoroughly than an}' other antiseptic. If an abscess develop in the brain in an intact skull, or after the fracture has healed, the skull must be opened at a point immediately over the abscess. By means of the measurements given, or by the use of Wilson's cyrtometer, the motor centre or centres affected by the abscess are marked upon the shaved and disinfected scalp before the skull is exposed ; and the exact location of the abscess is also marked on the skull by making a puncture through the scalp with a small perforator, so that the location can be recognized after the soft parts have been reflected. The bone is laid bare at this point by Horslej^'s flap, which is made by ahorse-shoe-shaped incision, the convexity of which is directed upward. The flap, with the periosteum attached, is turned downward. After all hemorrhage has been arrested the skull is opened, either by using a large trephine or, "what is better, with a chisel ; the button of bone or bone-chips are trans- ferred into a warm antiseptic solution, where the}' are kept until needed for re-implantation , should this be deemed necessar}^ or advisable. If the dura mater is tense and bulge into the opening, and cerebral pulsations are feeble and entirely wanting, the indications are that the skull has been opened near or directl}' over the abscess. The opening need not be larger than an inch in diameter. Methodical Exploration of the Brain. — Experiments and clinical experience have shown that the brain can be explored in diflTerent direc- tions with a fine, hollow, aseptic needle without an}' immediate or remote bad eflfects. Tlie brain should never be incised for abscess until the abscess has been located by methodical exploration. An ordinary BRAIN-ABSCESS. 279 exploring-syringe with a delicate needle about 4 inches in length should be used for this purpose. The needle is pushed into the brain in the direction in which tlie abscess is suspected, and to the necessar}^ depth, when aspiration is made and the result carefull}' noted. If no pus is found the needle is withdrawn or pushed forward in the same direction, and aspiration made at different points in its track ; and, if no pus is found in that direction, it is withdrawn and pushed in another direction, and the same manoeuvres repeated. In this manner a large territory can be explored and even very small abscesses located. When the abscess has been located by this method of exploration, the needle is used as a guide for a small pair of haemostatic forceps, which is pushed forward along its side until the abscess has been reached, when it is unlocked, the blades slightly separated, and as the instrument is with- drawn the track is sufficientl\" enlarged to permit the insertion of a rubber drain the size of an ordinar}' lead-pencil. The needle is only removed after the drain is in situ. Fenger, of Chicago, has written an exceedingh' Aaluable paper on exploration of the brain, in the diagnosis and treatment of abscess of the brain, in which he has furnished abundant proof both of the harmlessness and utilit}' of this procedure. After the abscess has been opened and drained, it is advisable to wash it out gentl}' with some non-irritating and yet effective antiseptic solution, either with half of a 1-per-cent. solution of acetate of -aluminum or a 2-per-cent. solution of boracic acid, or it is injected with peroxide of hjdrogen. As the abscess-walls are never firm, everj^ precaution must be taken to prevent overdistention, but gentle irrigation is continued until the fluid returns clear. If the skull has been opened by removing a disk of bone by trephining, an opening in this must be made at its lower margin, which will permit bringing the drainage-tube out to the external surface after implantation. If bone-chips are re-implanted, a space for the drain must be left in the most dependent portion of the opening. The drainage-tube is brought out at one of the lower angles of the wound or through a button-hole in the flap. The flap is secured in its position by a requisite number of sutures. Daily changes of dressing is required until suppuration diminishes, when the drain is shortened from time to time and the dressing changed less frequently. The drainage-tube is not to be removed until the abscess-cavity is closed, as otherwise a relapse would be liable to occur which would require a repetition of the first operation. The most unsatisfactory aspect of the surgical treatment of abscess of the brain is tlie fact that in some instances multiple abscesses are present, — an occurrence which is be3'ond the limits of the present means of diagnosis. In such cases the surgeon maj' cure one abscess, but the patient succumbs from the effect of those that have not been 280 PRINCIPLKS OF SURGERY. discovered. Tlie appearance ol" a hernia cerebri, after the evacuation and drainage of an abscess of tiie brain, is a condition wliich points to tlie existence of an additional abscess or abscesses. Should such a condition appear during the after-treatment of an abscess of the brain, treated by evacuation and drainage, it would furnish a strong temptation to resort to another methodical exploration with a view of subjecting additional abscesses to the same radical treatment. Should the first opening into an abscess of the brain not be suitable for eifective drainage, it would be well to follow the example of Macewan and open the skull at a lower point, tunnel the intervening portion of the brain, between this opening and the abscess cavity', with haemostatic forceps, and thus establish an additional and more efficient route for drainage. In the surgical ti'eatment of abscess following suppurative inflammation of the middle ear, it is well to remember that in these cases the abscess is usually located in the vicinity of the petrous portion of the temporal bone, and that in exploring the ])rain the needle should be inserted in this direction. EMPYEMA. Emp3'^ema is a collection of pus in the pleural cavit}'. It is always the result of a suppurative pleuritis. Bacteriological Studies. — A penetrating wound of the pleural cavity is more frecpiently followed by infection with pus-microbes and suppura- tive pleuritis than perforation of one of the bronciiial tubes, as in the latter accident the atmospheric air entering the pleural cavity has under- g6ne a process of filti'ation during its passage through the respiratory tract. Suppurative pleuritis, occurring without direct infection through a perforation in the thoracic wall or one of the bronchial tubes, is always caused by localization of pus-microbes within or upon the serous mem- brane lining the pleural cavit3\ Localization of pus-microbes occurs in the pleura or pleural cavity, either as a primar}' or secondar}' infection. Frankel made a bacteriological study of 12 cases of emp3'ema. In 3 cases, in which no special cause could be traced, the pus contained exclusively the strejjtococcus pyogenes. In 3 cases the pus contained only pneumococci. Other authors have found in such cases also other l)Us-microbes. Friinkel believes that when this is the case they have localized in consequence of a secondar}' invasion. The presence of streptococci in the pus from a suppurating pleural cavity presents noth- ing characteristic, as the microbe is also found in cases in which the emp3^ema is secondary to pneumonia and tuberculosis. On the other hand, he assigns to the pneumococcus, in pus taken from a pleural cavity, a diagnostic significance, as it proves, beyond all doubt, that the suppu- rative pleuritis occurred in the course of a pneumonia as a secondary EMPYEMA. 281 affection; consequently, its presence in the pus is positive proof that a pneumonia exists or has existed, even if the clinical and physical symp- toms were not sufficiently^ clear to indicate its existence. In 4 cases the empyema had a tuberculous origin, in 2 of which pneumothorax was present at the same time. The presence of the bacillus of tubercu- losis in the pus is not easih' demonstrated, but the absence of this microbe is no sign that the disease is not tubercuhu', tis inoculations with pus in animals almost constantly produce typical tuberculosis. In the pus of tubercular pyo-pneumothorax, if micro-organisms are present, the bacillus of tuberculosis can be found, and the pus shows no tendency to undergo putrefactive changes, in contradistinction to empyema occur- ring in non-tuberculous subjects, in whom spontaneous discharge through the bronchial lUbes takes place. Senator maintains that putrefaction is prevented bj' the parenchyma of the lungs acting as a filter, preventing ingress of bacteria with the inspired air, and by the presence of a large amount of carbonic-acid gas in the air of t'he cavity, as it is well known that microbes do not thrive so well in such an atmosphere as in ordinary air. Ehrlich has made an interesting bacteriological examination of the pus in 19 cases of emp3-ema ; in onl}^ 7 of these could the bacillus of tuberculosis be found ; in the remaining 12 this microbe could not be detected, and upon this negative ground the existence of tuberculosis was excluded. Further observation in these cases after operation cor- roborated the diagnosis. He asserts, therefore, that, in the purulent pleuritic exudation in tubercular patients in empyema and pyo-pneumo- thorax, the presence of the specific microbic cause can always be demon- strated. This author places the greatest importance on a bacteriological examination of the pus as a means of differential diagnosis between sup- purative and tubercular empyema. A serous eflusion is not infrequently transformed into an empyema b}- a change of the predominant bacterio- logical cause. In a number of cases I found it necessary to aspirate the chest for the removal of a copious effusion. The fluid removed at the first aspiration was clear serum ; the second aspiration removed a slight, turbid fluid, and the third aspiration jnelded a distinctly sero-purulent fluid ; while the fourth aspiration revealed a well-marked empyema. In all of these cases the subsequent historj- and termination showed that tubei'culosis was the primary' cause of the effusion. Infection of the tubercular foci with pus-microbes, and the entrance of these into a cavit}^ alread}^ changed b}' disease, altered the type of the inflammation and the character of the effusion. Putrefaction of the products of suppurative pleuritis occurs occasionall}- without the presence of a direct communi- cation of the pleural cavity with the atmospheric air. I have seen 2 cases of this kind, and both recovered after radical operation. In such 28'2 I'KINCIPLES OF SURGERY. instances we must take it for granted that saproplntic bacilli find tiieir wa}' into the pleural cavity through the respiratory- passages and the parenchjma of the lungs, and select the products of coagulation necrosis for their nutrient medium. The pus in such cases is exceedingl}^ fetid, thin, and usually contains large shreds of fibrin. The ptomaines of the putrefactive bacteria increase the fever and other symptoms of septic intoxication. Diagnosis. — The j)resence of a considerable quantity of fluid gives rise to wi'll-marked clinical and physical symptoms. Aside from the ordinary symptoms Avhich point to a supi)iinitive inflammation in other localities, such as chill, fever, pain, loss of appetite, the patient complains of difficulty of breathing, especially on lying down, and sometimes, but not alwa3's, of a short, hacking cough. On physical examination it becomes apparent that a part or nearl}- the entire pleural cavity is occu- pied by a fluid. Dullness on percussion and absence of respiratory and voice sounds over the area occupied by tlie fluid, and displacement of adjacent organs by the intra-thoracic pressure, are signs which cannot be well simulated by an3^thing else than accumulation of fluid in the pleural cavity. Bulging of intercostal spaces, as a rule, is more marked in empyema than hydro thorax. In empyema the subcutaneous tissues on the aflTected side are often slightly cedematous and the superficial veins are sometimes enlarged. In empyema of the right pleural cavity the liver is pushed in a downward direction, Avhile the heart is displaced toward the left side. In empj-ema of the left side the apex-beat of the heart can quite frequently be felt on the right side of the sternum. A temperature of 100° to 101° F. in the morning and 101° to 103° F. in the evening, continued for several weeks, speaks strongly in favor of empyema. A positive diagnosis alwaA's rests on demonstrating the presence of pus in the pleural cavity, which can be done, without danger and without pain worth mentioning, by an explorator}'- puncture with an ordinary hypodermic needle. In puncturing the chest for exploratory or therapeutic i)urposes, it should be borne in mind that the needle should be inserted in a direction which corresponds to the centre of the intercostal space, consequently in an oblique direction from below upward. If no contra-indications present themselves, the exploratory^ puncture should be made at the place where, later, the radical operation will 1)6 performed ; that is, in the axillary line, between the sixth and seven til or seventh and eighth ribs. If the needle is perfectl}' aseptic no harm will result, even should the lung or liver be punctured. Prognosis. — Simple, uncomplicated suppurative pleuritis offers a favorable prognosis if subjected to earl}' radical treatment. The prog- nosis is more favorable in children than in adults, and in recent than in EMPYEMA. 283 old cases. In long-standing emp3'enia the lung becomes atelectatic from compression, and its full expansion is also prohibited b}' numerous firm adhesions. In children, partial expansion of the lung is compensated for by retraction of the yielding chest-wall, enabling tlie pleural cavit}' to close ; while, in the adult, incomplete expansion of the lung results in a physical condition which renders definitive healing a difficult, if not even an impossible, occurrence. Pulmonary tuberculosis complicated by empj-ema constitutes a contra-indication to radical operation, as the patient is already affected b}' a disease which almost necessaril}- leads to a fatal issue, and a radical operation would only hasten this termi- nation. A fistulous communication between a bronchial tube and the pleural cavity, resulting from a rupture of an empyema in this direction, in exceptional cases, leads to a spontaneous cure, but more frequenth' becomes a cause of retardation of recover^' after an operation. Treatment. — An empjema is nothing more nor less than an abscess in the pleural cavit}^ and should be treated as such. There can be no doubt that in exceptional instances a cure has been effected b}' aspira- tion. This method of treatment promises more in children than in adults, and it is also in the former that the radical operation has 3'ielded the best results; lience it is not advisable to have recourse to an uncer- tain procedure if a radical operation accomplish the same result with greater certainty, more speedil}', and with no greater immediate and remote risks to life. It is a good plan in every case to combine aspira- tion with exploration, for the purpose of improving the conditions for a radical operation. By aspiration we demonstrate the presence of pus in the pleural cavit}^ and, b}^ removing the fluid completel}' or in part, we aid the expansion of the lung, which, by the time the radical operation is performed, has become adherent lower down. Aspiration is to be followed, in the course of two or three days, by a radical operation. B3' a radical operation we understand incision of the pleural cavity and draining the same. The operation for empj-ema b}^ incision and drain- age must alwa3-s be done under the strictest antiseptic precautions, as an}' mistake or negligence in this regard iS exceed ingl}' liable to be followed b}- infection with putrefactive bacteria, — an occurrence which would greatly increase the danger from sepsis. Nothing but perfectly aseptic material must be used, and the whole chest of the patient and the liands of the operator must be thoroughly disinfected by washing with hot water and potash-soap, and disinfecting with a 1-to-lOOO solu- tion of sublimate, and finally with alcohol. The instruments must be boiled for at least ten minutes. (a) Incisions. — If an empyema is perforating the chest-wall and 28-1: rUINCIPLES OF SURGEKY. appears as a subcutaneous abscess, the incision is made through the centre of the abscess and parallel to the ribs. If no such indication is present, the incision should be made over the centre of the sixth rib and parallel to it on the right side, and over the seventh on the left, at a point half-wa}' between the nipple and the axillary line. It must be about 4 inclies in length and extend down to the bone. (b) Resection of Rib. — The soft parts, with the periosteum, are reflected with an elevator, which is then passed between the periosteum and rib, posteriorly, from below upward, and the periosteum separated to the extent of U inches. If the elevator is l' diffuse septic peritonitis. The same can be said of i)erf()r;ition of the gall-bladder. Symptoms and Diagnosis. — DiHuse septic peritonitis spreads over the entire peritoneal cavit}- almost with lightning si^eed. The first symptoms are those of shock. If the disease follow an abdominal section, it is often difficult to determine whether the conditions presented are due to shock or diffuse peritonitis, as the latter may set in in a few hours after the operation and prove fatal within twenty-four hours. The temperature is variable. It may remain normal or become even. subnormal, or it may at first be onl}' slightl}^ increased and graduall}' reach 102° to 104° F. Vomiting and diarrhoea are frequently conspicuous symptoms. In other cases the symptoms point to intestinal obstruction. In extensive plastic peritonitis the immobilization of a considerable portion of the small intestine may give rise to persistent vomiting and absolute constipation. Again, arrest of the ftecal circulation may be caused b}' the tympanites alone, while perforative peritonitis is attended by a local and general shock, which causes intestinal paresis through the sympathetic nerves. Heusner has observed that perforative peritonitis gives rise to disturbances simulating intestinal obstruction ))y arresting intestinal movements. He narrates the histories of 2 cases of this kind in which the symptoms of intestinal obstruction w^ere so prominent that laparotomy was performed. In both cases perforative peritonitis, but not occlusion, wms found. Henrot, in his classical monograph on " Pseudo-Strangulation," describes a number of cases of perforation of the gall-bladder and the processus vermiformis, where the symptoms during life had pointed so strongly to the existence of intestinal obstruc- tion that a wrong diagnosis was made b}- able clinicians. He also calls attention to those cases of paralytic obstruction which are often observed after herniotom}', and in cases of strangulation of the appendix vermi- formis and testicle. The intestinal paresis, where it is not the result of inflammation, must be looked upon as a reflex symptom. Physical signs and sj'mptoms are sometimes utterly inadecjunte to distinguish between acute intestinal obstruction and diffuse peritonitis. SUPPURATIVE PERITONITIS. 299 In differentiating between these two conditions, it must be remembered that, in the absence of a tumor, absolute constipation and faecal vomiting are the most characteristic S3'mptoms of obstruction, and that in peri- tonitis the pain is severe and continuous, with diffuse tenderness, tympanites, and absence of visible intestinal coils. In mechanical obstruction of the bowels the temperature is, as a rule, not above normal unless complications have set in ; while in peritonitis a rise in tempera- ture is the rule, although in some of the gravest cases it is subnormal. Many cases of supposed recover^' from intestinal obstruction without operation undoubtedly were cases of dynamic obstruction, and the recovery was either entirelj^ spontaneous or facilitated by means which assisted in the restoration of peristaltic action. In 1851 a patient was admitted into Dupuytren's ward with well-marked s^nnptoms of acute intestinal obstruction. This eminent surgeon gave it as his opinion that without an operation a fatal termination was inevitable, but the patient objected to the operation and was transferred to another ward, where he recovered in three da}^ under the use of simple cathartics. Numerous similar cases could be cited in illustration of the difficulty of differentiating in all cases between mechanical occlusion and dynamic obstruction. In cases of perforative peritonitis and peritonitis with putrefaction the presence of gas in the free peritoneal cavitj' gives rise to an important physical sign. In tympanites from peritonitis and intes- tinal obstruction, the distended intestines push the liver in an upward direction ; hence, on percussion, the liver dullness is transferred higher up. But, under the circumstances mentioned above, the gas in the free abdominal cavity occupies the space between the liver and the chest- wall ; consequently", the liver dullness has disappeared, and the space over the organ is tympanitic on percussion. One of the most constant signs in peritonitis is the small, rapid, compressible pulse. In diffuse peritonitis it usually ranges between 120 and 140. In rapidly fatal diffuse septic peritonitis pain is often wanting. In circumscribed peri- tonitis pain and tenderness are limited to the affected region. T3-m- panites is often a most distressing sj-mptom in circumscribed peritonitis, and may be entirely absent in the most fatal form of septic peritonitis. Rigidity of the abdominal muscles is an indication of peritonitis, while it is absent in uncomplicated intestinal obstruction. In suppurative peritonitis the i)resence of pus is indicated b}' the physical S3mptoms arising from the accumulation of fluid, either in the free peritoneal cavit}- or in a circumscribed space of it. If the pus is not confined b}^ adherent intestines and plastic exudation, it will gi'aA'itate toward the most dependent portion of the peritoneal cavit3',and on this account the area of dullness will var3- according to the position of the patient. In 300 rRINCIPLES OF SURGERY. circumscribed suppurative peritonitis the pus is confined in y perforation of the appendix vermiformis, the appendix must be looked for, and when found perforated it is excised near its attachment to the caecum after tying its base with a fine silk ligature ; or, if this cannot be done, it maj- be slit open and drained, as was done successfully by Tait. 302 PRINCIPLES OF SURGERY. All operations for siippnmtive peritonitis are to be conducted upon rigid antiseptic principles, and the treatment is to be followed without relaxa- tion during the entire after-treatment. As patients suffering from peri- tonitis are alw.ays greatly debilitated from the effects of the disease as well as from lack of solid food, which for well-founded reasons must be withheld, ever}' eflbrt should be made to sustain strength by the sys- tematic administration of liquid nourishment and alcoholic stimulants. Absolute rest must be enforced for the purpose of limiting the extension of the disease and with a view of aiding the process of repair. CHAPTER XII. Septicemia. • Septicaemia, septaemia, sepsis, are synonymous terms used to desig- nate a general febrile affection caused by the introduction into the circulation of the products of fermentation or putrefaction, and which is characterized by definite blood-changes, a typical series of inflamma- tory processes, a peculiar group of nervous sj^mptoms and critical discharges. Clinically, and probably etiologicall^', it is closely related to pyaemia. The older pathologists entertained the belief that in cases of septicaemia the blood itself was the seat of putrefactive changes. At present it is generally conceded that it results from the introduction into the circulation of septic micro-organisms or their ptomaines. The sj-mptoms do not suffice for a full characterization of the disease, but the specific infection is the integral and essential factor. BACTERIOLOGICAL RESEARCHES. Septic processes were among the first to excite interest in the part played by micro-organisms in disease. Although some of the best pathologists have been diligently investigating this subject for years, we still remain in the dark concerning its true etiology and its relation to other infective processes. True sepsis is now regarded as a general infection from some local source, unattended by any gross pathological changes. Some writers have claimed the etiological difference between septicaemia and p3'£emia to be a quantitative and not a qualitative one, while others maintain that p3-aemia is a specific disease sni generis^ and that it is in no wise related to sepsis. There can be no doubt that true progressive sepsis, if not invariably, is, at least frequently, caused bj^ the same microbes which produce pyaemia. As we have seen in the fore- going chapter, the same microbes, when introduced into the peritoneal cavitj^ may either cause a circumscribed suppurative peritonitis or a diffuse septic peritonitis, with all the clinical features of progressive sepsis. The first reliable investigations into the microbic origin of sepsis were made by Rindfleisch in 1866, and, somewhat later, bj' Klebs, Recklinghausen, Waldej-er, and Hueter. Rindfleisch found bacteria in abscesses, while the researches of Klebs initiated a new era in the etiology of septic diseases. Klebs differentiated between septicaemia and pyaemia. (303) " 304 PRINCIPLES OF SURGERY. ulllioiigli he eliiiined tluit piilrid intoxication and septic infection were the same. In the tissues altered by septic processes, and in the lymph- spaces and in the blood, he found a microbe, a round coccus, isolated anvements; it refused food, the respiration became irregular and slow, and death took place within eight hours. The greater portion of the fluid injected was found after death not to have been absorbed. No inflammation at the seat of injection. No macroscopical pathological changes were found in any of the internal organs. Blood taken from the right auricle and injected into another mouse produced no symptoms. No bacteria could be found in the blood or any of the internal organs. Koch con- cluded that death was not caused by bacteria, but by the introduction into the circulation of a preformed poison contained in the putrid fluid, as when smaller doses were used the symptoms of intoxication were less marked, and when the quantitj^ was reduced to 1 drop the animal often recovered without manifesting any morbid symptoms. Al)out one-third of the animals which had received 1 or 2 drops of the fluid subcutane- ouslj^ remained well for about twentj'-four hours, when an increased secretion from the conjunctiva was observed ; at the same time the animal showed signs of great muscular w^eakness. It then ceased to take food ; its respirations became slower, prostration became more and more marked, and death came on almost imperceptibly. After death the animal remained in the sitting posture with its back strongly bent. Death occurred in from forty to sixty hours after inoculation. The only post-mortem change noticed was a slight subcutaneous oedema at the point of injection, and this was not constantly present. Koch then experimented with the oedema-fluid and blood of mice that had died of sepsis, ^^ drop of which was injected into another mouse, when exactl}' the same symptoms and result were produced in the latter animal, after the same lapse of time and in the same order as in the former. BACTERIOLOGICAL RESEARCHES. 305 From this second animal a third was infected in lilce manner witli identical results Siucessive inoculations proved that the virus could be propagated indefiuitel}' from animal to animal without losing its viru- lence. He could communicate the disease with certaint}' b}' passing the B/^V-5 B_,.cc-v-^ '' f~- 'm^ Fig. 66.— Vein of the Di.jlphragm of a Septicemic Mouse, x 700. (A'oc/i.)* A, nuclei of the vascular wall ; B, septicsemic bacilli ; C. white blood-corpuscles which have become transformed iuto masses of bacilli ; D, capillaries opening into veiu. point of a scalpel, which had been in contact with the infected blood, over a small wound of the skin. The blood of the animals which became * F^iss. Ot>, 67, aiul 68 are copied from '■ Traumatic Infective Diseases," by permission of the New Sydenham Society, London. 20 306 PRINCIPLES OF SURGERV. ill fifter injection of 1 to 10 drops of putref)dng blood was found to contain, as a rule, different varieties of bacteria in small numbers, micro- cocci, and large and small bacilli. If, however, it died after inoculation with putrefj^ing or septicemic blood, small bacilli alone appeared in the blood. This result was constant, and the bacilli were alwavs in large numbers. These bacilli lie singly or in small groups between the red blood-corpuscles. One often can see the bacilli in septicemic blood attached to each other in pairs, either in straight lines or forming an obtuse angle. In some cases Koch has also seen spores in the bacilli. Their relation to the white corpuscles is peculiar. They penetrate into these, and multiply in their interior. Microscopical examination of the tissues at the point of inoculation showed that the bacilli entered the capillary blood-vessels, where they caused such extensive alterations as to give rise to extravasation of numerous red blood-corpuscles. They were never found in the l^niiphatic vessels. Within the blood-vessels the^^ are almost always arranged with their long axis in the direction of the blood-current. In the capillaries the bacilli congregate, particularly at the points of division, but never cause complete obstruction. Rabbits and field-mice proved immune to inoculations with the septicaemic blood of the domestic mouse. The bacillus of Koch's septicaemia can be cultivated upon a mixture of aqueous humor and gelatin, or of gelatin, peptone (1 per cent.), salt (0.6 per cent.), and sodium phosphate in sufficient quantity to ren- der the mass alkaline in reaction. The bacilli grow well upon this mixture, and by repeated and rapid division form peculiar branched series. Septicaemia in Rabbits. — Although Koch was unable to produce sep- ticaemia in rabbits, either by injections or inoculations of septicaemic products from the domestic mouse, he caused the disease artificially by injecting a putrid infusion of meat. In these cases the injection pro- duced extensive suppuration, with putrefaction, and the animals died in three days and a half. Various bacteria were found in the inflammatory product. At the border of the local inflammation the connective tissue was infiltrated with a turbid, serous fluid, which contrasted strongly with the brownish ofTensive pus. In this cedema-fluid onl}^ cocci of an oval form were found. In the blood similar microbes were found, though onl}' in small numbers. Some of the small veins in the spleen and kidneys were seen to be completely blocked with the same microbe. Two drops of the oedema-fluid were injected under the skin of the back of a second rabbit. The animal died in twenty-two hours, and here, in the vicinity of the injection, not a trace of suppuration could be BACTERIOLOGICAL RESEARCHES. 307 found. Hsemoniiagic extravasations were found in the inflamed oedematous connective tissue. No alterations were found in the heart and lungs. In this animal the oval micrococci were alone present in the oedema-fluid. Micrococci were also found in the capillary ves- sels in different organs ; in some of them the lumen of the vessels was completel}' blocked. In the capillary vessels surrounding the A-- t ^J e © Fig. 67.— Glomerttltjs OF A Septicemic Rabbit. x700. {Koch.) A, capillary loop with oval micrococci spread out like a membrane ; B, micrococci deposited on the walls of a capillary vessel ; 0, loop completely filled with micrococci; D, individual micrococci in a eapillary vessel near a glomevnlus. intestinal glands numerous obstructing masses of the bacilli were present. At many points these were so extensive that branching accumula- tions were seen consisting entirelv of these organisms. This microbe was never seen to inclose blood-corpuscles, and, as they did not cause coagulation of the blood, embolism was never observed. The virulence of the bacillus was not increased by successive inoculation with infected 308 PRTNCTPLES OF SURGERY. 1)loocl from iiiiimal to aniuuil. The bacillus now under consideration ap- pears to be closel}' allied or identical with that of Davaine's septicaemia, ■which was first produced b}^ injecting rab1)its with putrid ox-blood. The two diseases are distinguished in that Davaine's septicaemia is easily trans- missible to guinea-pigs, but not to birds; while mice, pigeons, fowls, and sparrows are very susceptible to the bacillus of septicsemia in rabbits, discovered by Koch, but guinea-pigs, dogs, and rats resist. Hueppe be- lieves that this microbe is not a bacillus, but a coccus in a state of elonga- FiG. 68.— Capillary Vessels Surrounding the Intestinal Glands op a Septicemic Rabbit. X700. {Koch.) tion; and Gaffky, Schuetz, Kitt, Salmon, Fluegge,and Baumgarten classify it with the bacilli. It readily stains in aniline solutions. Upon sterilized gelatin it grows in the form of clear, finely-granular drops, which, wdien they become confluent, form a culture which appears as a gra3'ish-white film with jagged borders. Liquefaction of the gelatin never takes place. It can also be cultivated upon agar-agar, coagulated blood-serum, and potato. Gaffky investigated Davaine's septicaemia experimentally. He procured the infection by using water from a stagnant rivulet, and, bj' continually controlling the experiments with the microscope, using BACTERIOLOGICAL RESEARCHES. 309 Koch's methods, and working only with pure cultures, he was able to prove be3ond a doubt that the theories of progressive virulence of bac- teria were untenable. He showed that the highest degree of virulence was already attained in the second generation. He pointed out that the fallacious conclusions were due to impurification in the experiments, and that when the proper precautions are taken, in the process of steriliza- tion, to prevent the admixture of other micro-organisms, the introduc- tion of one kind alwa3's produces in the same animal the same definite result. The most interesting conclusions to be drawn from the experi- ments in Koch's laboratory point to the fact that septicaemia is only a general term which includes a number of morbid processes, and this is well illustrated by the injection into the tissues of the " vibriones sep- tiques " of Pasteur. Surface inoculations with these bacilli produce no eflTect ; their pathogenic influence became only evident after injections into the subcutaneous connective tissue. Gatfky found that this bacillus A B grows most readih^ upon potato. Koch applied to the condition produced b}' \ this bacillus the tei'm " malignant \ oedema." V / 1 7 ^ Fig. 69.— Bacillus of Malig>'axt CEdema. X700. (Koch.) ^ „„ . Malignant (Edema. — The bacillus of malignant oedema was de- scribed b}' Koch as the cause of a fatal disease in guinea-pigs and rab- bits. The same bacillus was described b}' Pasteur as " vibrion septique." Recently, this disease has been found also in some of the domestic mam- malia and in man. The bacillus resembles morphologically the bacillus anthracis. Usually, two or three bacilli are joined end to end, and thus form straight or curved rods two or three times the length of one bacil- lus. When stained, the threads present a granular appearance, from the unequal distribution of the staining material. This bacillus is somewhat narrower than the anthrax bacillus, and when stained does not present such a regular, chain-like appearance. Sometimes the bacillus is found motile, but not alwa^'S, while the anthrax bacillus is always devoid of this propert}-. It multiplies by spores, but these appear only in the middle and at the ends. 310 PRINCIPLES OF SURGERY. This microbe is juuierobic, and enii oiil}' be cultivated by exclusion of oxygen. The bacillus can only grow in the interior of agar-agar, gelatin, or coagulated blood-serum, if the needle-puncture on the sur- face of the nutrient medium is hermetically sealed. The growth of the bacillus is attended by the formation of gas-l)ubbles. The gas has an intensely- offensive odor. Blood-serum is liquefied. The temperature of the blood is most favorable to the grow'th of the bacillus, and cultures develop also, but slowly, at a temperature of 18° to 20° C. This bacillus is widely diffused, and can be found in almost any putrefying substance. The bacillus of malignant oedema possesses the power of peptonizing albumen. It is found in abundance in garden- earth and hay-dust. If a small quantity of either of these substances is inserted un- derneath the skin of a guinea-pig, death is produced within forty-eight hours. The most characteristic post-mortem appearance is a diffuse oedema at the point of inocula- tion. The oedema-fluid is a clear, reddish serum, in which can be found bubbles of gas and numerous bacilli. The spleen is enlarged, of a darker color than normal, but the other organs present no macroscopi- cal changes. The bacilli can be found in the parenchj'ma-fluid of nearlj^ all organs, and especially is their number great in the envelopes of the infected organs. Mice die in from sixteen to twenty hours after inocu- lation. Horses, sheep, and pigs can be suc- cessfully inoculated, while cattle are immune to the bacillus. The disease can be communicated from animal to animal b}^ implantation of fragments of infected tissue or b}^ inoculation with 1 or 2 drops of the oedema-fluid. Surface inoculation is harmless, as the bacillus will not multipl3' when exposed to atmospheric air. In man malignant oedema appears in the form of progressive gangrene with emphysema (gangrene gazeuse). Recently, the identity of this disease with malig- nant oedema has been proved by inoculation experiments by Chaveau, Arloing, Brieger, and Ehrlich. Animals which have recovered from an attack of malignant oedema remain immune to this disease, but prophy- lactic inoculations have so far yielded only negative results. Chaveau made man}- experiments on guinea-pigs, sheep, and horses by injecting the liquid contents of bullse which he found in cases of septic gangrene. Fig. 71.— IJULTUKES of Bacillus OF Malignant CEdeima in Gelatin. (Fluegge.) PYOGENIC MICROBES AS A CAUSE OF SEPSIS. 311 In doses of ^ drop in guinea-pigs and from 2 to 4 drops in horses, it produced death in a short time. In all cases the necrops3- showed, at the point of injection, localized oedema and turbid serum in the perito- neal, pleural, and pericardial cavities. In the fluids the bacillus could alwaj^s be demonstrated under the microscope. The disease could be reproduced in other animals b\' inoculation with the serous fluid con- tained in an}' of the serous cavities. The microbe proved less A-irulent when injected directh' into the circulation. PYOGENIC MICROBES AS A CAUSE OF SEPSIS. The general symptoms which accompan}- all suppurative affections represent, etiologically and clinicall}^, a form of sepsis, which differs in its intensity according to the quantitj' of pus-microbes, or their ptomaines, which reach the general circulation. The slight fever which often attends the development of a furuncle ceases with the removal of the products of inflammation, while a septic or diff'use suppurative perito- nitis results in death in a short time from septic infection. The different forms of suppurative inflammation result in gangrene if the disease prove fatal ; the immediate cause of death is usually septic infection or putrid intoxication. Watson Che3'ne maintains that the microbes of sepsis only grow in loco, and act by producing toxic ptomaines, or, if they occur in the blood, the}' do not make emboli, Yidal reported to the Academie de Medecine de Parisihe results of his studies of the " forme septicemique pure " in puerperal fever of typhoid type without suppuration. In all of the cases in which he made a bacteriological examination he found the streptococcus pyogenes, and from this and the results of his culture and inoculation experiments he comes to the conclusion that it is impossible, in the present state of our knowledge, to distinguish between the various forms of streptococci, and that one and the same kind can set up any of the various forms of septic infection. Besser has examined 22 cases of traumatic sepsis, and found microbes of suppuration in cA^er}^ one of them. During the patient's life he discovered the microbe (a) in the blood in 4 of 16 cases exam- ined ; {h) in the pus or fluid discharge from the primary focus, in IT of 17; (c) in the urine, in 3 of 4 ; and (d) in the sputa, in 3 of 3 ; while after death the micro-organism was present (a) in the blood, in T of 15 ; (6) in the internal organs, in 10 of 18 ; and (c) in the pus or uterine dis- charges, in 12 of 12. In 6 of 22 cases pus-microbes were simultane- ously detected side by side with masses of bacteria of many other species. In 3 cases, however, the streptococcus was found alone, unasso- ciated with any other microbe. Besser is of the opinion that the strep- tococcus of suppuration is the most frequent cause of sepsis. Smith 312 PRINCIPLES OF SURGERY. isolated and cultivated, from 2 cases of puerperal sepsis, a streptococcus vvhioh, by inoculation and cultivation experiments, differed from the streptococcus of Fehleissen and the ordinary streptococcus of suppura- tion. He made a series of gelatin cultures with blood taken from the heart. After an interval of two or thi'oe days numerous colonies appeared. Rats inoculated with a pure culture died in from tliree to four days ; the same microbe was discovered in their l)lood. Inoculations were also made in the ears of rabbits, and at the end of twent3-four hours a circumscribed redness without tendency to ditfusion was appar- ent, the redness disappearing in two or three da3s. Anotlier series of cultures and inoculations was made with blood taken from the finger of a woman sick with puerperal fever, with similar results. From these considerations it becomes evident that the essential bacterial cause of septicaemia is variable^ and that the disease rejiresents a general febrile condition, ivhich is brought about by the absorption from a local focus of different toxines from as many different microbes. As the in- troduction into the circulation of the products of putrefaction is fol- lowed by a complexus of symptoms which closely resembles what is understood clinically by the term septicaemia, and as different microbes have been cultivated from septic patients, it would seem that this disease can be produced by any of the microbes which, after their introduction into the organism, have the capacity to produce a sufficient quantity of phlogistic ptomaines to give rise to septic intoxication. CLINICAL FORMS OF SEPTICEMIA. A clinical description of septicaemia cannot be given without a sub- division of the disease upon an etiological basis. Since the publication of Gaspard's researches it is absolutely necessary to make a distinction between septic intoxication and septic infection. Bv septic intoxication is understood that form of septicaemia which is caused b}-^ the absorption from a local focus of a ferment or the products of putrefaction, while the term septic infection is limited to those cases where septic micro-organ- isms gain entrance into the circulation, and not only exercise their patho- genic properties in the blood, but retain their capacity of reproduction in the circulation and distant organs. Septic intoxication is caused by the absorjMon of a preformed ferment or toxine, which produces the maximum result as soon as it reaches the circulation, and the symptoms subside with the arrest of further supjjly and the elimination tf the septic material from the circulation. Sepdic infection, on the other hand, occurs in consequence of the introduction into the circulation of living micro- organisms which multiply with great rapidity in the blood, — a circum- stance which imparts to this form of septicaemia its progressive character. CLINICAL FORMS OF SEPTICEMIA. 313 Septic intoxication is caused either by the absorption of fibrin ferment or the products of putrefactive bacteria. (a) Fermentation Fever. — Fermentation fever (Bergmann), after-fever ^^Billruth), aseptic fever (^Yolkmann), resorption fever, are terms used to designate a general febrile disturbance caused by the absorption of the products of aseptic tissue necrosis. This, the most simple and harmless of all wound complications, appears as a temporarj- fever soon after an injury or operation, and is caused by the absorption of aseptic phlogistic substances. Different aseptic inert substances, when injected into the circulation, are known to produce a rise in temperature. Bei'gmann wit- nessed such a reaction after intra-venous infusion of a physiological solu- tion of salt; Freese, after transfusion of blood of healthy animals; and Bergmann, Strieker, Albert, and Billroth, after intra-venous injections of a considerable quantity of well-water. The same effect is produced b}^ intra-venous injections of water in which fine foreign particles, as flour or finely-puh^erized charcoal, are suspended. Yolkmann and Genzmer observed a rise in temperature in patients soon after the operation was completed and when the wound remained aseptic throughout, and hence called this form of fever aseptic fever. These authors attribute the fever to the reception into the blood of dead tissue material. Bergmann devised the terra fermentation fever upon the theory that the fever is caused b3' the presence of fibrin ferment in tlie blood. Augerer and Edelberg demonstrated experimentally that this fever occurs after transfusion, if the blood transfused contain fibrin ferment. Schmiedeberg attributed the fever to the presence of another blood fer- ment which he discovered and whicli he called " histozym." Bergmann and Augerer's experimental researches show that a fever which resem- bles the fermentation fever almost to perfection can be artificially pro- duced in animals by intra-venous injections of pancreatin, pepsin, and trypsin. It would appear that the albuminoid substances, which are in excess in the blood, undergo oxidation by the action of a ferment, and that the chemical changes brought about in tbis manner occasion rise in temperature, while the products of oxidation are eliminated tlirough the kidneys. Riedel found, in man}' cases of simple subcutaneous fracture, albumen in tlie urine during the first three or four days, and the urine alwaj'S contained brown masses, which he regarded as products of the red blood-corpuscles. Worm Miiller found invariably, after transfusion of blood, a considerable increase of urates in the urine. The occurrence of fever after the introduction of foreign aseptic substances into tlie cir- culation, can only be explained upon the supposition that they destroy red nnd white corpuscles in the blood, and that in this manner fibrin ferment, the cause of the fever, is generated. 314 PRINCIPLES OF SURGERY. Symptoms and Diagnosis. — Fermentation fever is prone to follow an oi)eratioii or injury if antiseptic solutions are allowed to remain in the wound, tliereby causing necrosis of the superficial tissues, or where, after closure of the wound, parenchymatous oozing gives rise to tension, — a local condition which forces the products of coagulation necrosis into the circulation. As not all extravasations of blood give rise to fever, we must take it for granted that when fever is not produced its absence is owing eitlu^r to an absence of fibrin ferment or the existence of local conditions which prevent its absorption. From my own observations I am convinced that the amount of extravasated blood holds no relation whatever to tlie frequency of its occurrence or its intensity. A small extravasation under high pressure is more frequently the cause of fermen- tation than a large blood-clot in a location less favorable to the absorp- tion of librin ferment. Fermentation fever makes its appearance within a few hours after an injury or operation, and, as a rule, it is not preceded b}' a chill. The temperature rapidly reaches its maximum, which varies from 100° to 104° F., and remains, without much variation, in the vicinit}' of the maximum height, to drop suddenly to normal at the end of the first to the third da3^ The pulse is correspondingly increased in frequency during the febrile attack. The sensorium remains intact, the appetite is not much disturbed, and none of the subjective symptoms are proportionate to the severity of the febrile disturbance. Patients with a high temperature feel so well that, if their wounds permit it, they will insist in walking around and will attend to their business, contrary to the advice of the attending surgeon. The most important diagnostic features of fermentation fever are its early onset after an injury or operation, and its spontaneous subsidence in from one to three days. As the disease is caused by the introduction of phlogistic substances from a local focus, and propagated by intra-vascular chemical changes, it is uninfluenced by any form of medication. The fever subsides sponta- neously upon cessation of the primary cause, and with the elimination through the kidneys of the products of intra-vascular chemical changes. As the remaining forms of sepsis usuall3' appear at a time wdien fermen- tation fever has run its course, the differential diagnosis presents no great difficulties. The treatment of fermentation fever is entirely of a prophylactic nature. The prophylactic measures consist in a careful ha^mostasis, and in cases where parenchymatous oozing, from the nature of a wound or the anatomical structure of the tissues, is to be expected, the prevention of the accumulation of the primar3' wound-secretion by eflficient drainage. Fermentation fever must be included among the septic diseases, as the fibrin ferment acts as a toxic substance in the same manner as the toxines CLINICAL FORMS OF SEPTICEMIA. 315 elaborated by septic micro-organisms. Future research maj' yet demon- strate that even this, the most harmless form of septicaemia, is not an aseptic fever, but that it is caused b}^ pathogenic micro-organisms, either too few in number or not of sufficient potency to produce the graver forms of the disease. (b) Sapraemia. — Tliis word was devised by Mathews Duncan to include a form of se[)ticffimia resulting from the absorption of the products of putrefaction. Sapraemia is the typical form of septic intoxication, as it is always caused by the introduction into the circulation of preformed toxines or ptomaines elaborated in dead tissues b}'^ putrefactive bacteria. It is closely allied to fermentation fever, as the S}' mptoms are never in- tensified after the removal of the primarj^ cause, but, as a rule, subside promptly- after this has been accomplished. As sapraemia never occurs without putrefaction of necrosed tissue, and as putrefaction never takes place without infection with putrefactive bacteria, it becomes necessary 1 to consider briefly the micro-organisms which are Icuowii to cause the clinical forms of putrefaction. •»> 9S^ ^/l Y^^ 2 3 FiQ. 72. Fig. 73. Fig. 74. Figs. 72, 73, and 74.— Bacillus Saprogenes 1, 2, 3. 962 :1. {Rosenhach.) Bacilli of Putrefaction. — The bacilli of putrefaction exercise their liatliogenic qualities onl^- in dead tissue exposed to the atmospheric air. Clinically the}' are therefore present in the products of coagulation necrosis, or as a secondary infection in tissues destroyed b}- other micro- organisms. Most of them possess gasogenic properties. Rosenbach discovered, in different fetid secretions, three forms of bacilli which he designated respectiveh' bacillus saprogenes 1, 2, 3. Bacillus Saprogenes 1. — A comparatively large bacillus, which mul- tiplies by end spores, which, however, grow only from one end of the bacillus. On nutrient agar-agar the bacillus grows in the form of an irregular sinuous streak, with a mucilaginous appearance. The bacilli grow readil}' also in blood-serum, and all cultures emit the odor of decom- posing kitchen refuse. Albumen or meat acted upon b}- a culture of this bacillus undergoes rapid putrefaction if exposed to atmospheric air, but if air is excluded the action of the microbes upon these substances is very slight. Cultures injected into healthy tissues and joints are harmless. 316 PRINCIPLES OF SURGEliY. Bacillus Saprogenes J. — This bacillus was isolated by Rosenbach from fetid sweat. The rods are shorter and thinner than the preceding ones. This bacillus develops very rapidly on agar-agar, forming transparent drops, Avhich become gray. The culture yields a characteristic fetid odor, similar to the last. Cultures of this bacillus injected into the knee-joint and pleural cavity of rabbits caused acute suppurative inflammation and death. Bacillus Saprogenes 3. — This bacillus was discovered by Rosenbach in the pus of 2 cases of osteomyelitis with septic manifestations comi)licating compound fracture. Cultivated on nutrient agar-agar, an ash-gray, almost liquid culture is developed, with a strong, characteristic odor of putrefaction. Injected Fig. 75.— Proteus Vulgaris. 285:1. Swarming Islets. (Hauser.) into the knee-joint or abdomen of a rabbit, an opaque, yellowish-green infiltration resulted. Proteus Vulgaris. — This and the following species have been recently described by Hauser as present in putrefying meat-infusions, and as being intimately connected with the process of putrefaction. As the name indicates, these bacteria are capable of changing their form during their development. Thedifterent species of proteus have been described as coccoid, bacteroid, spindle-shaped, and spiralinar, on account of the ever-changing form the}' assume during their growth. In proteus vul- garis the bacteria vary greatly in size. Many of the rods are actively motile, and cultivated upon nutrient gelatin they convert it into a turbid, gr:i3'ish-white liquid. If cultivated in a capsule containing 5 per cent, of nutrient gelatin, a few hours after inoculation, the most characteristic movements of the individual bacilli CLINICAL FORMS OF SEPTICEMIA. mi are observed on the surface of the gehitiii, although at this early stage no liquefaction can be detected. The movements are not observed if the nutrient medium contains 10 per cent, of gelatin. Spore formation was never observed. Injected subcutaneously in small doses, no results were obtained ; larger doses sometimes caused circumscribed abscess at the point of injection. Intra-venous injection of a large dose produced toxic sj-mptoms in rabbits and guinea-pigs, and these were not modifietl by .using the filtrate of a liquefied culture, showing that the toxic sub- stance was held in solution. Proteus Mirabilis. — Rods varying greatlj- in length, sometimes so short that they appear like cocci, at others of considerable length. The rods occur singl}- and in zodglcea, and sometimes in tetrads, pairs, chains, or as short rods in twos, resembling bacterium termo, — in fact, in all conceivable transition forms. Cultivated on nutrient gelatin they form a thick, whitish laj-er, in concentric circles, which in time lique- fies the medium. Similar movements are observed in capsule-cultivations as with proteus vulgaris. The patho- genic properties of the mirabilis are the same as those of vulgaris. Proteus Zenker!. — Rods about four times as long as wide, in two, like bacterium termo. Cultivated on nutrient gelatin no liquefaction re- sults, but a thick, whitish-gra}^ layer is formed, with sloping margins. The bacilli are motile, and the same phe- nomena are observed on the solid medium as in the other forms. Spirilli and spiralinar forms are seldom seen. Gelatin and blood-serum cultures emit no fetid odor, but meat-iu fusion undergoes rapid putrefaction and yields the usual fetid odor. The pathogenic qualities are the same as those of the other species of proteus. As the microbes of putrefaction, which have first been described, possess limited or no pathogenic qualities when introduced into health}^ tissue, it is evident that their toxic effect is caused bj' a soluble substance which they produce when they find their way into dead tissue exposed to atmospheric air. This leads us to a consideration of the Ptomaines. — Ptomaine is a term used to designate certain toxic substances (resembling alkaloids) which are produced during the process Fig. 76.— Pkotetjs Mieabii.is, Swarming Islets. (Hauser.) 285:1. 318 I'KINCIPLES OF SURGERY. of putrefaction. Gautier li:is shown that in dead animal tissues proc- esses of putrefactive decomposition set in, by which certain alkaloids are elaborated from alljiimiiious substances, which have I)een called ptomaines bv Selmi. In the latter part of the seventeenth century Klrcher and Leuwenhoek claimed that putrid su])st:inces contained minute microscoi)ical worms, which caused the putrefaction. In 1820 Kerner pointed out the resemblance between the symptoms of poisoning by sausages and by atropine. He was thus the first to raise the sus- picion that toxic alkaloids were formed through the decomposition of albumen. In 1856 I'anum sliowed that tlie inflammatory change which occurs in the intestinal mucous membrane of animals fed on putrid infusions is due to a chemical poison, which remained unaffected b}' boiling for a long time ; and his conclusion that the toxic substance contained in putrid fluids was of a chemical nature was confirmed b}'' Weber, Hemmer, Schweninger, Stich, and Thiersch. In 1875 W. B. / Fig. 77.— Involution Forms of Proteus Mirabilis. 524 : 1. (Hauser.) Richardson isolated a toxic substance, which he called " septine," from the inflammatory transudation in the peritoneal cavity of a person that had died of pyaemia. With this substance he successfully infected animals. He also found that this substance could be made to combine with acids, so as to form salts, without losing its toxic qualities. Berg- mann and Schmiedeberg isolated a crystalline poison from decomposing yeast, to which they gave the name of "sepsin." This substance, when injected into the subcutaneous tissue or venous circulation in animals, produced well-marked symptoms of septic intoxication ; the intensity of the symptoms were found to vary with the amount of the substance in- jected. Zuelzer and Sonnenschein obtained, from macerated dead bodies and from putrid meat-infusions, small quantities of a crystallizable sub- stance which exhibited the reactions of an alkaloid, and had a physio- logical action like atropine, dilating the pupil, paralyzing the muscular fibres of the intestine, and increasing the rapidity- of tiie pulse. In 1857, Pasteur made the important discover3- that specific micro-organisms CLINICAL FORMS OF SEPTICEMIA. '^\9 are the cause of the various forms of fermeutation and putrefaction. No discover}-, perhaps, attracted such universal attention as Pasteur's theor}' of fermentation. This theory was strengthened somewhat later by Lemaire's observation, that all fermentative changes in fluids are sus- pended on the addition to the fluids of phenic acid, from which he concluded that fermentation must be due to living organisms. Next came tiie care fully -conducted experiments of Lister, who showed that air is deprived of its action in causing putrefaction of organic substances if it is passed through a filter, or if the fluids are placed in on open vessel with the mouth of the vessel so arranged that dust cannot reach the fluid b}' gravitation. Lister's great life-worlc, antiseptic surgery, that has created a new epoch in the histor}- of medicine and surger^^, is based upon what then was still a theor}', that inflammation, suppuration, and septic infection of wounds are caused by living specific micro-organisms. Selmi discov- ered ptomaines in an exhumed bodj', in 18T2. The ptomaines isolated b}' him were volatile alkaloids. Gautier, independently of Selmi, and about the same time, made the same observations, but believed that the toxic substances were volatile, and that in their action they resembled the narcotics, morphia and atropia, and were more nearl}' allied to the alkaloid extracted from poisonous mushrooms. Semmer gives an account of the action of septic substances as studied experimentally by Guttmann, of Dorpat. The experiments were made with putrid substances, products of inflammation, septic blood, and cultivations of septic bacteria. These researches showed that a chemical poison is formed in putrefying substances, and that a certain qnantit}' of such poison produces S3'mptoms of sepsis and death in animals. Tlie blood of animals killed with such putrid poisons was found to possess no infective qualities, and the usual putrefactive bac- teria were destroyed in the blood, and only appear again after the death of the animal. It was claimed, even at that time, that the bacteria elaborate the poison, as experiments made with cultures grown outside the body produced the same effect. Another conclusion arrived at was that putrid substances administered subcutaneoush' ma}- produce gangrene, phlegmonous inflammation, or er^'sipelas, according to the stage of putrefaction, temperature, culture-soil, etc. The infective material was never found in the blood, but always in the products of inflammation. It M'as clearly stated that true septicaemia is alwa3's preceded by a stage of incubation, and that its contagium is destroyed by boiling, putrefaction, and germicides. Bergmann and Augerer produced a condition in animals resembling septicaemia, by injecting into the circulation pepsin, pancreatin, and 320 PRINCIPLES OF SURGERY. trypsin. When death occurred after intra-vascuhir injections of these ferments, fibrinous deposits were found in the heart and pulmonar}' vessels. These experiments were, therefore, confirmatory of the obser- vations previously nuide b}' p]delberg and Birck, who had shown that the injection of i)utrid substances into the circulation materially increased the free fibrin ferment in the circulating blood. Bhimberg concluded, from his numerous experiments on animals, that the symptoms which follow an injection of putrescent material into the circulation are not always constant ; that, in fact, extreme prostra- tion, high temperature, rapid pulse and respiration are the onl}' constant sj-mptoms found. The same author also confirmed the statement that the blood of patients dying from putrid intoxication contained no micro-organisms. Samuel maintains that putrid fluids, from the second da\' until the eighth montli of putrefaction, act differentl}', and divides their action according to this supposition into three stages : 1. Phlogo- genic, in which they produce only inflammation. 2. Septogenic , in which they produce in the living organism putrefactive processes. 3. Pyogenic^ in which they cause only suppuration, having lost in the meantime their other pathogenic qualities. Mikulicz found tliat putrid fluids, according as they are free from bacteria or contain more or less of putrefactive microbes, will produce a slight inflammation, a suppurative inflammation, or a progressive phleg- monous inflammation. Frankel detected but few micrococci in the blood of septiciemic patients, and observed that the}' greatly increased after death ; but, after the lapse of some further time, altogether disappeared, thus also confirming a fact previously known, that putrefaction destroj^ed septic microbes. These observations may tend to harmonize the dis- crepancy of opinion, growing out of the diflTerent results obtained by diff^erent experimenters, by injections of putrid substances, as some of the fluids may have contained an abundance of living micro-organisms, while others may have been rendered sterile by age, owing to advanced putrefactive changes. Brieger and Maas have rendered valuable service in the chemical isolation of ptomaines, or, as Brieger calls them, toxines, from putrid substances, and the results of their inoculation experiments established more firmly the fact of putrid intoxication by these soluble alkaloid substances. The number of bacteria in rabbits killed b}' septic infection is so great that death may ensue from simple mechanical causes, wliile in fatal cases of sepsis in man the number is often so small that it seems natural to suppose that the micro-organisms are capable of pro- ducing some poisonous substance, which destroj^s the patient before they have time to multiply' to the extent observed in septicaemia in rabbits and mice. CLINICAL FORMS OF SEPTICAEMIA. 321 Rinue asserts that the chemical products of pus-microbes alone, as well as sterilized putrid fluids, never produce metastasis. He sterilized fluid cultures of the staphylococcus p^-ogenes aureus after filtration, and injected directl}'^ into the blood-vessels of rabbits as much as 4 grammes of this fluid, and in dogs increased the dose to 14 grammes. Man}- of the animals showed slight symptoms of septic intoxication, somnolence, diarrhoea, and collapse. B3' using still larger doses the symptoms were intensified and the animals died from well-marked symptoms of septic intoxication. Metastatic abscesses were never found in these cases. The same author has recently published some xevy interesting observa- tions on the immediate cause of death in rabbits inoculated with a pure culture of Koch-Gaff" ky's bacillus. The animals were inoculated at the base of the ear, and immediatel}^ after death the ptomaines were isolated from the tissues b}' Brieger's method. In every instance he obtained a substance called meth^iguanidin, which on chemical analysis was shown to consist of the formula CgH^Ng. When this substance was injected into rabbits it produced s^-mptoms of septic intoxication which resembled, in eveiy particular, those produced by the injection of i)ure cultures obtained from septicEemic rabbits. As methylguanidin could not be produced from the cadavers by the same method, Hoffa naturally came to the conclusion that it was a product of the bacilli, and that death was to be attributed to the production of this toxic substance in the tissues of the infected animals b^^ the specific action of the bacilli. The source of methj^lguanidin in the body is kreatin, and the bacteria must possess the property of oxidation, as kreatin is transformed into methj'lguanidin only bj- oxidation. Brieger has isolated from human corpses a different set of toxic alkaloids, one of which he calls " cadav- erin" and the other " putrescin," which are but feeble poisons ; while two others, " madeleine " and " sepsin." v*iiich are produced later on in the decomposition, are much more powerful poisons, causing paralysis and death. From decomposing albuminous substances he has obtained many other well-defined chemical bodies, as well as some substances to which no names have 3'et been given. Bourget isolated several toxic bases from the viscera of a woman who had died of puerperal sepsis. He also obtained from the urine from patients suff"ering from the same disease similar toxic bases, which killed frogs and guinea-pigs, when administered bj' injection, showing that the toxic substances formed during life, and that the}' are elimi- nated through the kidneys. The experimental and clinical researches to which I have referred above show conclusively that septic intoxication is caused by the presence of dead tissue in the body in a state of putrefaction, from the presence 822 PRINCIPLES OF SURGERY. of putrefactive bacilli, and that the immediate cause of the intoxication is the absorption of preformed ptomaines from such a local focus of putrefaction. Symptoms and Diagnosis. — Septic intoxication snflicient in severity to give rise to grave general disturbances is usually initiated by a chill, or at least b}' a sensation of chilliness, followed by a continued form of fever, the temperature rapidly increasing to 102° to 104° F., with slight morning remissions. The character of the pulse furnishes the most reli- able information in regard to the intensity of the intoxication. All ptomaines of putrefactive bacteria exert a depressing influence on the heart; hence the force and frequency of the pulse furnish important diagnostic and prognostic CAndences. The pulse is always soft and com- pressible, — qualities which indicate diminished intra-vascular pressure, resulting from an enfeebled vis a tergo. Complete loss of appetite, vomiting, and diarrhoea are almost constant symptoms in grave cases. The tongue is usually furred, dry, and, in severe cases, presents the " dried-beef " appearance. The urine is scanty and heavily loaded with urates. Headache is often complained of in the beginning of the attack. Delirium, restlessness, insomnia, are symptoms which denote approach- ing danger. Subsultus, dilatation of pupils, clammy perspiration, livid appearance of visible mucous membranes, low-muttering delirium, invol- untary discharges, coldness of the extremities, fluttering, and feeble pulse precede death from septic intoxication. One of the most important elements in the diagnosis is the detection of a local focus of putrefaction. As the putrefaction alwa^^s occurs in parts of the bod}' exposed to the atmospheric air, its existence can readily be ascertained by the sense of smell. The intensity of the foetor of the gases produced by the putrefac- tive bacteria varies greatly, but the smell is always suggestive of decom- posing meat or kitchen refuse. The impression is quite prevalent, not only among the laity, but also in the profession, that the local lesions which cause septicaemia always emit a fetid odor. This is a grave mis- take. Foetor is associatad ivith putrefaction , and as such is suggestive of saprsemia, and not true progressive sepsis. The latter may be combined with saprsemia, but when it occurs independently of this no bad smell can be detected, and yet it is the most fatal form of sepsis. In reference to the differential diagnosis between saproemia, fermentation fever, and septic infection, it must be remembered that septic intoxication can onl}^ occur from putrefaction, and therefore three conditions must invariably be present in the etiology of this form of sepsis: 1. Dead tissue. 2. Infection of this dead tissue with putrefactive bncteria. 3. A sufficient length of time must have elai)sed since the injury or operation for the putrefactive bacteria to produce a toxic quantity of ptomaines to cause CLINICAL FORMS OF SEPTICEMIA. 323 symptoms of intoxication. The dead tissue ma}^ be a blood-clot in a wound, around the fragments of a compound fracture, or in the interior of the uterus ; it may be tissue devitalized b^- a trauma, heat or cold, the action of chemical substances, or the action of bacteria other than putrefactive ; or it may be detached, retained fragments of placental tissue. That such dead tissue has become the seat of infection with putrefactive bacteria can be ascertained by the presence of foetor and bubbles of gas. At the temperature of the bod}- putrefaction progresses verj' rapidly ; but a differential diagnosis can generall}' be made without much difficult}', between saprsemia and fermentation fever, b}- the time which has elapsed between the injur}' or operation and the manifesta- tion of the first symptoms of septic intoxication. Fermentation fever appears within a few hours, certainly always before the end of the first da}', while septic intoxication from putrefaction seldom begins before the expiration of twenty-four hours. If septic infection begin during this time it is not attended by any evidences of putrefaction. Prognosis. — Uncomplicated saprsemia proves fatal by the absorption of a deadly dose of ptomaines from a local depot of putrefaction, and the prognosis will therefore depend upon the stage of intoxication and the feasibility of the removal of the infected dead tissue by sui'gical treatment. If an efficient, radical treatment can be instituted at a time before a fatal dose of toxic substances has reached the general circula- tion, the prognosis is favorable. A decomposing blood-clot or detached fragment of a placenta can be readily removed and the field of operation sterilized. The prognosis in saprsmia complicating progressive gan- grene is always grave, as the dead tissue is increased by other microbes; hence the conditions created by both kinds of microbes are of a pro- gressive character. Treatment. — The prophylactic treatment of sapramia consists in the removal of dead tissue, prevention of subsequent extravasation and ac- cumulation of blood by cai-eful hsemostasis, — if necessary, by drainage, — and finally sterilization, by antiseptic measures, of dead tissue that cannot be removed. lodoformization of dead tissue is an excellent means of preservation. In the extra-peritoneal treatment of the stump after supra-vaginal extirpation of the uterus, the same object is accom- plished by toucliing the raw surface with a solution of perchloride or persulphate of iron or pure carbolic acid. Wounds in which dead tissue is unavoidably retained should always be treated by drainage. After symptoms of septic intoxication have developed early, radical treatment must be pursued. This treatment comprises the removal or sterilization of the dead tissue. A decomposing blood-clot .is to be removed and the parts are thoroughly irrigated with a solution of corrosive sublimate, and 324 PRINCIPLES OF SURGERY. re-iic'ciimuliitioa prevented by efficient drainage. In cases of gangrene complicated by putrid intoxication, where it is impossible to remove the infected tissues b^^ mechanical measures, and complete disinfection with- out such a procedure cannot be effected, the best results are obtained by permanent irrigation with a saturated solution of acetate of aluminum. Under this treatment the soluble toxic substances are washed away as fast as the}'^ are formed, and sterilization of the soil for the putrefactive bacteria is gradually accomplished by the saturation of the dead tissue with this safe and efficient autiseptic solution. If a suppurating cavity is the seat of putrefactive changes, it becomes necessary to remove the nutrient medium for putrefactive bacteria by first washing out the cavity with a strong antiseptic solution, to be followed by the mechanical re- moval of dead tissue, shreds of connective tissue, dead granulations, etc., by means of a sharp spoon or dull curette, and subsequently b}' another antiseptic irrigation. The surgical treatment of saprtemia will soon decide the fate of the patient. If a fatal dose of ptomaines has reached the general circulation before an effort is made to procure sterilization of a local depot of putrefaction the local treatment will, of course, prove unsuccessful in preventing a fatal result, and the disease will continue its relentless course uninfluenced by the treatment. If, however, the in- toxication has not progressed to this extent, efficient local treatment is followed by the most brilliant results. Within a few hours after the sterilization of the local focus of putrefaction the temperature falls to normal, the pulse becomes slower and fuller. If the tongue has been drj'- it soon becomes moist ; if the patient has been delirious consciousness returns, and the patient is convalescent in a few days. The results of the antiseptic local treatment in these cases are the strong contrast with the useless and often dangerous internal administration of antipyretics. The treatment directed toward the disinfection of the local focus of putrefaction removes the cause of the intoxication, while the antipyretics may effect a temporary reduction of the temperature, but at the same timCjb}^ diminishing the contractile power of the heart, onl}^ add to the danger by diminishing the resistance to the action of a depressing poison. The use of antip3'retics in the treatment of saprtemia is strongly contra- indicated. All debilitating treatment must be carefully avoided as being unscientific and as adding to the existing dangers. The best results are obtained by such local treatment by which the further production of ptomaines is prevented, consequentl\' hy measures ivhich meet the etio- logical indications. The debilitating effects of the ptomaines on the heart are met by the timely and judicious administration of stimulants. In urgent cases such diffusible stimulants as sulphuric ether, camphor, and musk can be administered with advantage subcutaneouslj^, in order CLINICAL FORMS OF SEPTICEMIA. 325 to gain time for the action of remedies which will have a more permanent effect on the heart. Digitalis, strophanthus, strychnia, and atropia in small doses are excellent cardiac tonics and stimulants, and are indicated in cases where the pulse is veiy rapid and soft, denoting a feeble peripheral circulation from a weakened heart. Where life is threatened from sjncope the patient is not allowed to assume a sitting postion, for fear that the increased intra-cardiac pressure might result in sudden death from heart-failure. Alcoholic stimulants are to be given in doses sufficiently large to improve the character of the pulse, and at sufficiently- short intervals to maintain this effect without interruption. Brandy or whisk}-, in doses of an ounce ever}' two hours, diluted with water, are most to be relied upon, but champagne, Greek sherr}', or Reich's Tokayer are excellem substitutes. If the stomach is irritable or the S3'mptoms are less urgent, concentrated liquid food, like beef-tea, milk, and eggnogg, must be giA-en at regular intervals to assist the action of stimulants in sustaining the heart's action until sufficient time has been gained for the elimination of the ptomaines. (c) Progressive Septicaemia. — This is the septic infection of modern authors, and differs from septic intoxication in that it is caused not by putrefactive bacteria, but by microbes which enter the circulation from some local septic focus, and which retain their capacity of reproduction in the blood. It is called progressive sepsis, because, only too often, it is not followed by any abatement of the s^^mptoms, as the essential cause has passed beyond the reach of any local treatment, and goes on increasing in the blood until it destroj's the patient. The intoxication in this form of sepsis is not only caused hy p>tomaines ivhich are produced at the primary seat of infection, but ptomaines are also produced in the blood by the microbes which it contains. True pi'ogressive sepsis is caused by the introduction of septic micro-organisms into the tissues, where the}^ multipl}^ and, later, reach the blood, where mural implantation and capillary thrombosis take place, which directl}' interfere with the proper nutrition and function of important organs, and where the septic intoxication is caused b}'^ the formation of ptomaines, both in the blood and living tissues. For this form of sepsis Neelsen has suggested the name of " acute mycosis of the blood," to distinguish it from putrid intoxication, which we have just described, and which Neelsen calls " toxic m3'Cosis of the blood," in which few or no microbes are found in the blood, and in which death is due exclusively to the absorption of preformed toxic substances from a putrefying depot. Causes. — Klebs discovered and described a microbe, the mikrosporon 326 PRINCIPLES OF SURGERY. sepiiciim, which he believed was the specific cause of septic processes, but recent researches seem to prove that the pus-microbes are the most frequent cause of progressive sepsis. Tlie pus-microbes either reach the circulation directly by permeating the vessel-wall, or they enter by a more indirect route, through the lymphatic channels. The latter mode of infection gives rise to the most acute and fatal form of sepsis. In many cases of septic infection the presence of l^nnphangitis can be demonstrated during life, and bj^ examination after death. A few years ago Bergmann advanced the theory that in septicaemia micro-organisms enter the colorless blood-corpuscles, and by multiplication within them cause their dissolution, a process during which the fibrin-generators are elaborated, — an occurrence ending in intra-vascular coagulation and capillar}' embolism. In Koch's septicaemia in mice such a chain of pathological conditions can be readil}^ demonstrated, but in many cases of fatal sepsis in man the microbes found in the blood are few, no de- struction of leucocytes can be shown to have occurred, and extravasations and capilhuy embolism are absent; hence death cannot be attributed to fibrin intoxication. In such instances we can only assume the j^f'ssence of a soluble ptomaine which is diffused throughout the entire body and destroys life by its toxic j^roperties. The formation of pus at the primary seat of infection is not necessary in the causation of septicaemia by pus- microbes. Septic infection is as liable to take place from wounds that do not suppurate as from suppurating wounds, "Why a wound infected with pus-microbes should give rise to progressive sepsis in one individual, and suppuration or suppuration and pyaemia in another, does not admit of a satisfactory explanation at the present time. Rinne has shown that diminution of the absorptive capacit}^ of the tissues at the seat of infection plays an important part in the develop- ment of septic processes. If the pus-microbes are rapidly absorbed, destroyed in the blood, or removed by elimination, septic inflammation is prevented. If, on the other hand, the local conditions are such that the microbes remain in the tissues, and b}- their rapid multiplication produce a large amount of soluble toxines, which, when they reach the blood, not only produce intoxication, but prepare the blood and tissues for the localization and reproduction of the microbes at points distant from the primary seat of the infection, the pathogenic eflect of the microbes on the tissues at the primary seat of infection diminishes their power of resistance, and the microbes either enter the blood-vessels directly or through the l3aiiphatics. Experimental!}' it has been shown that if a large qunntity of pus-microbes is introduced into the peritoneal cavity, or directly into the circulation, death results from sepsis before a sufficient length of time has elapsed for the pus-microbes to produce CLINICAL FORMS OF SEPTICEMIA. 327 the histological changes which are necessary for the production of pus. These experiments are strongly suggestive of the fact that, in man, infec- tion ivith pus-microbes causes jyj'ogressive sejisis, if a large quantity of pus-microbes is introduced into tissues debilitated by a trauma, antecedent pathological conditions, or the action of preformed ptomaines. Under such circumstances the i)us-microl)es are reproduced "with great rapidity at the primar}' focus of infection, enter the circulation before suppu- ration has had time to develop, and produce a complexus of symptoms and a series of pathological changes characteristic of progressive sepsis. Symptoms and Diagnosis. — The most typical clinical picture of progressive sepsis is produced in cases of septic peritonitis, dissection wounds, puerperal septicaemia, and acute multiple osteomyelitis. In septic peritonitis, after laparotomy or penetrating wounds of the abdomen, the septic inflammation, as a rule, develops within the first forty-eight hours, and with it the characteristic symptoms of septicaemia appear. In puerperal sepsis and the gravest form of acute suppurative osteomyelitis, the septic symptoms often overshadow the primary disease to such an extent that this is entireh' overlooked. Dissection wounds often prove fatal from septic infection, which spreads from the wound along the course of the lymphatic vessels, and finally becomes general through the medium of the circulation. Septic infection from an accidental or operative wound can take place within twentj^-four hours, and seldom occurs later than the third or fourth day, unless the infection has taken place after tlie first dressing. Like all other acute infectious processes, septicsemia is ushered in by a more or less pronounced chill, or at least a subjective sensation of chilliness, which may be repeated during the first twent3--four hours. The chill is never so pronounced as in p3-£emia, and does not return with the same regularity and intensitj- as in that affection. The chill announces the termination of the period of incuba- tion, and is promptl}' followed by s3'mptoms of reaction which, in their severity, are proportionate to the intensity and gravity of the attack. One of the most prominent features of the disease is a profound pros- tration, which may be well marked a few hours after the beginning of the attack. If septicaemia follow an operation, or a severe accident, it is sometimes almost impossible to decide whether the pronounced loss of strength should be attributed to shock, the use of an anaesthetic, or the beginning of an attack of septicaemia. One of tlie most delusive s^'mptoms is the utter indiiference of the patient, not only as to his own grave condition, but to all of his surroundings. This apathy is a char- acteristic symptom of profound septic intoxication. The patient com- plains of no pain, assures the physician and friends that he is feeling 328 PRINCIPLES OF SURGERY. well, shows jibsolutel}' no anxiety concerning his own fate, and does not comprehend the anxiety of those aronnd him. Drowsiness, border- ing almost on stupor, is frequently observed. The face presents a pale or ashy-gray color, and in advanced cases it presents a 3'ellowish, icteric tint, but the sclerotica always retains its white color. In the beginning of the attack the pulse ranges between 80 and 90 degrees, but becomes rapid, small, and compressible as the intoxication and capillary obstruc- tion progress. The character of the pulse is of great diagnostic and prognostic importance. If the pulse within a short time reach a fre- quency of 140, and imparts the sensation as though the artery were only half filled with blood, it is a s3^mptom which forebodes immediate danger. The temperature is variable. A subnormal temperature, with a rapid, feeble pulse, indicates a grave and probably fatal form of sepsis. If the temperature is at first only slightly increased, but gradually rises to 103° or 104° F., it denotes progressive sepsis. A high temperature and a firm pulse, not exceeding 120 beats to the minute, are indications of less serious import than a low temperature with a rapid, feeble pulse. The eyes are sunken, often suffused with an abundant secretion from the conjunctiva. The features present a stolid appeai'ance, without any expression of intelligence. Capillary oozing at the primary seat of infection is a common occurrence, and capillar}^ haemorrhage underneath the skin and visible mucous membranes is frequently observed. Vom- iting and diarrhoea are often present from the beginning, and in rapidly fatal cases remain as persistent symptoms, in spite of measures that may be employed to subdue them. The discharges from the bowels are often stained with blood. The urine, as a rule, is scanty and loaded with urates. Billroth places great importance upon the appearance of the tongue. The tongue is always coated ; in grave cases it is pointed at the tip, its margins are red, while the dorsal surface is dry and covered with a dry, often almost black, crust. Return of moisture is always a favorable omen. Great thirst and complete loss of appetite are always present. Delirium is a frequent, but not a constant, symptom. If the case progress to a fatal termination, the pulse becomes more and more frequent, respira- tions become shallow and labored, the face presents a cj'anotic hue, the surface is bathed with a clammy perspiration, the extremities become cold, and death finally is caused from heart-failure. In the differential diagnosis it is important to remember fermentation fever, septic intoxi- cation, typhoid fever, internal sepsis, and acute multiple suppurntive osteomyelitis. Progressive septicaemia always has a stage of incubation ; that is, a certain length of time intervenes between the time infection occurred and the appearance of the disease. This period of incubation CLINICAL FORMS OF SEPTICEMIA. 329 may terminate at the end of a few hours and it may be prolonged to four days, according to the number of pus-microbes introduced and the anatomical structure and pli3^siological properties of the tissues primarily infected. Fermentation fever follows an injury or operation within a few hours, and never occurs after the expiration of twenty-four hours. In fermentation fever the maximum symptoms appear at once, and the force of the pulse and strength of the patient remain unimpaired. Fermenta- tion fever seldom lasts for more than one or two days, while in progres- sive sepsis the s3'mptoms become aggravated as the infection increases. In putrid intoxication the maximum symptoms are pi'oduced b}' the in- troduction into the blood of preformed soluble toxic substances from a depot of putrefaction. Evidences of putrefaction in an}' part of the bod}^ would speak in favor of septic intoxication, while, if septic infec- tion exist at the same time, it must be regarded not in the light of a cause, but as a complication. Typhoid fever is preceded by a well- marked prodromal stage which is absent in septic infection. The erup- tion in t^'phoid fever is characteristic, while the eruption which is sometimes seen in progressive sepsis closely resembles the rash of scar- latina, and is caused by the presence of pus-microbes in the superficial lymphatic vessels. Internal sepsis is usually preceded by a septic phar- yngitis, and frequently attended by ulcerative endocarditis. Acute mul- tiple osteomj-elitis, the cause of fatal septic infection, can be recognized b}' searching for points of tenderness in the localities attacked most fre- quently b}' this disease. The final diagnosis of septic infection must be based upon the existence of an infection-atrium, through which pus- microbes have entered the tissues, and from which the}^ have reached the general circulation. Prognosis. — The prognosis of progressive septicemia is always grave. In cases where pus-microbes exist in large numbers at the pri- mary seat of infection, and reach the general circuhition with great rapidity^, and meet with conditions favorable for their reproduction, death is inevitable in spite of the most energetic local and general treat- ment. The prognosis is more favorable if infection has taken place from a localit}' amenable to thorough local disinfection, if this is practiced upon the first appearance of S3'mptoms, as this treatment prevents fur- ther ingress of pus-microbes into the circulation. The existence of mul- tiple points of metastatic inflammation renders a recover}- improbable. Delirium, rapid and feeble pulse, subnormal temperature, dry tongue, persistent vomiting and diarrhoea are all unfavorable symptoms from a prognostic stand-point. Capillary haemorrhages distant from the primary infection-atrium are infallible indications of progressive sepsis, and their existence warrants a most unfavorable prognosis. Progressive 330 PRINCIPLES OF SURGERY. sepsis ma}' cause death in twelve hours, and in fatal cases life is seldom prolonged for more than one week. Pathology and Morbid Anatomy. — In rapidly-fatal cases of progres- sive septic infection, tlie absence of gross macroscopical pathological changes is a characteristic feature of this disease. In such instances even the most careful search for tangible lesions will result negatively. Cloudy swelling of the parenchyma of internal organs indicates the existence of coagulation necrosis, caused by the action of the ptomaines of the pus-microbes. Pus-microbes have been frequently found in septic blood. IliTeniorrhagic extravasations into organs, and more par- ticularly underneath serous and mucous membranes and the skin, are frequently present. The blood presents almost a black color, and shows little or no tendency to coagulate. The lymphatics interposed between the primary seat of infection and the blood-vessels are frequently found in a state of septic inflammation. The wound through which infection has taken place may present but slight or no gross anatomical changes. The spleen is enlarged and the pulpa softened to the consistency^ of a blood-clot. Thrombosis and embolism are absent. Under the micro- scope the capillary vessels everywhere present all the evidences of a septic inflammation. The soluble ptomaines in the blood produce coagu- lation necrosis of the intima, which determines mural implantation of the pus-microbes and the colorless corpuscles and results in capillary hy[)er8emia and congestion. In some places alteration of the capillary wall has taken place to such an extent as to give rise to rhexis. The most important microscopical changes in the tissues and organs, in patients who have died of sepsis, are the pathological conditions within and in the immediate vicinity of capillar}' vessels that indicate the exist- ence of multiple foci of metastatic inflammation, which characterize clinicall}' and putliologically progressive sepsis. If life is prolonged for a suflicient length of time, these foci become the centre of a suppura- tive inflammation. Slight eff"usions into tlie large serous cavities are frequentl}^ found. Treatment. — The antiseptic measures which have been described in the treatment of wounds are the best and only known means of effective prophylaxis against septic infection. Any method or methods of treat- ment which can be relied upon in the prevention of suppuration will be found efficient in preventing septic infection. As retention of wound-secretion is one of the important etiological conditions in the causation of septic infection in Avounds that are not completel}' aseptic, drainage should be employed in all cases where an accuuiuhition of the primary wound-secretion is to be feared. As septic infection is just as liable to occur through a small as a large wound, the most insignificant CLINICAL FORMS OF SEPTICEMIA. 331 injuiy should be treated upon the strictest aud most pedantic antiseptic precautions. If, in spite of the greatest care, s3'mptoms of septic infection appear after an injury or operation, no time should be lost by the useless administration of antipj'retics, in the vain hope that by reducing the temperature the condition of the patient will be improved, but the first and essential object of treatment should be to remove the cause of the fever by resorting to secondary disinfection. All sutures must be removed and ever}- portion of the wound rendered accessible to local treatment. Extravasated blood and necrosed shreds of tissue must be removed, wlien the wound is to be irrigated with a 1-to-lOOO solu- tion of corrosive sublimate, after which it is dried and the whole surface brushed with a 10-per-cent. solution of chloride of zinc. After another irrigation and after drying the surface again, a thin film of iodoform is applied, and then the wound is tamponed with iodoform gauze and dressed antiseptically. Such a wound should never be re-sutured until tlie local and general s3'mptoms indicate that it has been rendered completeh' aseptic. If this secondary disinfection prove unsuccessful, recourse should be had to permanent irrigation with a saturated solution of acetate of aluminum. Secondary disinfection of the peritoneal cavity, in cases of septic peritonitis after laparotom}^, has so far not proved ver3" satisfactory^ but as it is the onl}^ recourse in dealing with such desperate cases, that without it would surely run a fatal course in a short time, it should never be neglected. A number of the sutures near the lower angle of the wound are removed Avitli blunt instruments, the margins of the wound are separated, and the abdominal cavity is flushed with warm salicylated water until the fluid returns perfectly clear. The end of the rubber tube attached to the irrigator must be inserted in such a manner that the stream will reach the most depend- ent portions of the abdominal cavity ; hence it is inserted into the deep- est portion of the pelvis, and when this portion of the abdominal cavity has been thoroughly washed out the lumbar regions are dealt with in a similar manner. After the irrigation has been completed, the patient is turned upon the face, so as to permit the escape of fluid b}- gravita- tion. A large glass drain is then inserted and its opening closed with salicylated cotton, after which the antiseptic di'essing is applied in such a manner that the end of the tube remains accessible to the removal of fluid 1)3' aspiration as often as circumstances ma3' require. In progres- sive sepsis, following in the course of progressive gangrene of a limb, amputation will become necessar3' if secondar3' disinfection and perma- nent irrigation have proved of no avail in arresting the septic infection. Tlie general treatment of septic infection is the same as has been advised in cases of septic intoxication. CHAPTER XIII. Pyemia. Pyemia, or pj'ohaemia, is a general disease caused by tlie entrance into the circulation of pus or some of its component parts, characterized by recurring chills, an intermittent form of fever, and the occurrence of metastatic abscesses. Although this disease .was known a long time before Piorr}' applied to it the name it still bears, its intimate relation- ship to suppurative processes was first pointed out by this surgeon. Piorr}' maintained that, as the name implies, pj^ffimia is caused b}' the entrance of pus into the blood. A^irchow, on the other hand, contended that no pus is found in the blood of pyaemic patients, and that the sec- ondary or metastatic abscesses are not true abscesses resulting from the accumulation of pus derived from the blood, but that the}' are the result of embolic processes, puriform softening, inflammation, and suppuration around the blocked vessel. Recent bacteriological investigations have shown that Piorry's views are so far correct in that pus is produced within blood-vessels by the entrance of pus-microbes into the circula- tion. As a wound complication pyaemia can only occur after suppura- tion has taken place in a wound, and, as a complication of non-traumatic lesions, it can only develop in the course of suppurative affections. The great prevalence of pj-femia in overcrowded and badly-ventilated hos- pitals, during the time before the antiseptic treatment of wounds came into use, gave rise to a general belief that the disease was due to a spe- cific cause, and ever since bacteriology became a science diligent search has been made to discover the specific microbe. Since the discovery of the microbes of suppuration, new light has been shed upon the etiolog}^ and pathology of this disease. Bacteriological examinations of pysemic products have shown that one or more kinds of pus-microbes are always present, thus establishing the direct relationship which exists between a suppurating process in some part of the body and the development of metastatic or pyoemic abscesses. Clinical experience has only corrobo- rated the scientific investigations of this subject, inasmuch as it has shown that the frequency of pyaemia has been diminished in proportion to the lesser frequency of suppurative inflammation under the antiseptic treatment of wounds and suppurating lesions. We are justified, upon the basis of well-established facts, in claiming that pyaemia is uot a ■ (333) 334 PRINCIPLES OF SURGERY. disease per se, but that its occnrrence depends upon an extension of a suppurative process from the primary seat of infection, and suppuration in distant organs by the transportation of emboli infected with pus- microbes through the systemic circulation. The distant, or metastatic, abscesses contain the same microbes which are found in tlie wound- secretions, or in the abscess from which the general purulent infection took place. Experiments have shown that a culture of pus-microbes from a furuncle ma}' produce pyjEmia in animals, and that the microbes cultivated from a pj^aemic abscess, when injected under the skin of an ani- mal, may cause onl}^ a localized suppurative inflammation without any general symptoms. BACTERIOLOGICAL AND EXPERIMENTAL RESEARCHES. While the direct relationship existing between suppuration and py- femia was well understood clinically for a long time, it was left for Klebs to demonstrate for the first time the direct connection of the p3'3emic processes with the presence of specific microbes. In his researches into the nature of this disease during the Franco-Prussian war in 1870, he discovered in the pyoemic products certain micro-organisms which he called micrococci of pyaemia. He found that these microbes alwa3-s arranged themselves in the form of colonies or groups which he termed zoogJcea. He found this microbe invariably' present, notably at the pri- mary seat of infection, but also in the most distant organs, — wherever, indeed, pathological changes occurred during the course of the disease. Pasteur, in studying the puerperal form of pj'semia, discovered a chain coccus which undoubtedly was identical with the streptococcus pyogenes, but which he called microbe enchapelet. Hueter and Yogt found a micro-organism in pysemic products which they include among the mo- nads. Burdon-Sanderson supposed that he had discovered the essential microbic cause of pyaemia in the shape of a " dumb-bell shaped germ,'''' which in all probability was a staphylococcus. SchuUer examined the contents of metastatic joint aflTections in 12 cases of puerperal pyaemia, and invariably found pus-microbes. Rosen- bach investigated 6 cases of typical pyaemia with a view to determine the nature of the microbes present in the p3^8emic pi'oducts. He found t lie streptococcus p3'ogenes present in the blood, and metastatic deposits in 5 of them; in 2 of these cases staph^dococci were also present, although fewer in number. In only 1 of them he found staphylococci alone, and this case recovered. Pawlowsky made a bacteriological ex- amination of the pus of metastatic abscesses in 5 cases of pj'aemia. In 4 cases he found the staphjdococcus pyogenes aureus, and in the fifth case, which was remarkable for the extent of the joint complications, he BACTERIOLOGICAL AND EXPERIMENTAL RESEARCHES. 335 found the streptococcus pyogenes. He believes that the staphj^ococcus P3'ogenes aureus is the usual cause of pyaemia, and especially of that form characterized by multiple abscesses in the internal organs. Large cultures of this coccus suspended in water and injected subcutaneousl}- in rabbits caused death, and at the necropsy multiple abscesses were found. He maintains that pj-amia in man occurs when disturbances in the circulation are present, so that floating cocci find favorable points for localization within the blood-vessels. He created such disturbances artificially in animals by making intra-venous injections of cinnabar, with the result that the glandular material determined localization of the microbes which were introduced into the circulation. Besser examined bacteriologicallj' blood, pus, and parenchymatous fluid from organs in 23 cases of pyaemia. In 8 cases the staphylococci albi and aurei were found ; in 14, streptococci ; and in I, streptococci and staphylococci simultaneouslj'. The microbes were discovei'ed during the patient's life in pus in ever}' one of 20 cases examiaed ; in blood, in II of 12; and in parenchymatous serum, in 1. After death, in pus, in 17 of 17 ; in blood, 4 of 9 ; and in organs, 9 of 14. Besser's predecessors described 23 additional cases of p^'femia, in 14 of which staphylococci Tvere found ; in 7, streptococci. Total, 46 cases : in 22, staphylococci ; in 21, streptococci ; in 3. both. Besser was unable to detect the slightest morphological or pathogenic difference between the microbes of suppu- ration and those of P3'ffimia. Okinschitz made the relationship which exists between tlie pus- microbes and p^ysemia the subject of bacteriological investigation. He found that pysemic blood invariabl}' contained either the streptococcus pyogenes or the staphylococcus pyogenes aureus, demonstrated b}^ cultivation and ordinarj^ microscopical examination. As the hseraic microbes seldom showanj^ signs of fission, as compared with the bacteria at the primar}' focus, it is reasonable to infer that reproduction takes place mainl}' in the pus, and not in the blood ; hence the great impor- tance of thorough disinfection and destruction of primary foci. The number of microbes in the circulating blood bears a direct relation to the gravity of the disease. If they are abundant, even in the absence of metastases in internal organs, the prognosis is grave, and if scant}', even if metastatic foci are present, the prospects of a favorable termi- nation are better. Pyaemia in Rabbits. — Koch produced pyaemia artificial!}' in rabbits by injecting putrid fiuids. A piece of a mouse's skin, about a square centimetre in size, was macerated for two days in 30 grammes of dis- tilled water, and a syringeful of this fluid was injected subcutaneously into the back of a rabbit. Two days the animal remained apparently 336 PRINCIPLES OF SURGERY. A— - iu well, then it began to eat less, became gradually weaker, and died one hundred and five hours after the injection. An extensive subcutaneous abscess was found at the seat of injection. In the abdominal wall the yellowish infiltration extended in parts through the muscles and even to the peritoneum. The peritoneal surface presented evidences of inflam- mation. The intestines were adherent, and the peritoneal cavity con- tained a small quantity of turbid fluid. The liver showed on sectic^n gray, wedge-shaped patches. In the lungs infarcts the size of a pea were found. A syringeful of blood taken from the heart of this animal was now injected un- der the skin of the back of a second rabbit. The second animal died in forty hours, and at the necrops}- nearly the same pathological con- ditions were found, only that the peritonitis was less advanced. Further experiments showed that y^ drop of p3'aemic blood proved fatal in rabbits in one hundred and twent_y-five hours. All subsequent experiments proved that the less the quantity of blood injected the longer the time which elapsed before death occurred, but where the quantity was reduced to the one-thousandth part of a drop no result followed. On microscopic examination cocci were found in great numbers everywhere throughout the body, and more especially in the parts which had undergone alterations visible to the naked e3^e. The description of the microbe found cor- responds with the staph3dococcus. The rela- tion of the microbes to the blood-vessels could be seen best in the renal capillaries (Fig. 78). In the interior of the vessel, at C, is a dense deposit of micrococci adherent to the wall, and inclosing in its substance a number of red blood-corpuscles. '^J'lie capillary stasis is either due to the power of the microbes of causing the red blood- corpuscles, to which the}' adhere, to stick together, or their propert^^ of pro- ducing in their immediate vicinity coagulation of the blood, and thus cause thrombosis. The microbes were found so arranged that the}^ inclosed red blood-corpuscles in the capillary vessels of all the organs examined, Fig. 78.— Vessel fkom the Cortex of the Kidney OF A Pyemic Rabbit. X 700. (Koch.)* A, nuclei of the vascular wall ; B, small group of micrococci between blood- corpuscles ; C, dense masses of micro- cocci adherent to the wall and inclosing blood-corpuscles; D, pairs of micrococci at the border of the large mass. * Copied from "Traumatic Infective Diseases," by permission of the New Sydenham Society, London. BACTERTOLOGICAL AND EXPERIMENTAL RESEARCHES. 837 as, for example, in the spleen and in the lungs. Koch believes that the large metastatic deposits in the liver and in the lungs do not arise by gradual growth of a mass of micrococci, as in Fig 78, but by the arrest of large groups and of the clots associated with them; in other words, by true embolism. In the metastatic deposits an extensive development of micrococci occurs, and these are not confined to the vessels, but invade the neighboring tissues. In the peritoneal cavity the micrococci were not found in large masses, but isolated, in pairs or in small groups. In the vicinity of the abscess he detected the microbes in the walls of veins, and their passage through these into tlie interior of the vessels could be readil}^ discerned in many places. As Koch has j^ointed out, the microbe of pyaemia in rabbits, which is a pus-microbe, when brought in contact with tlie red blood-corpuscles, increases their viscosity and the}' form larger or small coagula in the blood. The}' can thus no longer pass through the minute capillar}' net-work, but are arrested in the smaller vessels. From the point of infection fresh micrococci pass constantly into the blood, and also individual micrococci will become detached from these small thrombi and emboli, and mix with the blood- stream. As the microbes are constantly beiug deposited by mural im- plantation, their number in the circulating blood always remains relatively small. Klein described a micrococcus of pyaemia in mice. Certain cocci which were present in pork proved fatal to mice in about a week, producing both purulent inflammation at the point of injection and metastatic abscesses in the lungs. Inoculations in the same species of animal w ith pysemic products reproduced the disease in a typical manner. PawloAvsky found that by simultaneous injection of sterilized cinnabar, and of cultivation of staphylococcus pyogenes aureus into the circula- tion, he produced abscesses in various organs — in fact, the typical picture of pyaemia. The presence of particles of foreign bodies rendered material aid in the development of metastatic abscesses, as the mere arrest of pus-microbes in the circulation without them, as a rule, was not found sufficient of itself to lead to the production of true pyaemia. In rabbits, even, the introduction of a large quantity of a culture of pus-microbes into the circulation did not produce pyaemia. Twenty-four hours after the injection he found the microbes in large numbers in the pulmonar}' and other capillaries, but after forty-eight hours they had all disappeared from the blood. If the cocci are incorporated in, or are attached to, an embolus, this latter, by producing alterations in the endothelia of the blood-vessels at the point of impaction, create a locus viinoria residt'ntise favorable to the growth of the microbes. In the experiments of Pawlowsky, the particles of cinnabar acted upon the 338 tKINCIPLES OF SURGERY. endothelial lining of the capillary vessels in the same mannei' as the fragments of a thrombus, hy impairing the local nutrition of the tissues with which they were brought in contact. ETIOLOGY. If p3'aBmia can be artificially produced in rabbits, mice, and guinea- pigs with pus, or with a pure cultivation of the same with or without the presence of foreign bodies, the same local conditions are first pro- duced at the point of inoculation which invariably precede the develop- ment of pyaemia in man. Some of the veins at the seat of primar}- in- fection are invaded by pus-microbes, and become blocked by a thrombus ; this thrombus undergoes puriform softening; small fragments containing pus-microbes become detached and are washed awa}^ and enter the general circulation as emboli, which, when they become arrested, establish independent centres of suppuration. In such cases the same microbes can be found in the wound, in the blood, in the tissues around the abscess, and in all distant pyaemic products. Although the strep- tococcus pyogenes has been found most frequently in the pus at the primary seat of infection and in the metastatic abscesses of pysemic patients, there can be but little doubt that any of the pus-microbes, when present in sufficient quantity in the blood, can produce the disease. The occurrence of pyaemia from suppurating wounds or abscesses does not depend so much upon the kind of pus-microbes xohich have caused the primary suppuration as upon surrounding circumstances. The location and anatomical structure of the tissues, in which the jjrimary infection has taken place, exert an imp)ortant influence in the production of the disease. It is an exceedingly familiar clinical fact that suppurative inflamma- tion of the medullary tissue in bone is frequently the cause of p3'8emia. Acute suppurative osteom3^elitis, without direct infection through a wound, is always due to intra-vascular infection — localization of pus- microbes in the capillary vessels of the medullary tissue. The microbes come first in contact with the endothelial cells when mural implantation has taken place, and the coagulation necrosis which follows leads to thrombosis. The products of the intra-vascular coagulation necrosis furnish a most fiivorable nutrient substance for the growth and multipli- cation of the pus-microbes; consequently the area of intra-vascular in- fection is rapidly increased. The growth of the tlirombus in a proximal direction soon leads to extensive thrombo-phlebitis, and, as softening of the thrombus takes place, to embolism and metastatic suppuration. Pyaemia following a suppurative inflammation in a wound, or in the course of a phlegmonous inflammation of the connective tissue, is the ETIOLOGY. 339 i'esult of :ui intection willi pus-microbes which penetrate the veins from without. The pus-microbes, coming first in contact with the outer coats of the veins, give rise to phlebitis, which progresses from w'ithout in- ward, and which is foUowed b}' thrombosis as soon as the intima is reached. The intra- vase uhir dissemination of the pus-microbes then lalies place in the same manner as in cases of primary tlirombo-phlebitis. Ordinary jyyogenic microbes may and do cause pysemia, if they enter the blood incorporated in, or attached to^ fragments of an infected blood-clot, or other solid materials, which, after they have become impacted in blood- vessels as emboli, prepare the soil in distant organs for their localization and reproduction. The importance of thrombosis and embolism, as essential factors in the causation of pyemia, has been clearly established b}^ clinical obser- vation and experimental research. Emboli niaj' originate in the lym- phatic vessels when these are the seat of invasion b}^ pyogenic microbes, which, however, is very seldom the case. In chronic pj'aemia, in wdiicli multiple metastatic abscesses are formed, embolism takes no essential part in the process ; the microbes enter the blood-current without such a vehicle, and are brought in direct contact by mural implantation with the interior lining of vessels weakened by injur}', or other local and general debilitating influences. Experimental research has shown con- clusivelj^ that the mere introduction of pus-microbes into the circulation is not necessarily, or even usuall}', followed by pygemia, and their acci- dental entrance in the course of a suppurative inflammation is not alwaj's followed by serious consequences. There can be no doubt that some pus- microbes reach the circulation in nearly every case of suppuration, but their pathogenic action is prevented, or neutralized, by an adequate resist- ance on the part of the tissues with which they are brought in contact and their rapid elimination through healthy excretory organs. A limited nnmber of pus-microbes injected into the circulation of a health}' animal, or accidentalh- introduced into the blood of an otherwise health}' person. are effectively disposed of by the white blood-corpuscles. If, however, the same number of microbes are present in combination with fragments of a blood-clot, the infected foreign particles produce such nutritive changes in the tissues surrounding them as to transform them into a favorable soil for the pathogenic action of the microbes. The same happens if free pus-microbes localize in a part the vitality of which has been previously diminished by trauma, or antecedent pathological changes, which constitute a locus minoris resistentise for the growth and multiplication of the pus-microbes. Pya?mia, therefore, must be looked upon rather as a serious and fatal complication of suppurative lesions than an independent specific disease. The immediate causes of pyaemia 340 PRINCIPLES OF SURGERY. are the formation of au infected thrombus at the primary seat of infec- tion and disintegration of this tlirombus to such an extent that frag- ments become detached and are conveyed by the blood-current to distant organs, where tliey are arrested in the smaller arteries as emboli. Thrombosis. — A thrombus is an intra-vascular blood-clot locally formed within the heart or a blood-vessel, and the process by which it is formed is called " thrombosis." A thrombus is called uenous if it occur in a vein, arterial if it form in an artery. A red thrombus is produced if the blood coagulate in its entirety, while a white thrombus is com- posed of fibrin exclusivel}' or the fibrin and the colorless and third cor- puscles of the blood. A mural thrombus is a thrombus w'hich is attached to the inner surface of a vessel-wall without occluding the entire lumen of the vessel. Notwithstanding the numerous and ingenious experi- ments which have been made for the purpose of ascertaining the imme- diate cause of intra-vascular coagulation of the blood, this subject awaits a more satis factor}' explanation than can be given at the present time. Richardson, Bruecke, and Lister have shown that the mere mechanical interruption to the flow of blood in a vessel is not a sufficient cause of coagulation. Blood has been kept in a fluid condition in a vessel between two ligatures for au indefinite period of time in the living- tissues. Yirchow, Cohnheim, Baumgarten, and Zahn maintain that the color- less corpuscles are in the closest manner related to thrombus formation. Zahii, from observations on the living mesentery- of the frog, found that when the wall of a vessel was injured the colorless corpuscles accumu- late around the injured part, constituting what he calls a white throm- bus. The corpuscles subsequently, in great part, disintegrate and give rise to a granular accumulation, which, by its action upon the fibrinogen of the blood, causes a precipitation of fibrin. Since the discovery of the third corpuscle, or heematoblast^ by Hayem and Bizzozero, the part taken by this element of the blood in the process of coagulation has been carefully studied by Eberth and Schimmelbusch. The third corpuscle possesses a peculiar property to adhere to an}' foreign bodj' or irregularit}' of surface of the intima of the blood-vessels. The authors just quoted found that when a vessel is injured, as by t3'ing a ligature around it and removing this in a quarter of an hour afterward, these minute blood-disks manifest a peculiar ten- dency to adhere to the injured part of the tunica intiuia and to each other, forming a white mural thrombus. The process by which mural implantation of the third corpuscle takes place these authors call conglu- tination^ the mass thus formed being composed primarily and exclusivel}' of this morphological element of the blood. If an aseptic thread is ETIOLOGY. 341 drawn across the lumen of a vessel in which the blood-current is moving, the third corpuscle is arrested in its course and becomes deposited upon the tliread, which in time becomes the centre of a white thrombus. Con- glutination, under sucli circumstances, is a purely mechanical process. Eberth and Schimmelbusch demonstrated by their experiments that conglutination is most liable to occur where irregularities of the tunica intima are present. If b}' a trauma inflammatorj^ or degenerative changes take place, the endothelial lining of a blood-vessel is rendered rough and uneven ; conglutination takes place first at the points which project farthest into the lumen of the vessel, because here the projecting bodj- encroaches upon the axial current, which conve3'S the third cor- puscle. In thrombosis from pathological causes, mural implantation of the third corpuscle takes place upon an intima roughened by inflamma- tory- or degenerative changes. Thrombus formation^ as we observe it in jyyaenna^ always lakes place upon a vessel-wall altered by the action of pus- microbes. The form of thrombosis intimately- associated with the etiology and pathological anatomy of pyiemia occurs in a vein within or in close proximity to the primary suppurative lesion. The close relationship of phlebitis to pya?mia was well understood by John Hunter, who believed that the former always preceded the latter. He taught that the phlebitis resulted in intra-venous production of pus and the formation of metas- tatic abscesses. Cruveilhier. on the other hand, regarded thrombosis as the first link in the chain of pathological conditions in pyaemia. The idea of primary thrombosis as a cause of disease was carried b}- his pupils so far that nearly all inflammatory processes were by them attrib- uted to thrombotic changes in small veins ; not only inflammatory lesions, but even tumors were supposed to originate in this manner. A new as- pect was given to the pathology of this disease b}' the careful experi- mental investigations of Virchow on thrombosis and embolism. He showed that the metastatic deposits always occurred at points where vessels had been blocked by an embolus derived from a disintegrating thrombus. In the light of recent research phlebitis precedes thrombus formation at the primary- seat of the infection. The pus-microbes which are present in the infected tissues permeate the vein-wall, and induce inflam- matorj- changes characteristic of this form of infection. As soon as the infection has reached the intima this structure is roughened, and upon the projecting points conglutination takes place, and the foundation for thrombus is laid by a pavement composed of the third corpuscles of the blood. Upon this surface aggregation of the colorless corpuscles takes place, and, as these structures undergo coagulation necrosis, fibrin is formed and a mural thrombus is established. The pus-microbes, which have reached the interior of the vein through 342 PRINCIPLES OF SURGERY. the inflamed vein-wall, multipl}- in the tliroml)us, and produce here, as elsewhere under similar favorable circumstances, their specific patho- genic eflect. The thrombus thus formed is an infected thrombus which precludes the possibility of its removal l)y absorption. With an in- crease of the intra-veuous infection coagulation is hastened, and a red thrombus soon fills the entire lumen of the vein, surrounded by a zone composed exclusively of blood-disks, colorless corpuscles, and fibrin, which compose its mural portion. As soon as the lumen of the vein has been completely obstructed the conditions for coagulation are improved, and the thrombus increases in size in both directions. The contact of ■■■■■-■.■. ^v.'--:- '\y-^:^^m!'Mm Fig. 79.— Lamixated Thkombtts ijt a Vein. The Dark Granular Lay- ers ARE Composed of Colorless Blood-corpuscles and Fibrin : the Central. Lighter Portion, of Red Corpuscles. 1:97. {Birch- Hirschfeld. ) the blood with the dead, infected thrombus results in coagulation, and in this manner layer after layer is added to the thrombus. If thrombus formation take place in advance of the primary phlebitis, inflammation of the vein-wall follows as an inevitable consequence from the presence of the infected thrombus, the inflammatory process spreading like the infection from within outward. The growth of a thrombus is seldom arrested in a central direction until some large vein-trunk is reached, into which the apex of the thrombus projects. The blood-current in a vein into which the apex of a thrombus from an adjacent vein projects frequently arrests its proximal extension, but ETIOLOGY. 343 if the venous circulation is impeded, or tlie tlirombus continues to grow by the addition of new laj-ers, in spite of the obstacles presented, one portion after another of a vein becomes involved, and the thrombus rapidlj' increases in length in a proximal direction. A venous thrombus in a pjaemic patient is only loosely attached to the vein-wall, as the pus-microbes transform the white corpuscles, which remain after coagu- lation has occurred, into pus-corpuscles, and in this manner softening and disintegration of the thrombus are accomplished. If a thrombus, at the point where it is in contact with the venous circulation on the proxi- mal side, become sufficiently softened, fragments become detached and are carried awa}' by the venous current as emboli. Embolism. — An embolus is a detached thrombus, part of a thrombus^ or any foreign substance transported by the arterial blood-current to its place of impaction. The process or act by ichich this is accomplished is called embolism. An aseptic embolus produces disturbances at the seat of impaction, which result exclusivel)^ from the sudden interruption of the blood-supply to the tissues fed b}' the obstructed vessel. The effect on the tis- sues is the same as though the vessel had been tied with an aseptic ligature. Yirchow found that aseptic caoutchouc emboli, introduced into the right side of the circulation through the jugular vein, produced no serious trouble after their impaction in the branches of the pulmonary artery. Pauum ascertained, b3' his experiments, that small, simple emboli in the pulmonar}' arter}^ become encysted. The emboli of foetal cartilage which Maas introduced into the jugular vein in dogs did no damage to the pulmonar}' tissue, and not onl}- retained their vitalit\" but became the nucleus of a temporary' tumor. An aseptic embolus, derived from plastic intra- vascular exudations or an aseptic thrombus, affects the tissues at the seat of impaction in the same manner as the aseptic substances which have been used to produce embolism artificially in animals. An embolus consisting of a fragment of ayi infected thrombus, as is the case in jnjsemia, is a culture medium which contains the same microbes as caused the primary infection, and which at the seat of impaction estab- lishes an independent centre of infection, which etiologically and patho- logically is identical with the primary invasion. The embolic origin of metastatic abscesses was first pointed out by Yirchow, who, at the same time, showed that the emboli are always Fig. 80.— Thrombo- phlebitis. i-Hillrotli.) A, central end of venous thrombus projecting into a larger vein-trunk ; B, vein- branch not closed by a thrombus. 844 PRINCIPLES OK SURGERY. derived Iroin venous thiouibi undergoing puriform softening. Tlie closure of :i vessel b}- tlirombosis is always a slow, gradual process, while the obliteration of an artery by an embolus is the work of a moment. The gradual closure of a vessel by the slow growth of a thrombus is not attended by tlie same degree of disturbance of nutrition as wlien a vessel of similar size is suddenly blocl^ed by tlie impaction of an embolus. Septic thrombo-pldebitis does not lead at once to eml)olism, as new layers are constantly being added to tlie proximal end of the thrombus, from where the fragments which constitute the emboli are always derived. Embolism only occurs if the proximal end of the thrombus has become sufficiently softened that fragments separate spon- taneousl}^ and enter the venous circulation, or if the fragments are washed away by the venous current from a projecting thrombus. As the infected thrombus is always located in a vein within, or in close proximity to, the seat of primary infection, the detached fragments or emboli reach the right side of the heart with the venous blood, and, as the}'' are usually too large to pass through the pulmonary capillaries, they become impacted in the branches of the pulmonary arter3\ The lung acts as a filter^ and is therefore the most frequent seat of embolism and metastatic abscesses. The circulatory disturbances at the seat of impaction give rise to pathological conditions which are characteristic of embolism, and can be readily recognized in the examination of organs after death. The area of tissue affected by the sudden closure of a vessel by the impaction of an embolus is called an infarct, and the process which produced the pathological changes infarction. Infarcts are abvays wedge-shaped, the apex of the triangle corresponding to the location of the embolus, and the base to the tiltiinate branches of the obliterated, vessel. Cohnheim has described what he calls a terminal arterj^, by which is meant one whose branches inosculate onl}^ with those of the corre- sponding vein, one which is devoid of collateral anastomosis. Such are the renal and splenic arteries, and, in a less complete manner, those of the brain^heart, stomach, and lungs. If a terminal arter}^ in the kidney or spleen is obstructed collateral circulation cannot be established, and necrosis of the tissues whi(;h depend on the closed artery for their blood- suppl}' is an inevitable consequence. The same result follows embolism of a terminal arter}' in the spleen. In the other organs which have been enumerated the terminal arrangement of the arteries is not as absolute, and embolism is not followed by necrosis with the same degree of certainty, as circulation cannot be restored, under favorable circum- stances, by collateral branches. The first effect of the closure of an artery, by an embolus in an}' of these organs, is the appearance of a wedge-shaped area of ischtemia, which in size corresponds to the size of ETIOLOGY. 345 the vessel obstructed. It may be so sninll that it can hardly be detected by the naked eye, or the base of tlie wedge may be 1^ inches in length. The border of this wedge-shaped space becomes the seat of active hyper- semia, the surrounding vessels undergoing rapid dilatation. The liyper- a^mia is usually so intense that rhexis takes i)lace and the parts become infiltrated with blood ; hence the expression h senior rhagic infarct. Hamilton is of the opinion that the hasmorrhagic infarcts in the lung- are not caused by embolism, but by rupture of small vessels and haemor- rhage into the alveoli, the distribution of the fine branches of the bronchi determining the shape of the infarct. Although the ultimate branches of the pulmonary artery cannot be called terminal arteries, in the strictest sense implied by this term, if the}' become suddenly blocked by an embolus, collateral hypersemia is so intense that haemorrhage into the Fig. 81.— Embolus of Branch of Pulmonary Artery. Hjemorrhagic Infarction OF Alveoli. Chromic-Acid Specimen. 1:1()0. (Birch- Hirschfeld.) parenchyma of the organ frequently takes place, — a condition well represented in Fig. 81. In Imemorrhagic infarcts of the lung resulting from embolism the tissues involved are firmer than normal, and, on section, present pneu- matic appearances, which are due to infiltration with leucocytes and extravasation of blood, as well as transudation of blood-plasma through the walls of the liypera?mie blood-vessels surrounding the iscluvmic area. As the einl)oli usuall}' lodge in the peripheral branches of the pulmonary artery, the infarcts are most frequently located near the surface of the lung. Immediately after embolism has occurred the district supplied by the obstructed vessel presents an aniemic appearance, which soon gives place to a reddish color, resulting from the haemorrhagic infiltration. As in p3-aemia the embolus conveys from the primary seat of infection the 346 PRINCIPLES OF SURGERY. specific microbes of suppuration, it becomes the centre of a suppurative inflammation. The pus-microbes multiply' in their new location and at once induce a suppuratiA^e arteritis, and, after their passage through the inflamed vessel-wall, the}' attack the histological elements contained in Fig 82.— I'Y^Mic Abscess of Lung. X 350. {Hamilton.) A, walls of alveoli ; B, effused, small, round cells ; C, fibrin lying in alveolar spaces ; D, cell entangled in meshes of same; E. E. E, masses of micrococcus (staphylococcus) lying in exudation. the exudation, which breaks down, becomes purulent, and is converted into an abscess. In the lung the leucocytes which are present in the infarct are converted into pus-corpuscles, and the interstitial connective tissue undergoes necrosis and can be found as detached shreds in the abscess. ETIOLOGY. 3^7 Embolism and metastatic abscesses, although more frequently found in the lungs in p\-ifimia, are not limited to this organ. To explain the occurrence of embolism in more remote organs, as the kidne3S, spleen, liver, brain, etc., we must assume either that an embolus in the pulmonary arter}- becomes the nucleus of a thrombus, which, b^' its growth, reaches across the pulmonarj' capillaries and projects into the pulmonarj^ vein, where fragments again become detached and enter the systemic circula- tion, or zoogioea of pus-microbes, passing the first filter (the lungs), are arrested in the capillaries of distant organs, or, finally, leucocj'tes im- pregnated with pus-microbes serve as minute emboli, and, after their localization in distant organs, become the cause of metastatic suppura- FiG. 83.— Coagulation Necrosis feom a Kidney Infarct. x300. (Birch-Hirschfeld.) A, zone of reactive inflammation ; B, loss of nuclei in the necrosed epithelia. (The nuclei of connective- tissue cells are in part preserved.) tion. In the kidney the infarctions appear as sharply circumscribed areas of a pale, cream-3-ellow color. When cut into, the infarct has a wedge shape, the narrow end pointing to the hilus. The red zone is not so marked as in infarctions of the spleen, and the greatest vascularity is in the direction of the embolus. As in infarcts of the lung, the hy- persemic zone corresponds to the vessels nearest the ischemic area. Extravasation of blood, although present, is never so marked as in the lung. The epithelial cells within the hypersemic zone are destroyed by coagulation necrosis, and if the embolus is aseptic this portion of the kidney is removed by molecular degeneration and absorption, leaving a cicatrix behind. 348 PRINCIPLES OF SURGERY. Infarcts of the kidney occurring in pyaemia are converted into abscesses in the same manner as in the lungs, by the escape of pus- microbes from the embolus tlirougli tlie inflamed arterial wall into the tissues starved by defective blood-sup])l3^ SYMPTOMS AND DIAGNOSIS. As a wound complication p3'a?mia never occurs before suppuration has taken place, seldom before the seventh, usually about the ninth to eleventh, day after the accident or operation, if it is the result of a primary infection of the wound. In patients threatened with pyaemia, an ill-deiined train of premonitor}^ symptoms precede the actual develop- ment of the disease These symptoms apply to the appearance of the wound and tlie general condition of the patient. The onset of the disease may be suspected at any time after suppuration has occurred, when evidences of serious capillary stasis manifest themselves at the seat of injury or operation. The thrombo-phlebitis gives rise to oedema; the margins of the wound appear pufled and elevated, the granulations pale and flabby ; suppuration, which may have been profuse, becomes scanty ; the pus changes its character, and, instead of a yellowish, cream- colored fluid, it becomes sanious, serous, or sero-sanguinolent. Careful inspection of the parts at this time may reveal the existence of thrombosis in one or more of the veins leading from the focus of primary infection. The general premonitory symptoms are indicated by a slight degree of intoxication, the result of the introduction into the circulation of pus-microbes and their ptomaines, from the primary focus of suppuration, causing a slight rise in the temperature and a general feeling of malaise, thirst, and loss of appetite. The actual development of the disease is initiated by a well-marked severe chill or rigor, which lasts from a few minutes to an hour or more. The chill resembles a malarial chill, and has often been mistaken and treated as such. Such a chill in a patient suHering from a suppurating wound or abscess is always an alarming symptom. It is an entirely subjective symptom, as the ther- mometer placed in the axilla during the algid stage indicates a rise in the temperature, which often reaches 104° to 105° F. before the patient ceases shivering. Chills have been artificially produced in animals b}- the introduction of foreign substances into the circulation, and in pyaemia it is an indica- tion that fragments of an infected thrombus, and witli them a large quantity of pus-microbes, have entered the circulation. The chill may recur at regular intervals daily or every other day, — a feature which may still further add to the difficulty in making a differential diagnosis between pj-semia and malaria. Usually, however, the chill recurs at SYMPTOMS AND DIAGNOSIS. 349 irregular intervals, one, two, or three times a clay, as a rule, increasing in frequency, and often in intensity, as the disease progresses. If, for instance, during the first few days the patient has one chill dail}', and, after a few days two or more during the same time, ever3' additional chill indicates a more advanced stage of intoxication, and an increase in the number of metastatic foci. After the chill the fever continues for several hours, with a temperature of 103° to 104° F., until the appear- ance of profuse perspiration, when the temperature falls to normal, or even a little below that. The chill, fever, and sweating coming in the same order and of about the same duration as in malaria, the clinical picture resembles the latter almost to perfection, and on this account many cases of pyaemia have been mistaken in the beginning for malaria, and vice versa. The fever which attends pysemia always is of an intermittent or re- mittent type. In acute pyaemia the chills may return several times during twenty -four hours, the temperature between them showing re- missions, but seldom returning to normal. In subacute and chronic cases the remissions are well marked betw^een the chills, the temperature often sinking below normal. Vomiting and diarrhoea are less constant symptoms than in septicaemia. The pulse in its frequency corresponds to the temperature ; its force is always reduced by the depressing eftect of the ptomaines upon the heart. Delirium is occasionally present, but, as a rule, the mind is clear until the end. The yellowish color of the skin, almost constantl}? present in pyaemia, has been attributed to icterus, resulting from metastatic processes in the liver; but in the majority of cases it is not the result of retention and absorption of bile, but is caused by destruction of red blood-corpuscles and pigmentation of the tissues with the coloring material thus liberated. It is an icterus, which, on account of its origin, is called '■'•lisematogenous icterus'''' The metastatic deposits in the kidnej^s are indicated by the appearance of albumen and sometimes pus in the urine. Metastatic Suppuration. — Infarcts in one or more of the internal organs are present in ever}' case of pj'aemia, and suppuration in some of the large cavities is of frequent occurrence. In reference to the number of secondary' metastatic foci of suppuration, a great deal depends on the clinical form which the disease assumes. In the acute form, which proves fatal within one to three weeks, the infarcts are numerous and the abscesses quite small, while in some of the infarcts the existence of supi)uration cannot be demonstrated macroscopicall}'. In chronic P3'aemia, in which life is prolonged for months, and sometimes even a year, the number of secondary foci are few, but the}' have resulted in the formation of large abscesses. The presence of infarcts of the lung ,S50 PHINCIPLES OF SURGERY. jire imlicuUd hy symptoms and signs which point to circumscribed foci of inflamnuition in this organ. If tlie infarct is immediately underneath the pleura, it gives rise to circumscribed pleuritis and sharp, lancinating pain at a point corresponding to the location of the infarct, always aggra- vated bj' the respiratory movements. In such cases friction-sounds can often be heard over the infarct. The consolidation of the tissues in- volved by the infarct by inflammatory infiltration from the vessels sur- iDiinding it is attended by crepitant rales, bronchial breathing, and ilullness on percussion, over an area corresponding to the size of the infarct. A pulmonary abscess which takes the place of an infarct in- creases in size by encroaching upon the surrounding tissues, and in chronic cases may emi)ty itself into a bronchial tube. A subpleural infarct, infected with pus-microbes, not infreciuentl}^ leads to sui)purative pleuritis and empyema by the extension of the infection from the lung- tissues to tlie adjacent pleura. In the same manner a suppurating infarct of the lung may become a direct cause of suppurative pericar- ditis, and pyocardium if its location is adjacent to the pericardium. The onset of metastatic foci in the lungs is often insidious, and even large infarcts often occasion only slight subjective symptoms and ob- jective signs. Embarrassed breathing should admonish the attendant to search for evidences of multiple infarcts of the lung. Abscesses in the liver, caused by septic emboli, vary in size from that of a pea to an orange, but occasion no symptoms unless they are located immediately underneath the serous covering, when they cause localized pain. Embolic infarcts in the kidneys may be suspected if the urine contains albumen, or pus, or both. The spleen is always enlarged in pyaemia, but, as this is the case in all acute infective processes, the presence of an infarct or abscess is only to be suspected if the symptoms, especially pain and cir- cumscribed tenderness, point to the existence of perisplenitis. Enormous pyaemic abscesses often develop insidiously and without pain, or the ordinary symptoms of acute inflammation between muscles and in the subcutaneous connective tissue. Metastatic suppuration in p3'8emia takes place not only where infarction has occurred, but also in localities where the existence of embolism cannot be demonstrated anatomically-, this being notably the case in joints and the large serous cavities. Sup- purative pericarditis, pleuritis, and peritonitis frequently complicate acute, rapidly-fatal py.'emia. Suppurative synovitis, multiple or limited to one joint, is a frequent complication, both in acute and chronic pysemia. Metastatic suppuration in these localities develops without demonstrable infarcts, and occurs, in all probability, in consequence of mural implantation of pus-microbes or infected leucocj'tes upon the wall of capillary vessels, the intima of which has been damaged b}- ptomaines SYMPTOMS AND DIAGNOSIS. 351 held in solution by the circulating blood. As in all cases of p^'aemia pus-microbes and their ptomaines necessarily constantly enter the cir- culation from the primary focus of infection, they prepare the soil for the reception and pathogenic action of pus-microbes in the vessels and tissues of certain organs, more especially the synovial membrane of joints and the serous membranes lining the large cavities. Pyaemic abscesses, when well-developed, always contain yellow pus of the con- sistence of cream. Examined under the microscope, such pus contains corpuscles in which no sign of a nucleus can be found. The pus-microbes arc always present in great numbers, both within the pus-corpuscles and in the pus-serum. While some doubt may remain after the tirst chill as to the nature of the disease, this doubt is dispelled Avith the recurrence of the chills. In acute cases the ciiill returns once or twice daily, but, unlike in cases of malaria, if the chill is of daily occurrence, it does not come at a fixed time, as is the case in mnlnria. If the disease does not culminate into a daily chill, the temi)erature /^ then shows an irregular remittent . .' •, -' type of fever. The patient loses ; ■.'°° °:° strength and flesh rapidly, and the .7 ; ' ^ • - /"''•- •': face presents the color of a mixture • •. ; , '' ,,_^' of the hectic flush with the icteric "^ L ^"^^ hue. While the pulse at first rises only to 100 to 120 beats per minute " " during the febrile exacerbations, it ^^^ ^i.-rx^Mic its. showing com- soon remains at from 120 to 150 per J^^^^^f^ JT^^'^^S^. 11 minute. Great thirst and complete ^lli'o'^^^f^l^r^f2^n1c:?e?r^^''''" loss of appetite remain constant s^-mptoms. The tongue and lii)s are dry, diarrha\a is more common as septic intoxication advances, and the stools are frequently stained with blood. As the fotal termination approaches, delirium and sopor come on, and under increasing symptoms of depression death takes place gradually from heart-failure, or suddenly from embolism of the pidmonary artery. In chronic cases the duration of the disease is sometimes prolonged for months, and Billroth relates a case where the i)atient lived for a year. In chronic cases the chills recur at long intervals, and the fcA'er assumes a remittent type between them. In still another class of chronic p3'aemia the chills ultimately disappear, and the fever assumes a mild, continuous t3pe, while the patient gradu- all}' succumbs to decubitus, amyloid degeneration of internal organs, or a slow form of septic intoxication. 352 PRINCIPLES OF SUKGERY. PROGNOSIS. The prognosis of pyjemia, is alvvuys grave. Acute pj^femia, in spite of all treatment, almost without exception terminates in death in IVom one to two weeks. The few recoveries which have been reported were cases of subacute or chronic pyjiemia. As pyjvmia is not a priniar}-, but secondary, condition, it is a fatal disease from the very beginning, as during its commencement transportation of infected tissue has taken place to localities inaccessible to radical treatment. In acute cases death seldom takes place before the end of the first week, more frequently from the second to the end of the third week. In chronic cases not compli- cated by pulmonary- infarcts, the metastatic suppuration in parts accessi- ble to surgical treatment are occasionally amenable to successful treat- ment, and a cure can be obtained after a long and lingering illness. Prospects of a successful issue in chronic cases can be only entertained when the disease attacks young individuals otherwise in good health. The prognosis of pyaemia is also modified by the location of the primarj' focus of infection, as when this is not accessible to direct treatment the disease will progress uninfluenced by general treatment. If, on the other hand, further suppl}' of septic material from the primar}- infection- atrium can be prevented b\' a prompt removal of the infected tissues, one of the most important indications of treatment has been met, and the hope of a favorable termination has been thereby increased. PATHOLOGICAL ANATOMY. The pathological changes found in patients who have died of pyaemia are cliaracteristic. The primary' focus of infection may no longer be present, as it may have healed, but, as a rule, this has not occurred, and examination shows a suppurating wound, an abscess, an osteomyelitic focus, a suppurating phlebitis or sinus phlebitis. The vein in which the fatal thrombus formed may not be a large one ; indeed, it may be so small as to elude detection b}- macroscopical examination. If the imme- diate cause of the py{emia,the thrombosed vein, can be located, it will be found filled with a softened, loose blood-clot, which is very variable in length, and the proximal end of wdiich projects usually into the lumen of some larger vein-trunk on the proximal side. The vein-wall itself is in a state of suppurative inflammation that prevents the formation of firm adhesions between the thrombus and the intima, as we find it in cases of plastic throrabo-phlebitis. The new^ histological elements that are produced by the inflammatory process are at once converted into pus-corpuscles, and some of these are distributed through the substance of the blood-clot, and furnish an additional cause for the softening and disintegration of the coagulum. The infarcts are most numerous in the PATHOLOGICAL ANATOMY. 353 lungs, but are also found in tlie spleen, kidne3'S, and liver. An embolus catches in an arter3- at a point where the lumen suddenl3' becomes smaller, which is the case where the vessel bifurcates. The ('ml)olus, after it has become impacted, becomes the nucleus of a thrombus, as the blood which comes in contact with it undergoes coagulation, and in this manner la3"er after layer are added on each side. As the embolus under these circumstances is always composed of dead infected material, it causes at the seat of impaction a s})ecific inflammation, which in every respect represents the type of inflammation at the primary' seat of infec- tion. As the tissues wJiich are in immediate contact with the embolus are the coats of an artery^ a su]jpurative arteritis follows the impaction, and as soon as the pus-microbes have passed thi'ough the softened, inflamed arterial wall the infection extends to the tissues weakened b}^ the sudden abstraction of blood ; that is, the tissues which are within the borders of the wedge-shaped infarct. The h3'per8emic zone around the infarct con- stitutes a wall of protection against unlimited extension of the infection and inflammation. In the lungs the infarct becomes rai)idly infiltrated with the products of inflammation from the hj'persemic zone, which gives rise to consolidation of that portion of the lung. Suppuration is attended bj- liquefaction of the exudation, and the infarct is transformed into an abscess. In pyaemia the emboli that reach the systemic circulation are smaller than those which reach the pulmonary arter}' ; consequently the infarcts, as a rule, in the kidney, spleen, liver, and other distant organs are smaller than those in the lungs. In metastatic suppuration without embolism, in the strict sense in which this word has been heretofore used, the pus- microbes which become implanted upon capillary walls, changed by the action of pre-existing ptomaines diff"used in the blood, reach and infect the para-vascular tissues and the interior of large cavities, thus causing a rapidlj'-spreading, diffuse, suppurative inflammation. In metastatic suppurative inflammation of the cynovial membrane of joints, the peri- toneum, pleura, and pericardium, the process represents all the essential features of a specific surface inflammation, characterized b}^ rapid exten- sion of the inflammation over the whole surface, and the accumulation of a large purulent collection in a short time. Microscopic examination of nearly all organs in fatal cases of p^-eemia reveals the existence of coagulation necrosis resulting from the action of pus-microbes and their ptomaines upon tissues with which they have been brought in direct con- tact. The spleen is always enlarged and softened, even if no infarcts are present. The heart is flabb}' and the muscular tissue softened. The intestinal mucous membrane is swollen, vascular, softened, and at points shows submucous extravasation from rupture of capillary vessels, — 354 PRINCIPLES OF SURGERY. evidences that tliis structure has also become the seat of metastatic inflaiH' matioii. Embolism of cerebral vessels is an unusual occurrence in P3'8emia, while they are frequently obstructed by emboli which become detached from valvular vegetations in the left side of the heart. TREATMENT. Before the use of antiseptics in surger}', pyaemia figured largely as the cause of death after injuries and operations. Only twenty -live years ago a large percentage of the surgical patients in the old, in- fected, European hospitals died from tliis disease. Insignificant injuries and minor operations were frequently followed by this fatal complica- tion. At present it is a source of pride to the teachers of surgery, if during a course of lectures they do not succeed in finding a case for clin- ical study and instruction. In hospitals where antiseptic surgery is thoroughly and conscientiously practiced the disease is almost unknown. Helpless as we still are in curing the disease, as surely can we prevent it, in the management of recent injuries or intentional wounds, if we re- sort to careful and eflScient antiseptic precautions. The premnlion of supplication in a wound furnishes absolute pi'otection against p)ysemia. Again, the early radical treatment of suppurative lesions has been the means of diminishing the frequenc}' of pyaemia from causes other than wounds. The prophylactic treatment of pyaemia consists in preventing suppuration in wounds by antiseptic means, and in sterilizing suppurating foci before septic thrombo-phlebitis has occurred by early incision, anti- septic irrigation, drainage, and in maintaining asep)ticity under antiseptic dressings. In the treatment of suppurating wounds a great deal can be done toward the prevention of pyaemia by resorting to thorough secondary disinfection, and in guarding against tension and accumulation of the products of septic inflammation b}' efficient drainage, or, still better, by combining drainage with permanent irrigation. Suppurative osteom^-e- litis should be treated by early operative measures, not only for the pur- pose of preventing unnecessary destruction of bone and of relieving pain, but more particularity with a view of warding off this fatal compli- cation. Klebs has recently made the suggestion to surgeons that the prophylactic treatment of p^-aemia should be carried still farther, b^^ excising such veins as are known to contain infected thrombi before embolism has taken place. The justifiability and advisability of such treatment cannot be doubted, and surgeons will be glad to adopt this suggestion in cases where it is possible to asccrt.iin the location of the thrombosed vein or veins, and where such an operation is feasible on an- atomical grounds. In grave cases of osteomj'elitis an operation for this TREATMENT. 355 special indication would often make it necessary to amputate, as even the most thorough scraping out of the infected medullary cavitj^ might fail in removing all of the infected thrombi. It has also been suggested to interrupt the venous circulation in one of the principal ver.ous trunks of a limb b}' ligation, for the purpose of preventing mechanicall}- the entrance of detached fragments of a thrombus into the circulation ; but this procedure has not answered the expectations, as the emboli will reach the general circulation through collateral branches. Removal of the infected thrombi b}' anii)utation or resection of the affected portion of a vein are more reliable prophylactic measures than ligation in the continuit}' of a principal vein-trunk on the proximal side of the primary' seat of infection. Detachment of fragments of a disintegrating throm- bus must be prevented as far as possible by securing absolute rest for the infected part, as all sudden movements, active and passive, and sudden disturbances of the circulation may become the means of separation of fragments, and their transportation as emboli into the circulation. The curative treatment of pyfemia, medical and surgical, is unsatisfactory. Quinine, natrum benzoicum, and the different preparations of salicylic acid have been used quite extensive!}' in the treatment of the fever which attends the disease. Antifehrin, antipyrin^ and other drugs of the same class of remedies are worse than useless, as the favorable effects from their antipy7-etic action are inore than overbalanced by the harm they do in depressing the action of the heart. External heat and the internal ad- ministration of diffusible stimulants should be used to shorten the dura- tion of the rigors. Alcoholic stimulants are indicated in the acute and chronic forms of the disease. In chronic pyaemia a daily tepid bath is of the greatest value. In the same class of cases it is of the utmost importance to support the patient's strength by systematic feeding and the use of the malt bever- ages, such as beer, ale, and porter, with a view of prolonging life until the primary cause is eliminated from the primarj^ and secondar}^ depots of infection, spontaneously or by surgical treatment. In acute cases of pyaemia, originating from a wound of one of the extremities, or from acute suppurative osteomyelitis of the long bones, the question of removal of the primar}^ focus of infection by amputation will present itself. If, from a study of the symptoms, it become apparent that multiple infarcts exist in the lung, or lungs, and other organs, amputation is not permissible, as it would onl^^ result in shortening the life of the patient. The jyropriefy of an amputation should only be considered in the begin- ning of the disease, and before extensive dissemination of the purulent infection by embolism has taken place. In a suppurating, compound fracture, amputation may be indicated for other reasons than those of a 856 PRINCIPLES OF SURGERY. threatened ov developed attack of pyivniia. Secondary disinfection of a suppurating ivound with excision of thrombo-phlebitic veins, where this is ponf^ible, should be practiced in all cases of pyfsmia for the purpose of preventing or limiting general dissemination by embolism. In chronic cases the secondary metastatic processes should receive earl}^ and careful attention. As in these cases the metastatic suppuration, as a rule, is not caused by embolic infarcts, life is threatened b}' the secondary lesions, from which ptomaine intoxication is ninintained, and from Avhich new places ma}' become infected l)y localization of j^us-microbes in capillary vessels weakened b}' the action of ptomaines. Suppurating joints are incised, drained, and irrigated under strict antiseptic precautions, and if the metastatic suppuration is limited to a single joint this can be done witli a fair prospect of a favorable result. Purulent collections in the serous cavities or connective tissue are dealt with in a similar manner. Careful attention to diet and the sanitar}^ surroundings of the patient, combined with energetic surgical treatment of the suppurating foci, will, at least occasionally, be rewarded by an ultimate recovery. SEPTICO-PY^MIA. In the absence of more accurate knowledge concerning the microbic cause of septicaemia, we must, at least for the present, assign to septi- caemia and p3'aemia the same bacteriological cause. That pus-microbes can produce septicjemia, when introduced into the circulation in sufficient quantity, has already been shown, and that pus-microbes have been frequently cultivated from septic products is a matter of demonstration ; hence the disease, if not identical with pyaemia, from a bacteriological stand-point, is at any rate closel}' allied to it. It has also been shown that, in case the life of septic patients is prolonged for a sufficient length of time, the metastatic foci of inflammation are the seat of incipient suppu- ration ; hence such cases resemble pyaemia upon a pathological basis. In pyaemia, after cessation of the rigors, which are the most character- istic clinical symptom of this disease, the fever resembles septicaemia, and, as the clinical picture thus developed rests upon pathological con- ditions typical of pj'semia, it would be proper to apply to such cases the term septico-pysemia. For the same etiological and pathological reasons we apply the same term to septicaemia in which post-mortem examination reveals the presence of minute, multiple, suppurating foci. Septico-pysemia may be defined as a condition in which the sj^mp- toms indicate the presence of both septicaemia and p^-aemia, and in which the post-mortem appearances point to septic and purulent infection. Leube described such a combination of the two diseases, which as yet are SEPTICO-PY.EMIA. 357 considered as distinct, occurring in patients in whom ie Avas unable to trace tlie source of infection from witliout ; hence he called the affection spontaneous sejytico-jjysemia. Litten, on the other hand, in similar cases, was always able to locate the infection-atrium, but the primar}' infection at the time acute S3-mptoms set in had either disappeared or its location could onlj' be ascertained by most careful examination. Jiirgensen applied to these cases the lengthy compound word " kryptogenetic- septico-pyaemia,^^ as he was unable to find a tangible infection-atrium. In ia recent article on the subject he gives an account of 100 cases that came under his own personal observation. The patients were usually attacked first with acute phar^-ngitis, and, as this stage was generally attended b}' a chill and a general feeling of malaise, the patients generally attributed the onset of the disease to exposure to cold. In most cases the general infection was announced by a severe chill. Rapid loss of strength was one of the most prominent sj-mptoms ; the patients in a few hours after the chill became utterly prostrated. The sj-raptoms Avhich pointed to local processes during life were referred most frequentl}^ to the lungs, liver, spleen, pleura, heart, and the long bones. Whether the primary infection occurred through the phar^-nx, where the first S3'mptoms were manifested, could not be definitely ascertained. In the acute cases, the sj-mptoms were grave from the beginning and increased in intensity as the infection progressed, while, in the chronic cases, infection is kept up from some suppurating focus, and the disease may continue for several years. Subcutaneous and retinal hemorrhagic extravasations were frequently observed. Post-mortem examinations revealed suppuration in some of the internal organs, and vascular changes which are characteristic of sepsis. These cases may be compared with acute suppurative osteomj^elitis, where, after the most careful inc^uirj' and the most scrutinizing examina- tion, we often fail in furnishing reliable evidence for locating the primary source of infection. It is possible that the pus-microbes enter through an intact or inflamed mucous membrane, or through the appendages of the skin, and that they remain in a latent, inactive condition until a weak point is created somewhere in the body, where they localize in a soil prepared for their reproduction and pathogenic action, or, what is more likely the case, they entered through an abrasion or slight lesion, wdiich may have been so insignificant that the patient himself failed to notice it, and produced no symptoms until, by accident or disease, a proper soil was prepared for the initiation of an acute attack in one or more of the internal organs. The remote dangers which may follow infection through an insignificant wound, or from a small, suppurating focus, should remind the surgeon of the importance of treating these little 358 PRINCIPLES OF SURGERY. ailments with tlie necessary care and attention, and by so doing he "will often be the means of preventing fatal complications. In 2 cases of kryptogenetic septico-p^'temia that have come under my own observa- tion the disease was complicated by ulcerative endocarditis. In 1 of these cases the immediate cause of death was gangrene from embolism of the popliteal artery. CHAPTER XIV. Erysipelas. Erysipelas is a self-limited, ucute, non-suppurative inflammation of tlie lymphatic vessels of the skin or mucous membrane, attended by red- ness and a continued type of fever. As a wound complication it occurs independently- of suppuration, and in its uncomplicated pure form remains as a superficial affection, the inflammation never passing beyond the structures of the skin or mucous membrane. HISTORY OF ITS MICROBIC ORIGIN. The contagiousness of erysipelas has been recognized for centuries, and on this account early attempts were made to include it among microbic diseases. In 1868 Hueter maintained that erysipelas and hos- pital gangrene were identical diseases and caused by the same micro- organism. Its microbic nature was again made the subject of investi- gation in 1872, when Napveau discovered micrococci in the blood of erj'sipelatous patients. Wilde detected the same microbes in the blood, but asserted that similar micro-organisms could be found in the pus in wounds from which the er3'sipelas developed. In 18T4 Recklinghausen found masses of micrococci in the Ij'm- phatic channels in the inflamed skin at the border of an erysipelatous inflammation. Nearly the same time similar observations were made by Billroth. Ehrlich, Tillmanns, and Koch. Tillmanns produced the disease artificially in animals b}' injecting subcutaneousl}- the serum con- tained in the bulla of erysipelatous skin. Koch attempted to produce the disease artificially in rabbits with injections of difterent putrid fluids, but failed until he made inoculations with mouse-dung softened in distilled water. He injected the material under the skin of the ear, and produced an inflammation which in its course resembled er3sipelas. Tlie swelling and redness spread slowly downward from the point of inoculation. On the fifth da}' it had extended as far as the root of the ear. The ear became exceedingly vascular, so that the separate vessels could no longer be identified, while the tissues were softened and edematous. The animal died on the seventh day. Blood taken from the heart of this animal produced no effect in other rabbits, Xo microbes could be found in the blood or in any other (359) 360 PRINCIPLES OF SURGERY. organ except the affected ear. In transverse sections of the ear the blood-vessels were seen to be markedl3' dilated, full of red corpuscles, and surrounded by the nuclei of white corpuscles. Between these and the cartilage-cells bacilli were found. The bacilli were present close to the cartilage onl}-. Here thej^ were Fig. 85— Section of Ear of Rabbit Parallel to Sttrface of Cartilage. The Morbid Process Resembled Erysipelas. X 700. {Koch.)* A, ball-like accumulation of bacilli ; B, accumulation of nuclei above the layer of bacilli : C, nuclei of flat cells connected with the cartilage below the layer of bacilli : D. bacilli arranged parallel to each other. found in large clusters, from which the bacilli radiate in all directions. This net-work of bacilli extended over the whole cartilage of the ear on both surfaces. Inflammation was most marked in the vicinity of the bacilli, and, consequentl}^, in the absence of other causes, there could be no doubt that the erj^sipelatous inflammation was caused by these * Copied from " Traumatic Infective Diseases," by permission of the New Sydenham Society, London. DESCRIPTION OF STREPTOCOCCUS ERYSIPELATOSUS. 361 microl)es. Orth found micrococci in the contents of the bulloe of erysip- elas. Recklinghausen and Lukowsky found them in the lymphatic ves- sels and the connective-tissue spaces in the structures aftected by erysipelas. Billroth and Elirlich found bacteria not only in the lym- phatic vessels, but also in the blood-vessels of the inflamed skin. Till- manns found microbes in er^-sipelatous skin, and Letzerich, in cases of erysipelas attacking vaccination wounds, found them in the wound itself, in the blood-vessels, muscles, liver, spleen, and kidnej^s. The essential specific cause of erj^sipelas was finallj'^ discovered by Fehleisen in 1883. He cultivated the microbe from erysipelatous products, and demon- strated its essential etiological relationship to erysipelas by producing the disease artificial]}', in animals and man, by inoculations with pure cultures. From the morphological appearance of the microbe and its direct etiological bearing to erysipelas he called it the streptococcus of erysipelas. With pure cultures of this microbe he produced b}'^ inocula- tions not only erysipelas in animals, to prove its specific pathogenic qualities, but successful inoculations were also made in man for thera- peutic purposes, DESCRIPTION" OF STREPTOCOCCUS ERYSIPELATOSUS. The streptococcus erj'sipelatosus, discovered by Fehleisen, when examined under the microscope appears in the form of chains, the links of which are minute \ ...- "N.— -•' "^ / cocci, 3 to 4 micromillimetres in diameter. .vi. L-*"'' / The streptococcus of er3'sipelas invades the J — >. .-••.'^''^ superficial l3-mphatic channels of the skin or (.., ^^ ' ' \ mucous membrane exclusivel}", but it can also *'•"••'' i-.,.,/" be found in the serum contained in bulhe. Each *'" coccus, when it is about to divide, becomes larger ^eryI^ii^^lTt^sus^ Pu^^^ and oval, and soon appears made up of two hemi- AxST'Mf ^stained^with spherical masses, the two new cocci resulting from ^arUnT' ^ ^^^' ^^"""'' fission of the old one. Morphologically, the strep- tococcus of erysipelas and the streptococcus p3-ogenes are nearl}- iden- tical, onl}^ that the cocci of er^'sipelas are somewhat larger, while botli are somewhat smaller than the staphylococci. CULTIVATION. This microbe can be readily cultivated in bouillon at ordinary room- temperature ; also upon gelatin, agar-agar, and solidified blood-serum. Upon solid nutrient media the appearances of the cultures resemble very strongl}^ those of streptococcus pyogenes. There is less tendency, however, to the formation of terraces the margin is thicker and more 362 PRINCIPLES OF SURGERY. irregular in outline, and the appearance of the growth is more opaque and whiter. Rosenbach mentions, as another distinguishing feature between the two, that the culture of the streptococcus of erysipelas represents the shape of a fern, while the outlines of the cultures of the pus-strepto- coccus describe the shape of an acacia-leaf. The culture appears as a ver}' delicate grayish-white film. The growth is ver^' slow, and the individual colonies remain small. The streptococcus of erysipelas does not liquefy gelatin. The microbe of erysipelas grows equally well when oxygen is excluded. If gelatin is inoculated by puncturing with a needle charged with a i^ure culture, microscopical colonies can be seen the whole length of the track of the needle at the end of twenty-four hours. In four days the culture has reached the height of development, and colonies the size of a grain of sand to that of a pin's head occupy the whole length of the needle-track. In cultures the microbe retains its pathogenic qualities for about four months. INOCULATION EXPERIMENTS. Fehleisen produced, artificial!}', typical erj-sipe- las in rabbits by injecting pure cultures \;nder the skin of the ear. Koch and Gaff ky used cultures grown upon solidified blood-serum and inoculated 9 rabbits. In 8 of these typical erysipelas de- veloped, the attack lasting from six to twelve daj'-s. Krause obtained positive results by inoculat- ing gray mice. In all cases where the inoculation proved successful the erj'sipelatous inflammation started at the point of inoculation, and extended rapidly, always following the lymphatic channels. In Krause's experiments the animals died after three or four days, even when only a minute quantity of the culture was injected under the skin of the back. Examination of the infected tissues after death showed that inflammation followed the invasion of the microbes, and consequently the principal pathological changes were found Avithin and in the immediate vicinity of the Ij^mphatic channels. INOCULATION FOR THERAPEUTIC PURPOSES. As soon as it was demonstrated experimentally that simple, uncom- plicated erysipelas is a disease attended by but little danger to life, the suggestion was near that, if the disease could be artificially produced in \ Fig. 87.— Stale Cttl- TURE OF Streptococ- cus OF Erysipelas in Gelatin at Ordi- nary Temperature OF Room, Four Days Old, Natural Size. {Baumgarten.) INOCULATION FOR THERAPEUTIC PURPOSES. 363 man by inoculation witli pure cultures, the local and general conditions thus produced might prove useful in the cure or amelioration of some diseases not amenable to operative treatment and internal medication. Of 7 persons the subjects of incurable tumors, inoculated b)^ Fehleisen with pure cultures, 6 developed typical erysipelas ; in the seventh case the patient had passed through an attack of erj-sipelas only a few weeks previously-, and was, in all prol)ability, still protected against a new attack. This patient was inoculated a second time with a negative result. In other instances a second inoculation failed after a successful inoculation. The period of incubation was fixed at from fifteen to sixt}^- one hours. The microbe was found onl}- in the lymphatic vessels and con- nective-tissue spaces, and when the culture was pure suppuration was never produced. Fehleisen has seen, by this treatment, a cancer of the breast become smaller, a lupus disappear almost completely, while a case of fibro-sarcoma and another of sarcoma were not materially aflfected b}^ this method of treatment. Janicke and Neisser have recorded a death from erysipelas thus intentionally produced in a case of cancer of the breast beyond the reach of an operation. At the necropsy it was proved that the tumor had almost completely disappeared, and the microscopical examination of portions that had remained appeared to show that the tumor-cells had been destroyed through the direct action of the microbes. Biedert saw, in a child suffering from a sarcoma involving the posterior part of the cavity of the mouth and pharj-nx, the left half of the tongue, the naso-pharyngeal space, and the right orbit, the tumor disappear almost completely during an attack of erysipelas. Cases, on the other hand, have been reported in which, after an accidental or intentional attack of er^'sipelas, the tumor commenced to grow more rapidly. Neelsen reports a case of carcinoma of the breast, in which, after two severe attacks of erysipelas, the tumor not only commenced to grow faster, but at the same time the regional infection progressed also more rapidly. Babtchinsky made the accidental discovery that the microbe of erj-sipelas is a direct antagonist to the virus of diphtheria. His son, while suftering from a most severe attack of diphtheria, was suddenly attacked b}' erysipelas. This complication, grave of itself, seemed to hasten the fatal termination of the case, and during the first few hours of the eruption the patient was much worse. But the next day the symptoms had much improved, and the patient made a rapid recovery. Following this indication Babtchinsky inoculated a second case of diphtheria with a culture of the microbe of erysipelas grown on agar- agar, and with an equally happy result. Since this time, of 14 cases of diphtheria treated with these inoculations, 12 resulted in recovery, and, 364 PRINCIPLES OF SURGERY. as in the 2 cases resulting fatally the inoculation produced no effect, these negative results onl}- tend to confirm tlie efficacy of the curative inoculations. It is remarkable that in all of the cases where erysipelas was produced artificially this disease pursued a mild course, and the patients recovered rapidly from both diseases. Schwimmer gives an account of 11 cases of lupus, in all of which no improvement was observed after an intercurrent attack of erysipelas. In a case of keloid an attack of erysipelas was followed by marked improvement, and a lii)oma underwent a similar favorable change from the same cause. Syphilitic lesions he saw temporarily benefited, while the erysipelas had no effect in permanently influencing the course of the disease. Bruess gives an account of the effect of erysipelas on tumors in 22 patients. Among these 3 cases of sarcoma were permanently cured. Two cases of multiple keloid after burns were also cured. In 4 cases of lymphoma of the neck some of the glands became smaller and some disappeared. In 5 cases the erysipelas was artificiall}^ produced b}' inoculation with a pure culture. In 3 cases of carcinoma of the mamma 1 was not influenced by the disease, 1 became one-half smaller, and 1 was reduced to a small induration in the scar the size of a pea. A multiple fibro-sarcoma was greatly benefited, while an orbital sarcoma was not improved. In view of the uncertaint}^ of the result, and the not inconsiderable danger which attends tlie intentional form of erysipelas in patients debilitated by antecedent disease, it is safe to predict that no further inoculations will be made in man until, perhaps, future research will demonstrate a certain specific antagonistic action of the streptococcus of er3'sipelas against some other pathogenic microbes, the cause of grave diseases not amenable to successful treatment by less heroic measures. MANNER OF INFECTION. An intact skin or mucous membrane furnishes absolute protection against infection with the streptococcus of erysipelas. This microbe cannot reach the lymphatic vessels without an infection-atrium, which may be a small abrasion, a wound, blister, ulcer, — in fact, any breach of continuity in the skin or mucous membrane. Before antiseptic surger3' was practiced, infection frequentl}^ occurred through accidental or inten- tional wounds. Antiseptic surgery has greatly diminished the frequency' of traumatic erysipelas, but has not completely eradicated it, as an occasional case will occur in the hands of the most careful antiseptic surgeons. Even before the microbic cause of erysipelas was known, Trousseau, one of the closest of clinical observers, claimed that infection MANNER OF INFECTION. 365 with the virus of erj^sipelfis is onl}' possible through some wound or abrasion of the skin ; the latter maj- be so insignificant as to be unnotice- able and entirely overlooked by both patient and phj'sieian. Idiopathic or spontaneous erN'sipelas, so called, does not exist ; every case of ery- sipelas is traumatic, in so far that by injury or disease the necessar}^ infection-atrium must be created through which the streptococcus can reach the lymphatic vessels. In erysipelas without a tangible infection- atrium, infection occurs through a minute puncture or abrasion, which ma}', perhaps, never have attracted the patient's attention, and which has become invisible at the time the disease is first noticed. Infection, however, may also take place through a mucous membrane, through which the microbes enter the tissues in the same manner and under the same conditions as when infection takes place through the skin. One of the severest cases of er3'sipelas that ever came under my observation Fig. 88.— Section through Skin near the Margin of the Erysipelatous Zone, x "00. (Koch.) 1, 1, e.ach a lymphatic vessel filled with streptococci in chains. commenced in the pharynx, or tonsils, and, as the symptoms subsided here, a typical and severe facial erysipelas developed. As the patient was suffering at the same time from secondary syphilis, it is probable that the streptococcus of erysipelas entered the tissues through the secondary syphilitic lesions in the phar^-nx. In the tissues the strepto- coccus of erysipelas invades the Ijnnphatic channels exclusively, and manifests here its specific pathogenic qualities. The erysipelatous inflammation is, in reality, a specific, progressive lymphangitis, the para-lymphatic tissues becoming affected by contiguit}'. Within the lymphatic channels the microbe multiplies, and diflfusion of the infection takes place in the course of the lymphatic vessels, but does not always follow in the course of the lymph-stream. The lymphatic vessels are often found crowded with the microbe, which is destroyed in a short time, as with the subsidence of the inflammation the microbe disappears. According to Koch, and Fehleisen, the microbe is always 366 PRINCrPLES OF SURGERY. found most numorous in the portion of the skin corresponding to the border of the inflamed area. At this point the lymphatics frequently :il)pear completely blocked by dense colonies of this microbe, so that no lymph-corpuscles can be seen among them. As the inflammation extends to the surrounding connective tissue, some of the microbes leave tlie lymphatics and enter the connective-tissue si)aces, where they come in contact with the inflammatory exudation. Within the lymphatic vessels the streptococci are found l)etween the lym[)h and colorless blood-cor- puscles ; in the connective tissue they are found also within the proto- plasm of leucocytes. Metsclinikofl' maintains, in opposition to most of the modern au- thors, that the arrest of the extension of the erysipelatous inflammation is accomplished by phagocytosis. The accumulation of leucocytes in the inflamed tissues has, undoubtedly, a salutary effect in mechani- cally blocking the avenues through which infection takes place ; but as most of the microbes are outside of, and not within, the leucocytes and lymph-corpuscles, it is difficult to conceive how limitation of the extension of the infection could be accomplished solely by phagocytosis. The microbes have a very short existence in the tissues ; the inflammation which the}^ initiate continues for some time after all microbes have dis- appeared. The ptomaines which microbes secrete produce protoplasmic alteration of the connective-tissue cells and the capillary blood-vessels, Avhich prolong the inflammation be^^ond the period when the tissues are in a sterile condition. Others have claimed that self-limitation of ery- sipelas is due to destruction of the microbes by the high temperature which attends the disease. De Simone has recently shown that pure cultures of the streptococcus of erysipelas lose their power of reproduc- tion if thej'^ are exposed for two da3^s consecutively to a temperature of 39.5° to 41° C. Clinical experience, however, has demonstrated conclu- sivel}' that erysipelas is not arrested in its course by a temperature of 40° C, or more. It appears that the streptococcus exhausts the soil of the nutrient material which it requires for its growth and reproduction in a short time. In the blood-vessels of the inflamed skin no strepto- cocci can be found, but that they occasionally enter the blood-vessels is sufficiently evident from the occurrence of metastatic erysipelas, and the direct transmission of erysipelas from mother to foetus by infection through the placental circulation. As the streptococcus of erysipelas produces its pathogenic effects in the lymphatic vessels, and diff"uses itself through these channels in the tissues, it becomes obvious that in all cases infection takes place as soon as localization is eflfected in the superficial l3"mphatic structures, or in the spaces contributary to them, and in direct connection with an infection-atrium. RELATION OF JERYSIPELAS TO PUERPERAL FEVER. 367 RELATION OF ERYSIPELAS TO PUERPERAL FEVER. Obstetricians recognized tlie danger of exposing puerperal women to the infection wliich might emanate from er^^sipehitous patients long before the microbe of erysipelas was known. Since the discovery of the microbe by Fehleisen, this subject has attracted renewed attention, and positive knowledge has accumulated both from accurate clinical obser- vation and from the fertile and more positive field of experimentation. Gusserow asserted, upon the basis of an extensive experience, that no direct etiological relations exist between the contagium of erysipelas and puerperal fever. He had under his care puerperal women suffering from erysipelas of the skin without any serious disturbances following in the genital tract. In 10 other cases, one of them occurring during an epi- demic of puerperal fever, the erysipelas was observed as a complication of septic affections of the genital organs. Gusserow claims that in this case it cannot be claimed that erysipelas could have caused the puerperal affection, as the latter preceded the former. But another point could be raised, as it might be claimed that the septic processes should be made answerable for the occurrence of erysipelas. This author has studied this subject also by way of experiment. A pure culture of the strepto- coccus erysipelatosus, which had been tested and found reliable in pro- ducing erysipelas by the usual methods of inoculation, was injected into the peritoneal cavity of 2 rabbits ; in 2 others it was applied to an open wound of the abdomen, and in the last 2 animals it was injected into the subserous connective tissue of the peritoneum. In all of these animals no effect was produced, and no pathological changes were detected at the point of injection when the animals were killed, some time after the inoculation. Gusserow looks upon the results of these experiments, if not as positive proof, nevertheless as strong evidence against the claim that erysipelas can cause puerperal sepsis. Winckel, an equally reliable and able observer, has come to entirely' opposite conclusions. He culti- vated from a parametritic abscess, which had developed after childbed, Fehleisen's streptococcus. Injections of this culture into rabbits pro- duced tj-pical erysipelas. The same author also observed erysipelas fol- lowing in a puerperal woman suffering from suppurative perimetritis, pleuritis, and metro-l3'mphangitis. The patient died on the thirteenth day. The starting-point of the ei*ysipelas could be traced to an ulcer of the vulva. Blood taken i'rom the right side of the heart soon after death was inoculated upon a solid nutrient medium, and produced a culture of the streptococcus of erj'sipeias. The same culture was obtained by in- oculations with fluids taken from the peritoneal and pleural cavities, the uterus, kidne3's, and the liver. In 3 cases a culture thus obtained was injected into the peritoneal cavity of rabbits, and no peritonitis followed. 368 PRINCIPLES OF SURGERY. Ill 1 ».'Xi)t'riineiit the injection produced supi)urative peritonitis. Guinea- pigs proved less susceptible to in lection than rabbits. In white mice the inoculations were invariably i)rodiictive of a fatal disease. From the results of these experiments the author claims that the virus of ery- sipelas is one of the most virulent puerperal poisons, and believes that llicy prove the casual relations of erysipelas to puerperal sepsis. Doyen also found, both in mild and severe cases of puerperal fever, a streptococcus similar to the one described b}^ Rosenbach and Fehleisen. lie made some inoculations to determine the relationship between puer- peral sepsis and erysipelas. The streptococcus found in the infected tissues of puerperal-fever patients caused er3'sipelas, and the streptococ- cus found in erysipelas developed puerperal fever. From his own obser- vations and experiments the author arrived at the conclusion that the microbe of puerperal sepsis is the same as that of erysipelas. From a clinical and bacteriological stand-point it is evident that puerperal sepsis from infection with the streptococcus of erysipelas can only occur when the streptococcus is brought in contact with an absorl)ing surface in the genital tract; but when this takes place, and the microbes reach the en- larged lymphatic vessels of the puerperal uterus, the most violent and fatal form of puerperal sepsis is almost certain to follow. RELATION OF ERYSIPELAS TO PHLEGMONOUS INFLAMMATION AND SUPPURATION. Some difference of opinion still exists, among bacteriologists, with regard to the question whether the streptococcus of erysipelas possesses pyogenic properties. The majority of those Avho have studied this subject experimentally do not consider the streptococcus of erysipelas as a pus-microbe, and assert that when suppuration takes place in er3^sipelas it is the result of a secondary infection with pus-microbes, and, on this account, look upon phlegmonous inflammation as a complication, and not as a condition belonging to the erysipelatous process. Hajeck made careful investigations to show that the streptococcus of erysipelas is neither in form nor culture materially different from the streptococcus P3"0genes, but he showed, also, that in 51 cutaneous or subcutaneous in- oculations with a pure culture of the streptococcus of erysipelas in rabbits the result was always a superficial migrating dermatitis which resembled to perfection erysipelas in man, Avhile similar injections with the strepto- coccus of pus produced a more intense and deeply-seated inflammation, which in almost ever}' instance terminated in suppuration. The diflTer- ence in the action of the two microbes on the tissues plainly demon- strated their non-identit3^ Microscopical examination of the inflamed tissue showed a still more important difference as far as the localization PHLEGMONOUS INFLAMMATION AND SUPPURATION. 369 and local diffusion of the microbes were concerned. Tlie microbe of er3^sipelas was alwaj-s found with the products of inflammation xvithin the li/mphatw vessels^ and only exceptionall}' in the connective-tissue spaces, which anatomically^ are onl}' a part of the lymphatic sj'steni. The pus streptococcus penetrates the tissues more deeply ; it is not only found in tlie l^'mphatic vessels and connective-tissue spKces, but it mi- grates beyond the lymphatic channels and infects different kinds of tissue . thus giving rise to a more deeply-seated and more intense injlammation. The streptococcus of erysipelas is found only exceptionalh' in the im- mediate vicinity of blood-vessels ; ivhile the microbe of pus can always be seen arranged in radiate lines around vessels entering the adventitia, the muscular coat, and often even in the lumen of the vessel. In man the same histological differences can be seen in the tissues the seat of erysipelatous and phlegmonous inflammation as in the artificial conditions in animals subjected to experiment, and the same pathological differences are also constantly found. The author asserts that Fehleisen was in error when he claimed that the formation of abscesses occurred independently of the erysipelatous infection. He affirms that in rabbits inoculated with the virus of erysipelas after the acute inflammation has subsided circum- scribed small nodules which remain may suppurate, but suppuration never becomes diffuse, while after injection with cultures of the strepto- coccus p3'0genes the inflammation assumes a phlegmonous type and the suppuration is always more diffuse. Hajeck maintains that under certain circumstances a circumscribed superficial suppuration can also take place in erysipelatous inflammation in man. When suppuration in a joint takes place, however, it is not caused b}^ the erysipelatous infec- tion, but is due to the presence of pus-microbes. Eiselsberg, Bonone, Bordini, Passet, and Simone are of the opinion that the streptococcus of erysipelas and the streptococcus of suppuration do not differ in their pathogenic effects. Smirnoff found in 1 case of erysipelas the specific microbe in the metacarpo-phalangeal joint of the left hand, which was the seat of the disease. In the case of a man who had died of erysipelas, enormous col- onies of the streptococcus were found in the right shoulder and knee joints. The synovial fluid injected into rabbits occasioned erysipelas migrans. Rheiner found Fehleisen's streptococcus in all cases of traumatic erysipelas which he examined, but was unable to find it in 2 cases of gangrenous erysipelas following t3'phus. In these cases he found bacilli which he believed were identical with Klebs-Eberth's bacillus of typhus. Kahlden, after a careful study of the recent literature on er^'sipelas, and the difference in opinion on the pathogenic properties of the strepto- 24 370 PRINCIPLES OF SURGERY. coccus erysipelatosus, remarks that the subtilit}" in the differences between the morphology' and the cultures of the microbe of erj-sipelas and the streptococcus of suppuration is undoubtedly the reason why no uniformity of opinion exists in regard to their specific pathogenic effects, especially as to the possibility of Fehleisen's streptococcus producing suppuration. To this I might add that not ever}- superficial diffuse inflammation of the skin is er3'sipelas, and not ever}' abscess occurring during, or soon after, an attack of erysipelas should be considered as a product of the erysipelatous infection. The surgeon will do well to adhere to the teachings of Fehleisen, who is positive in his assertion that the streptococcus of erysipelas never produces suppuration^ until more convincing proof shall have been furnished of the pathogenic identity- of the streptococcus of er3'sipelas and the streptococcus of suppuration. SYMPTOMS AND DIAGNOSIS. Erysipelas, like most of the acute infectious diseases, has no well- marked premonitory stage, the attack being sudden and followed b}' all the symptoms which usher in an acute febrile affection. The period of incubation in man has been fixed at from fifteen to sixt^'-one hours b}- the inoculations which have been made to produce the disease artificially for therapeutic purposes. Inoculations prove successful if the skin is punctured with a needle the point of which had been dipped into a pure culture of the streptococcus. Such punctures have no visible lesion after a few hours, — a fact which readily explains the disappearance of a visible infection-atrium at the time the disease appears, in cases of erysipelas developing without a demonstrable breach of continuity in the skin. In the adult the disease commences, almost without exception, with a chill which sometimes amounts to a severe rigor. Nausea and vomiting are often present during the first few hours. The chill is followed by a rise in the temperature, w^hich in a few hours increases to 104° F. or more. The fever assumes a continuous t^pe, and in uncomplicated cases the difference between the morning and ■evening temperature is slight. Headache, thirst, and complete loss of appetite are constant and promi- nent s^-mptoms. The pulse is at first full and bounding and seldom exceeds 100 beats per minute. In severe cases delirium is present almost from the beginning, and continues until the fever subsides. Almost simultaneously with the appearance of the general symptoms, the skin in the immediate vicinitj^ of the infection-atrium shows evidences of the existence of a superficial inflammation. The patient complains of a sense of tightness in the part, which is accompanied by a burning and itching sensation. SYMPTOMS AND DIAGNOSIS. 371 In traumatic erysipelas the wound presents no changes in its appear- ance ; if suppuration is present the purulent dischai'ge becomes some- what diminished in quantity and the pus is rendered more serous. The skin around the seat of infection is firmer to the touch, and if the er3'sipelas has started from a wound infection has occurred from a certain portion of the wound, wliile the remainder shows no evidences which point to er^^sipelatous inflammation. The skin which is involved by the er^'sipelatous inflammation presents, almost from the beginning, a characteristic rose or crimson color. With the appearance of the tj'pical discoloration the inflammator3' exudation has reached its height. The color disappears under pressure, but upon the removal of the press- ure no depression is left, showing that little or no oedema is present. The induration of the skin is most marked at the border of the erysipe- latous zone, and disappears with the absorption of the inflammatory product and the return of the natural color of the skin. Tlie margin of the zone is abrupt and distinct on the side of the healthy skin. The border of the erysipelatous zone is not straight, but irregular, and often fan-like projections can he felt which project into the healthy skin, and, when present, they are characteristic, almost jMthognomonic , of this form, of dermatitis. The degree of swelling varies according to the intensit}^ of the infection and the anatomical structure of the part involved. If the infection is intense and parts are implicated which are abundantly supplied with loose connective tissue, the swelling is greater than in cases where the infection is mild or the skin is stretched over firm, resisting parts. In facial erysipelas, for instance, the swelling is much greater around the orbits than in the scalp, because in the former locality the loose, cellular, connective tissue underneath the skin becomes swollen and oedematous from the escape into it of the inflammatory^ transudation. The specific inflammation, starting from the point of infection, spreads continuoush' and uninterrupted!}' along the course of the super- ficial lymphatics, but is not limited to the direction of the Ijmph-current. The intra-lymphatic diffusion of the streptococcus is not a passive, but an active, process. As this microbe is non-motile, its transportation in a direction opposite to the lymph-stream can only occur by its reproduc- tion. The lymph-current in most, if not all, of the inflamed lymphatic vessels is temporarily arrested by the blocking of the interior of the lym- p)hatic vessels with colonies of the streptococcus and the accumulation of lymph-corpuscles; consequently the colonies become fixed points from which new tissues are infected by their increase in size in all directions, owing to rapid reproduction of the microbe. Tiie fever continues until the infection comes to a stand-still. The intensity of the subjective 372 PRINCIPLES OF SURGERY. symptoms does not always correspond with the temperature, as patients may feel quite well when the temperature registers 104° to 105° F., while others show evidences of serious disturbance with a much lower temperature. Small vesicles and large bullae usually result from conflu- ence of a number of vesicles. The contents of these blisters are first serous, but suppuration may follow later from the entrance of pus- microbes. Bullae with haeraorrhagic contents denote a grave attack. The duration of erj'sipelas is extremel}^ variable. Genuine erysipelas may run a typical course and terminate in recover}'' in two days, or the disease may extend over a period of two weeks or more. The extent of surface successivelj^ invaded determines its duration. If it start from a wound of the hand it ma}- extend along the forearm and arm to the shoulder, from here along the back to one or both of the lower extremi- ties, and before such a large territor}' of skin has passed through all the stages of the disease more than four weeks may elapse. As soon as the disease ceases to migrate the general symptoms subside, and within a few days the skin returns to its normal condition, and the patient recovers his usual health in a remarkably short time, — a fact which tends to prove that er3'sipelas, in its uncomplicated form, does not impair the function of any of the internal organs to an}- considerable extent. Exfoliation of the skin is a usual occurrence. In the differential diagnosis we liave to consider lympliangitis, erythema, phlegmonous inflammation, and throrabo-phlebitis. In lymphangitis from other causes than the streptococcus of erysipelas tlie inflammation follows larger lymphatic channels, which appear as red lines, and seldom, if ever, is the skin proper inoculated in the inflammatory process, while erysipelas is a combination of lymphangitis with dermatitis. Erythema appears as circumscribed points of inflammation in the skin with healthy tissue between, while, on the other hand, erysipelas shows no such interruptions, the inflammation being a continuous, uninterrupted process followed by speedy repair. Phlegmonous inflammation is accompanied by inflamma- tion of the skin, which, in its external appearances, closely resembles erysipelas ; but the differential diagnosis rests on the location of the primary inflammation, which is always the superficial lymphatics of the skin in erysipelas, and the subcutaneous tissue in phlegmonous inflam- mation. In phlegmonous inflammation the deep-seated inflammatory exudation is the primary pathological condition, and the lymphangitis follows as a secondary result, while in erysipelas the primary specific lymphangitis and dermatitis are primary conditions, and if the subcu- taneous tissue become involved later on it must be regarded as a com- plication, and not as an integral part of the disease. Patients suflfering from erysipelas complain of a smarting, burning, or itching sensation in CLINICAL FORMS OF ERYSIPELAS. 373 the affected skin ; phlegmonous inflammation is attended by severe pain, which is of a tlirobbing character. Thrombo-phlebitis, starting from a chronic ulcer of the leg, has often been mistaken for erysipelas, not only by laymen, but also by phj^sicians. Thrombo-phlebitis is often attended by inflammation of the tissues around the inflamed vein and of the superimposed skin, but the inflammation follows in the course of the vein, and not in the course of lymphatics ; at the same time the vein can be felt as a solid, tender cord. CLINICAL FORMS OF ERYSIPELAS. The clinical forms of er3sipelas are identical in so far that they are all caused by the same microbe, and that the disease primarily consists of a specific l^-mphangitis and dermatitis; but the^' vary greatl}', accord- ing to the location and structure of the part affected, the intensity of the infection, and tlie existence of complications. Erysipelas Erythematosum. — This is the mildest form of erysipelas. It is described as ery thematic because the affected skin shows but little swelling, and the affection appears more as an efflorescence than an inflammation. No bulljfi form, and only slight exfoliation takes place during convalescence. Erysipelas Bullosum. — In this form the inflammation of the skin is more intense and the swelling more marked, in consequence of which blisters or bulla form underneath the cuticle. The pathological condi- tion resembles a burn in the second degree. Removal of the cuticle leaves the papillary layer of the skin exposed. The bullae often become the seat of secondary infection with pus-microbes, which transform the serous contents into pus. From such superficial foci of suppurative inflammation mny develop what has been termed — Phlegmonous Inflammation. — As we are not in possession of con- clusive proof that the streptococcus of erysipelas possesses pj'Ogenic properties, we can only explain the occurrence of phlegmonous inflam- mation of the tissues underneath the skin affected by erysipelatous inflammation b}' taking it for granted that the deep-seated phlegmonous inflammation is caused not only by the streptococcus of erysipelas, but by the accidental entrance into the tissues of microbes of suppuration. As soon as secondary infection with pus-microbes takes place the clinical picture of erysipelas is overshadowed or obscured by the suppurative inflammation. The typical general and local symptoms which char- acterize the erysipelatous inflammation give way to sjmptoms which indicate the existence of a diffuse suppurative inflammation. The tem- perature shows greater remissions, and the pulse becomes more rapid and feeble. The tongue is often red and dry, while all of the remaining 374 PRINCIPLES OF SURGERY. s3'^mptoms point to intoxication from absorption of ptomaines produced in the tissues by tiie i)us-nHerobes. The swelling of the part affected is no longer limited to exudation into the substance of the skin, but affects mainly the deep-seated tissues. We have reason to believe that in most, if not in all, cases of phlegmonous erysipelas the secondarj' infection with pus-microl)es takes place from a superficial suppurating focus as from a suppurating bulla, and that the microbes from here invade the subcutaneous connective tissue. The phlegmonous inflammation spreads with great rapidity, so that in a few da^^s the skin of an entire extremity may become under- mined with pus, the patient, in the meantime, having complained but little of pain. Such an extremit}^ on palpation imparts the sensation of a partially filled diffuse abscess-cavity. The external appearances furnish, often, no reliable indications of the extent of the deep-seated destruction. If incisions are made at this time a large quantity of pus escapes, mixed with shreds of necrosed connective tissue, and examina- tion reveals extensive destruction of the subcutaneous connective tissue and intermuscular septa. Phlegmonous inflammation, as a rule, does not attack tissues the seat of an erysipelatous inflammation, but the tissues weakened b^' this disease and infected with pus-microbes. A sudden increase in the temperature of patients suffering from erysipelas is often the first symptom which commences this complication, and such an occurrence should admonish the attendant to detect it early in order to subject it to timely and efficient treatment. Erysipelas Gangpaenosum. — This is an exceedingl}^ grave form of erysipelas. Most of the authors are of the opinion that if the strepto- coccus of erysipelas multiplies with suflScient rapidity, in the interior of the Ij^mphatic vessels and the connective-tissue spaces, so as to com- pletely' block these channels by its growth, a sufficient amount of ptomaines is produced to cause necrosis of the tissues, and under such circumstances the er3^sipelatous inflammation terminates in gangrene of the skin. This gangrene ma}' take in circumscribed multiple patches, so that after separation and elimination of the dead tissue the skin presents a cribriform appearance, or it may involve a large district of the skin, and then give rise to extensive loss of this structure in case the patient survives the disease. As the gangrene often commences in the portion of skin covered by bullae, it still remains an open question whether it results from the action of the streptococcus of erysipelas, or whether it is the result of a secondary infection with pus-microbes. Isolated patches of gangrene of the skin are met with in many cases that termi- nate in recovery, but extensive gangrene of the skin is alwa3^s a serious complication, as it may result in death from septicaemia, or, if life is not CLINICAL FORMS OF ERYSIPELAS. 375 destro3-ed, it at least greatl}- protracts the recoverj-jand often calls for a tedious treatment to restore the lost tissue by skin-graftins:. Erysipelas Metastaticum. — B3- metastatic erj-sipelas is meant the occurrence of an erysipelatous inflammation in an organ or a part where the process developed separately from the primary field of infection. If, for instance, er^'sipelas should appear in an extremity opposite to the one primaril}'^ affected, without extension of the disease across the skin of the trunk, it would furnish a good example of what is meant by metastatic erj'sipelas. Again, if during an attack of erysipelas of one of the extremities the patient should be attacked with s^-mptoms of men- ingitis, and at the necrops}- the streptococcus of erysipelas could be demonstrated in the inflamed envelopes of the brain, this would furnish another illustration of metastatic er3sipelas. Two possibilities present themselves in explaining the occurrence of metastatic er3'sipelas. In the first place, colonies of the streptococcus in an active condition might reach a part distant from the erysipelatous inflammation with the 13'mpli- current, and, meeting with favorable conditions, might establish an addi- tional focus of erysipelatous inflammation, which, of course, would have to be necessaril3^ in a part between the primary field of infection and the termination of the l3'mphatic vessels leading from the infected dis- trict. If no such connection can be established, then the metastatic process results from the entrance of streptococci in an active condition into the circulation and their localization in distant parts or organs by mural implantation upon the wall of capillar3' vessels prepared for their localization and reproduction. In most instances metastatic er3'8ipelas is of such an embolic origin. Erysipelas Migrans. — Migration of the inflammatory process is one of the characteristic clinical features of er3'sipelas. In ordinar3' cases migration is limited to the anatomical region affected. In cases of facial erysipelas the disease seldom spreads be3'ond the scalp, and in er3'sipelas of the extremities the disease usuall3' subsides after it has extended over an extremit3'. Migrating er3^sipelas is that form of the disease where the er3-sipelatous inflammation extends from place to place, and from limb to limb. I have seen this form most frequentl3' in infants, starting from the umbilicus or the external genital organs. I have seen it start from these points, ascend in an upward direction along the anterior aspect of the bod3', and, after reaching both shoulders, spread to the upper extremities, later to descend down the back, and finally terminate in the toes after traveling nearl3' over the whole surface of the bod3\ Er3'sipelas of the extremities or trunk never extends to the face or scalp, while, in exceptional cases, er3'sipelas of the face assumes the migrating form. Migrating erysipelas is usuall3- attended b3- onl3- moderate swelling 37() PRINCIPLES OF SURGERY. :uid slight constitutional disturbances. One peculiarity of this form of erysipelas is that the same regions may become involved a second time. Erysipelas Facialis. — This is the so-called spontaneous or idiopathic form of erysipelas, as in most cases even close inspection does not reveal the existence of an infection-atrium. The disease usually commences in one of the alae, or at the root of the nose, — localities where minute skin lesions are frequently produced, and localities which nu)re than any other part of the face are exposed to infection by contact As far as its extension is concerned, facial er3'sipelas pursues the most t^jiical course. The inflammation spreads toward the cheek and orbit on the side first aflfected, and then creeps across the bridge of the nose to the opposite side, to foHow a similar course here. About the second ortliird day it reaches the forehead, and from here and the outer margins of the orbits it invades the scalp, to terminate usually aljout the end of a week at the nape of the neck. The chin and anterior aspect of the neck never become affected in facial er3^sipelas. Facial erysipelas is attended by considerable swelling, the eyes being often completely closed bj- the oedematous lids. Bullae form frequently about the centre of the cheeks and the forehead. One of the dangers of facial erysipelas consists in the direct extension of the erysipelatous inflammation from the skin along the blood-vessels to the meninges of the brain. The meningitis under these circumstances is not a metastatic process, but the result of a direct extension of the inflammation from the skin to the meninges, along structures which connect them through the intervening skull. Patients who have suffered from facial er^'sipelas are not protected against subsequent attacks ; in fact, experience has shown that they are more prone to infection in the future than persons who have never suffered from this disease. If the bullae suppurate, there is always danger arising from suppurative throrabo-phlebitis, suppurative lei)to-meuin- gitis, and suppurative encephalitis, — fatal complications plainly attribu- table to secondary infection with pus-microbes. Traumatic Erysipelas. — We have seen that, in the strict sense of the word, all cases of erysipelns are traumatic in their origin, in so far that infection never takes place through an intact skin or mucous membrane; consequently the disease never occurs without an infection-atrium, which may be a wound or a lesion of the surface through which the strepto- coccus gains entrance into the lymphatic channels. The expression " traumatic er^-sipelas" is still retained for the purpose of designating er^'sipelas as one of the numerous forms of wound complications. If a recent wound is infected with the microbe of erysipelas the disease de- velops within fifteen to sixty-one hours after the accident or operation. PROGNOSIS. 377 The disease ma^- occur in consequence of later infection at any time before cicatrization is completed, as granulations furnish no absolute protection against infection. I have seen the disease originate more frequently in granulating than in recent wounds, — a strong argument in support of the advice that full antiseptic precautions should not be relin- quished until the healing process is completed, if the patient is to be pro- tected against an attack of erysipelas. Another important fact should always be remembered : that small wounds are more frequently attacked by erysipelas than large wounds, because the latter receive more careful attention, and are, as a rule, subjected to more rigid antiseptic treatment. PROGNOSIS. Simple uncomplicated erysipelas is not a fatal disease unless it attacks infants or persons debilitated b}- age or antecedent diseases. Death is caused more frequently by complications. The most common fatal complications are suppurative inflammation at the seat of erysipe- latous inflammation, or metastatic suppuration in distant parts or organs, resulting from secondar}- inflammation with pus-microbes, or, finally, ex- tension of the erysipelatous inflammation to important organs, as the brain or its envelopes, in cases of facial erysipelas, or the occurrence of metastatic erysipelas in vital organs from embolic processes. The prog- nosis is, thei'efore, based largely upon the absence or presence of com- plications, which must be carefully sought for in all cases where general or local s3-mptoms point to their existence. The temperature, pulse, and condition of nervous and digestive organs furnish important and valuable prognostic indications. TREATMENT. The number of specifics which at diflerent times have been recom- mended in the local and general treatment of er^'sipelas must throw doubt upon tiie etticac}' of an}' local applications or internal remedies in arresting the further progress of erysipelas. At the same time it must not be forgotten that uncomplicated erysipelas is a disease which tends to spontaneous recover}', and seldom proves fatal, even if it is al- lowed to pursue its own course, unaided by any local application or in- ternal medication. The erj'sipelatous inflammation is of short duration, and passes through its diflerent stages uninfluenced by local or general treatment. Since its microbic origin has been suspected diff"erent meth- ods of treatment have been recommended to arrest the further progress of the disease by destroj'ing or rendering inert the primarj' cause. Hueter aimed at the destruction of the specific microbe by injecting at diflerent points at the border of the erysipelatous zone 5 to 6 cubic 378 PRINCIPLES OF SURGERY. centimetres of 3-per-cent. solution of Ccirbolic acid. This method of treat- ment in the hands of others has been followed almost without exception by negative results. It is possible that subcutaneous injections of a 1-to-lOOO solution of corrosive sublimate in non-toxic doses would yield better results. The continued application of cold, even of an ice-bag, has been found useless in arresting the disease. As it has been found that a temperature of over 40° C. continued for two days has at least an inlii])itory effect on the growth of the streptococcus of erysipelas in artificial nutrient media, it would appear rational to resort to hot anti- septic compresses in the local treatment of erysipelas. If the area involved is limited, a compress, saturated with a weak hot solution of corrosive sul)limute, would answer a most admirable purpose. If a large surface is affected some of the weaker germicidal solutions could be used in the same manner. Moisture and heat relieve also the burning, smart- ing sensation more promptly and eflicientl}' than the different filth}' oils and salves wliich have been employed. Application of tincture of iodine, muriated tiucture of iron, and solutions of nitrate of silver are worse than useless, because they destroy the skin, which shoiild be carefully preserved in order to protect the patient against secondary infection Avith pus-microbes. Recently Kraske recommended multiple minute incisions or, rather, scarifications in the skin, at the peripheral zone of the erysipelatous inflammation, for the purpose of preventing further extension of the disease. If the skin is first rendered aseptic, and subsequent secondary infection is guarded against by the application of a reliable anti- septic, this treatment may prove valuable in modifjang the progress of the disease. After scarification a hot, moist, sublimated compress should be applied, to be immediately replaced bj' another wdien removed. The external use of ichth3'ol, so highl}^ recommended by Nussbaum, has proved useless in my hands, both in relieving suffering and in prevent- ing the extension of the disease. Wolfler has recently called attention to the value of the mechanical treatment of erysipelas. He has published 18 additional cases of ery- sipelas treated b}^ pressure of strongl^y adhesive plasters. After the plaster is applied the disease extends into the compressed parts of the skin, which swell considerably and remain swollen for several days, and then both the swelling and the fever diminish. He recommends that by way of precaution a second line should be commenced several centi- metres distant from the first. The part must be carefully inspected once or twice dail}- in order to detect any loosening of the plaster. Occa- sionally the erysipelatous inflammation extends in diminished intensit}'^ for a short distance bej'ond the first line of plaster, but this does not TREATMENT. 379 last long. This method of treatment is at least harmless, and if future experience should prove, as it probably- ^vill, that it will not succeed in arresting the local extension of the disease, it will at least provide an eflScient protection for the inflamed skin. Phlegmonous inflammation and metastatic suppuration should be prevented, as far as possible, by the emplo3'ment of such measures as will guard against the formation of suppurating foci in the inflamed skin. Bulla? should be evacuated as soon as they form by puncturing with an aseptic needle, carefully preserving the cuticle as a protection against the entrance of pyogenic microbes. Infiltrated air should not reach the inflamed skin, and lor this purpose it should be covered either with an antiseptic, moist compress, or a thick layer of antiseptic cotton. The skin is disinfected in advance of the extension of the disease, and is sub- sequentl}' protected against additional infection by applying a hot, moist, antiseptic compress, or by covering it with antiseptic absorbent cotton. If suppuration take place in the interior of bullye the cuticle should be removed, after which the surface is carefull_y disinfected by irrigation with a germicidal solution, followed by an application with a 10-per-cent. solution of chloride of zinc, and further infection prevented by an anti- septic dressing. If phlegmonous inflammation develop in spite of these prophylactic measures, early and free incisions are made, free drainage established, and a subsequent treatment followed out appropriate for phlegmonous inflammation not complicated b}' erysipelas. Gangrene of the skin is to be treated by appl3'ing a hot antiseptic compress until the dead tissue is eliminated, when the defect is replaced by skin-grafting. Internal medication has even been less satisfactor}^ than the local meas- ures in the treatment of er^^sipelas. During the febrile stage the admin- istration of the tincture of ferric chloride and the mineral acids does more harm than good. If the temperature is high, a daily antipyretic dose of quinine is indicated, and exerts a favorable influence upon the local process and the general condition of the patient. If the patient is restless a full dose of Dover's powder should be given at bed-time. Sj^mptoms of prostration are met earl}- by the use of a substantial wine or some other alcoholic stimulant. Symptoms of collapse are treated b}' administering internally 1^ grains of camphor every hour, or the same amount of the drug is dissolved in oil of sweet almonds and injected subcutaneouslj' everv half-hour or hour until symptoms of intoxication, delirium, and reduc- tion of the pulse to 50 or 55 beats per zninute are produced. The cam- phor treatment in grave cases of erysipelas was introduced by Pirogolf. and has yielded excellent results when the threatening symptoms point to an enfeebled heart. 380 i'KINCIPLES OF SURGERY. ERYSIPELOID. A new form of infective dermatitis, which in many respects resembles erysipelas, has been recently described by Rosenbach under the name of *' erysipeloid." It attacks usuall}' the fingers and exposed portion of the hand, and is most frequently met with in persons who handle game or dead animals, as cooks, butchers, fish-dealers, and tanners. The affec- tion starts from some minute abrasion of the skin as a bluish-red infiltra- tion, which slowly advances in an upward direction. The inflamed parts are the scat of a burning, smarting sensation. While the skin at the l)oint of infection returns to its natural condition and color, the zone of infiltration becomes larger, as it continues to spread until the disease api)e:irs to exhaust itself in the course of from one to three weeks. The infectious material which produces this disease is contained in decom- posing animal substniices. Infection may take in any abraded part of the body which comes in contact with material containing the virus. The temperature remains normal, and the general health is not affected. The inflammation travels ver_y slowly, so that if infection take place in the tip of a finger it reaches the metacarpo-phalangeal joint in about eight dajs, and during the second week it spreads over the back of the hand, from where an adjacent finger may become affected, the extension then taking a direction opposite to the lymph-current. Repeated experiments to obtain a pure culture of the microbe failed, until in November, 1886, the author succeeded in cultivating it upon gelatin from a case in which the disease could be traced to infection from old cheese. The author injected a pure culture under the skin of his own arm at three different points. After forty -eight hours he experienced a smarting, burning sensation at the points of injection ; at the same time a circumscribed redness appeared around each puncture, which soon be- came confluent. On the fifth day each puncture was surrounded by a zone of inflammation the size of a silver dollar, somewhat elevated above the niveau of the surrounding skin. While the centre of this red patch became pale, the zone of inflammation continued to enlarge. In the in- flamed skin the capillary vessels could be seen dilated, — a condition of the circulation which imparted to the tissues an arterial hue with a slight tinge of brown, while inside of the zone the color was a livid brown. In the skin which had returned to its norm;il pale color slight suggillations appeared, as though some of the red blood-corpuscles in the tissues had been destro3'ed during the progress of the disease. The in- flammation appeared to have completely subsided on the eighth day, when the smarting sensation returned, and a new zone appeared around the old one. On the tenth day the area measured in its transverse diameter 24 centimetres, and in the parallel direction of the arm 18 centimetres. ERYSIPELOID. 381 After this the affection disappeared permanentlj'. During all this time tlie general health remained unimpaired, and the temperature varied from 36.8^ to 3T.2° C. A microscopical examination of the pure culture showed that it was composed of swarms and heaps of irregular, round, and elongated bodies somewhat larger in size than the staph3do- coccus. The author first believed that these bodies were cocci, but later he saw a net-work of intertwining threads, and decided that they were thread-forming microbes. In old cultures the threads were verj' abun- dant, and arranged in everj' possible wa3- and direction. These threads appeared as though branches were given off, but on closer examination it could be seen that no organic connection existed between them. Ter- minal spores at the tips of the threads were numerous and could not be stained. Neither the microbes nor the threads manifested motile power in the culture, or when suspended in water ; a gelatin culture became visible on the fourth day as a delicate cloud, which increased in size ver}' slowly at a temperature of 20° C. The older cultures change into a brownish-gra}' color, and then resemble the culture of the bacillus of septicaemia in mice. In cultures 4 months old the growth was not entirel3' suspended. The author, as j-et, has not given a name to this microbe, but believes, on botanical grounds, that it belongs to the " clado- thrix " variety of micro-organisms. He wished to ascertain the action of this microbe on lupus, but in several cases in which it was tried the inoculations failed. Erysipeloid is a harmless form of infection, and subsides spontaneouslj" in the course of two or three weeks. I have seen a number of cases in persons handling fish and game, Avhere the affection started in one of the fingers, extended slowl}- as far as the dor- sum of the hand, and then gradually invaded an adjacent finger and the buck of the hand as far as the wrist. In the cases that have come under my observation the infiamniation never extended be^'ond the wrist. The disease is self-limited, and its local extension is not arrested by an}- topical applications. CHAPTER XV. Tetanus. The wound-infective diseases in which the microbes or their pto- maines act upon the central nervous s_ystem are represented by tetanus and hydrophobia. The specific microbes which are the cause of these diseases produce no gross pathological changes in the brain or spinal cord, but the minute tissue changes cause a central irritation, which is manifested by spasm of certain definite muscular groups. Tetanus is an infective disease in which the specific microbic cause exerts its patho- genic action on the central nervous sj'stem, and which is clinically char- acterized by spasm and rigidit}^ of definite muscular groups. BACTERIOLOGICAL STUDIES. The classification of tetanus with the infectious diseases is of recent date, but the infectious nature of the disease was well known and estab- lished before the discovery of the bacillus tetani. In 1859Betoli related the case of a bull that died of tetanus after castration. Several slaves ate some of the flesh of the dead animal, and of these 3 were (in a few days) seized with tetanus and 2 of them died. He adds, further, that in Brazil, where this occurred, the flesh of animals dead of tetanus is generall}' regarded as capable of transmitting the disease. In 18V0 Auger reported a case in which a horse had spontaneous tetanus, after which 3 puppies which had been in the same stable were also affected. Larger, in 1853, saw a woman who had a fall while cleaning a farm-yard, causing a slight wound of the elbow. Four weeks later she was seized with tetanus, and on investigation it was found that a horse affected with that disease had been in a stable opening into the yard where she fell. He also mentions another circumstance which strongly points to the infectious nature of tetanus. In a small village, where tetanus was previousl}^ unknown. 5 cases appeared in eighteen months under quite different chmatic conditions. Of these, 1 had been taken to a hospital, after which 2 others in the same ward became aff"ected with the disease. In 1884 Carle and Rattone produced the disease artificiallj- in animals by inoculations with pus from tetanic patients. Nearly at the same time the real microbic cause of tetanus was discovered by Nicolaier and Rosenbach. Nicolaier showed the exogenous origin of the disease by (383) 384 PRINCIPLES OF SURGERY. finding a bacillus in earth, which produced tetanus in animals when injected into the tissues, llosenbach found the same bacillus in the pus of a patient suffering from traumatic tetanus. The identity- of the bacillus of tetanus with Nicolaier's bacillus of earth tetanus was demon- strated in Koch's laboratory, April 10, 1887. Bacillus Tetani. — Rosenbach describes the bacillus as an anaerobic micro-organism which presents a bristly appearance, with a sjjore at one of its extremities which gives it the resemblance to a pin, or drum-stick. According to Kitasato the bacilli produce spores in thirty hours in cultures kept at a temperature of the body. They possess great resistance to heat, as they have been found active after an exposure of one hour to 80° C. of moist heat, but they are destroyed by placing them in a steril- FiG. 89.— Tetanus Bacilli. Spore-bearing Rods from an Agar Cttlture. Mounted Preparations, Stained with Fuchsin. x 1000. (Frunkel-Ffeiffer.) izer heated to 100° C. for five minutes. The bacillus has been found in different kinds of surface soil and in street-dust. In man it has been found in tetanic patients in the wound-secretions, in the nerves leading from the seat of infection, and in the spinal cord. Cultivation. — Rosenbach found it impossible to obtain a pui-e culture ; although he resorted to fractional cultivation, it was found that the last cul- ture was still contaminated by one or more additional microbes. Fluegge claimed to have obtained a pure cultivation by heating for five minutes the mixed culture to 100° C, but after this procedure the bacillus was incapable of further propagation. After many trials it was found that sterilized solid blood-serum was the best soil for the propagation of the bacillus outside of the bod}'. Both Xicolaier and Rosenbach observed BACTERIOLOGICAL STUDIES. ' 385 the anaerobic nature of the bacillus, as it was found impossible to obtain a culture b}^ streak inoculations, or in any other manner by which oxygen could not be excluded. The culture appeared slowl}', as a delicate, whitish-gra}' film, in the track of the stab inoculation, below the surface of the culture substance. B3' a long series of cultures, Rosenbach finallj' succeeded in eliminating all other microbes, with the exception of a bacillus of putrefaction. The growth of the bacillus takes place most readily at an equable temperature of 37° C. (98.6° F.), and becomes first visible about the third daj' in the depth of the culture media. Kitasato has finall}' succeeded in obtaining a pure culture of the bacillus of tetanus from pus taken from a patient suffering from this disease. As the bacillus will only grow where atmospheric air can be excluded, he exposed his cultures to hydrogen gas with complete exclusion of oxygen. Mixed cultures, which had been kept for several da3-s in the incubator, were then exposed for half an hour to a temperature of 80° C. Further growth was then obtained upon plate cultures in closed glass vessels filled with hj-drogen gas. By heating the mixed culture to 80° C. he destroyed all microbes with the exception of the bacillus of tetanus, which, later, was cultivated upon solid nutrient media in an atmos- phere of hydrogen gas. At a temperature of 18° to 20° C, a visible culture appeared at the end of a week. If the temperature was increased to blood-heat the bacilli and spores developed more rapidl3\ Inoculation Experiments. — Nicolaier produced tetanus in rabbits and mice, experimentall}^, by inoculations with different kinds of surface soil. Out of 140 experiments, in 69 a disease was produced identical with tetanus in man. In the pus, at the point of inoculation, bacilli and micrococci were constantl}' found. Among the bacilli one form was constantly present; this bacillus resembled in appearance and culture the bacillus of septicaemia in mice, but was more slender. This bacillus was found in isolated places in the connective tissue, but could not be found in the muscles, nerves, and blood. Earth sterilized by exposing it to a high temperature for an hour proved harmless, showing conclusively that the contagium of tetanus liad been destroyed. Inoculations with pus taken from tetanic animals were most successful. Inoculations with mixed cultures grown in solidified blood-serum j-ielded positive results. Rosenbach made his experiments with mixed cultures grown from pus, taken from the line of demarcation of a case of frost gangrene, in a patient who had died of tetanus. The inoculations proved successful. Bonone reports the case of a man suffering from paraplegia, the result of disease of the spine in the dorsal region, complicated by an exten- sive sacral decubitus, the seat of phlegmonous inflammation, who was 25 386 PRINCIPLES OF SURGERY. suddenl}^ attacked by tetanus, which proved fatal in two days. One hour after death a small portion of the infiltrated tissue around the gangre- nous part was removed, and after reducing it to a fine pulp by tritura- tion he injected it under the skin of a rabbit. Twenty-two hours after inoculation tlie animal died with well-marked symptoms of tetanus. The products of inflammation from the point of injection thrown into tlie subcutaneous tissue of other animals produced the disease, while intra- venous injections proved harmless. The gravit}^ of symptoms following subcutaneous injections was commensurate with the quantity of fluid injected. Guinea-pigs proved less susceptible to infection than rabbits. In the pus taken from the dead tissue he found, ])esides the usual pus-microbes, a bacillus which resembled in every respect the one de- scribed by Nicolaier and Rosenbach. Hochsinger made his observations on a case of tetanus which proved fatal on the fifth day. The day before the patient died blood was abstracted from a vein, under strict antiseptic precautions, for microscopical and bacteriological study. No micro- organisms could be found in it. With the greatest care sterilized, solid blood-serum was inoculated with the blood, by making, with the needle, both superficial streaks and deep punctures. The nutrient medium was kept at a temperature of 37° C. (98.6° F.). On the third day a white, cloud}' streak marked the direction of the deep punctures, while the superficial plant remained sterile. On the third day a portion of the culture was removed and stained with aniline gentian, and the character- istic bacillus was found. A large rabbit was infected by injecting blood obtained from the patient during life. The blood was diluted with sterilized water, and a syringeful of this mixture was injected under the skin in the iliac region, and half of this quantity under the skin of the left thigh. The next da}' the animal was quite ill and unable to use the left hind-leg, which was dragged along in walking. At this time great nervous excitability was observed, the exaggerated reflex symptoms being especially well marked in the posterior extremities, which, on the slightest touch, were thrown into clonic spasm. On the following day the animal was found dead. A few hours before death well-marked symp- toms of tetanus developed. Injections of blood from this animal pro- duced no results in otlier rabbits, and culture experiments were equally fruitless. A syringeful of inspissated blood of the patient, kept for three weeks, thrown under tlie skin of a white mouse, was followed by a fatal attack of tetanus, while a second animal inoculated in a similar manner with one-half of this quantity remained perfectly well. Fluegge had before observed that by injecting blood from animals rendered tetanic by inoculation it was noces^ary to use a large quantity in order to reproduce the disease in other animals, and even by doing so BACTERIOLOGICAL STUDIES. 387 the result was not alwaj^s satisfactory. It appears that the blood of tet- anic patients possesses greater toxic properties than the blood of animals suffering from the same disease. Hochsinger also made inoculations with the mixed cultures. A S3^ringeful of a liquid culture was injected into the subcutaneous tissue of a medium-sized rabbit. The next day the reflexes were increased, respiration more rapid, and the animal appeared otherwise quite sick. On the third day the posterior extremi- ties were stiff, the animal dragging them in walking; reflex irrital)ility enormousl^^ exaggerated. On the fifth day the animal died, with well- marked symptoms of tetanus. A number of similar successful experi- ments are reported by the same autlior. In rabbits, Fluegge estimated the stage of incubation at from three to five days, and the duration of of the disease, from the time the first S3'mptoms were noticed to tlie fatal termination, from five to seven days. Beumer gives an accurate and able description of his studies in 2 cases of tetanus. Tlie first case occurred in a mechanic, who injured himself under the nail of the right middle finger with a splinter of wood. Eight da3's after the injur}', tlie patient having had but sliglit pain in the finger, pains appeared in the neck and muscles of the back. Tlie next morning spasms of the muscles of the chest, abdomen, and jaw developed. These attacks occurred at intervals of an hour and a half Four daj^s later the lower extremities were affected, also the upper, but in a less degree. An incision was made and the foreign bod}' removed, which was followed b}^ the escape of a drop of pus ; death on the fourth day. The second case was a boy 6^ years old, who was brought into the clinic with well-marked symptoms of tetanus, and who lived only a few hours after his admission. The author obtained some of the dust and splinters of wood from the place where the mechanic had injured himself, and in- serted small particles under the skin of mice and rabbits. In all experi- ments the animals were attacked with tetanus in from two to three daj'S after inoculation, and during the third or fourth. The spasms were always noticed first in the muscles nearest the point of inoculation. A fragment of tissue from the sole of the foot was taken from the bo}^ and small particles of it inserted into the subcutaneous tissue of 6 mice. In all of these symptoms of tetanus appeared after two days, developing gradually into general convulsions and death. The same results were obtained in mice and rabbits b}' inoculations of particles of dust taken from the spot where the boy sustained the injury. The same author also made numerous experiments with different kinds of earth. Of 10 experiments with soil taken from the ocean- beach, tetanus followed in onl}' 2. On the other hand, of 10 inocu- lations with garden-earth and street-dust, all proved successful but 1. 388 PRINCIPLES OF SURGERY. Of the greatest scientific and practical interest are the observations made b^' Bonone, in reference to the causation of tetanus by infection with earth containing the bacillus discovered by Nicolaier. He had an opportunit}' to observe a number of cases of tetanus after the earth- quake at Bajardo. Of the 70 persons injured in the ruins of the church, 7 were attacked b}' tetanus. From bacteriological investi- gations in connection with these cases, he came to the same conclusions in regard to the cause of the disease as Nicolaier, Rosenbach, Fluegge, and Beuraer before him. Of special importance is the observation made by him, that the secretions from the wounds and the exudation from the part, the seat of tetanic convulsions, when dried and preserved between two sterilized watch-glasses, retained tlieir virulent properties for at least four months. All animals inoculated with dust from the debris in the interior of the church were attacked with tetanus. Control experiments with dust from the ruins at Diano-Marina were alwa3's followed by nega- tive results. Of the many persons injured during the same earthquake at this place, not one Avas attacked by tetanus. Ohlmiiller and Goldsclimidt made a thorough bacteriological inves- tigation of a case of tetanus following complicated fractui'e of the right thumb. The disease appeared the da^' following the injury, and proved fatal in seventeen hours. Soon after death inoculation experiments were made with blood taken from the heart and spleen, and pus from the seat of fracture. The cultures were grown in solid blood-serum kept at a temperature of 38° C, (100.7° F.). The tubes containing blood from the heart and spleen remained sterile, but the nutrient media infected with pus showed signs of growth. The bacilli which were detected re- sembled those of mouse-septicsemia, onlj- somewhat larger in size. In addition to these microbes streptococci and a thick bacillus were found. Two mice were inoculated with this mixed culture. Twelve hours after infection tetanus developed, followed b}^ death in seventeen hours. The spasms commenced in the tail, extended to the posterior extremities, and then gradual]}' advanced in a forward direction. From these animals blood-serum was taken, with which other mice were infected. Again, tetanus was produced, and successful cultivations were made of 2 mice of equal size and age; 1, which received one portion of a culture, died of tetanus on the ninth day, wliile the other, which received a dose three times as large, died on the third day. Of 3 cases of tetanus which recently came under the observation of Lumniczer, he Avas able to demonstrate the microbic origin in 1. In this case the attack followed a gunshot injury. After the disease had developed fragments of hemp were removed fi'om the canal made b\' the bullet, and in them the char- acteristic bacillus was found. Cultures were made to the tenth genera- BACTERIOLOGICAL STUDIES. 389 tion, and with them animals were inoculated, and tetanus was invariably' produced. Pus taken from abscesses produced at the point of inocula- tion contained the bacillus, and inoculation experiments made with it yielded positive results. Cultures made from the blood or organs of the tetanic animals remained sterile. Inoculations with blood from these animals proved harmless. Kitasato experimented with a pure culture of the bacillus of tetanus on mice, rats, guinea-pigs, and rabbits, and never failed in producing the disease, provided a sufficientl}' large dose of the culture was adminis- tered. In mice the disease appeared, without exception, twenty-four hours after the inoculation, and proved fatal in two to three daj'S. The tetanic convulsions were first always local, appearing first in the muscles nearest the point of inoculation, and becoming gradually' more diffuse. He was unable to find tlie bacillus at the seat of inoculation, the blood, or in any of the internal organs. He is of the opinion that if tetanus is produced by inoculation with a pure culture the bacilli do not remain in the body for any length of time, but are rapidly eliminated. The ex- periments and clinical observations which have just been quoted furnish conclusive proof that tetanus is a microbic disease, and that the bacillus of tetanus discovered by Nicolaier and Rosenbach is its essential cause. Whether cultivations from chronic cases of tetanus can produce an acute and rapidly-fatal attack in animals remains to be determined. In this direction I have recently' made an observation which, if not convincing, is at least very suggestive. A boy 15 j-ears of age, previousl}' in good health, was attacked with acute osteomyelitis in the lower extremity of the femur. The surgeon in attendance trephined the bone just above the external cond^-le during the first few da3'S,and before an abscess had formed in the soft parts. A few da3-s after the operation trismus set in, followed by typical chronic tetanus. Six weeks later the patient entered the Milwaukee Hospital, and was placed under m}' charge. At this time the patient had become emaciated to a skeleton. Trismus and opisthotonus were well marked, and the lower ex- tremities were rigid and fixed in the extended position. The slightest touch, or a draught of air in the room, would bring on intense convul- sive attacks for several minutes, attended b}' excruciating pain. Pro- fuse fetid discharge at the site of operation ; pulse, 140 ; temperature, from 99° to 101° F. (37.3° to 38.8° C). Believingthat the primary infection had taken place through the operation wound, and that the osteomjelitic products served the purpose of a nutrient medium for the bacillus tetani, I determined to operate in spite of the grave s3nnptoms. As the spinal cord at this stage of the disease was necessaril}- the seat of the intense congestion, I resorted to chloroform as an anoesthetic in preference to 390 PRINCIPLES OF SURGERY. ether. The usual operation for necrosis of the lower end of the femur was made, and a large triangular sequestrum removed from the lower and posterior aspect of the bone. The involucrum was defective, and its inner surface was found lined with a thick layer of flabb}- granulations. Gelatin tubes were inoculated with blood, pus, and granulation tissue. The tube inoculated with blood remained sterile, while the two remaining tubes showed a copious growth of staphylococcus pyogenes albus, which rapidly liquefied the gelatin. A portion of the granulation tissue was disinfected with a weak solution of carbolic acid, dried between layers of antiseptic gauze, and inserted under the skin of a full-grown, large rabbit. No suppuration followed, and the animal remained perfectly well for six weeks, when both posterior extremities became rigid and could not be used in walking. The next day tetanic convulsions aflfect- ing the muscles of the back and all the limbs appeared, and on the fourth day death supervened. The interesting features in this case are that the patient recovered from the tetanus after a long illness, extending over three months ; that marked improvement followed the operation, which had for its object thorough disinfection of the infection-atrium; and that the inoculation with granulation tissue in the rabbit was followed by an acute attack of tetanus after an incubation stage extending over six weeks. In the ex- periments related above the animals were inoculated with cultures, earth, other infected foreign substances, fi-agments of diseased tissue, or with wound-secretions from tetanic patients ; the stage of incubation rarely extended over two or three days, and often the spasms appeared in eighteen to twenty-four hours, and the disease produced death in from two hours to three days. The same question has been raised in connection with the pathogenic action of the bacillus of tetanus as with pus-microbes: Is the disease of which it is the specific cause due to the presence of the microbe, or the ptomaines which it elaborates in the tissues ? Ptomaines of the Bacillus Tetani. — Brieger, by his indefatigable labors, has demonstrated beyond all doubt that the ptomaines of the bacillus of tetanus cause tetanic convulsions. Str3'chnia in toxic doses produces a condition which, so far as the muscular spasms are concerned, closely resembles tetanus. If this and other drugs belonging to the same group can act upon the si)inal cord in such a manner as to cause spasms and muscular rigidity, we should, a priori, expect that if the microbe of tetanus produce ptomaines in the tissues these might produce the same eflTect on the cord, and that the symptoms are produced by them and not b}^ the direct action of the microbe. Nearly all authorities are agreed that the bacilli present in the blood of tetanic patients are BACTERIOLOGICAL STUDIES. 391 few, and iu animals in which the disease was produced artificially the blood was often found sterile. More microbes have been found at the seat of primary infection, and in the tissues between it and the spinal cord, than in the blood itself, — another proof that the direct cause of the disease is the product of the microbes, and not the microbes themselves. Brieger has succeeded in isolating four toxic substances from mixed cultures of the tetanus bacillus in sterilized emulsion of meat. The first, tetania, in doses of a few milligrammes, administered subcutaneously in mice, produced the characteristic symptoms of tetanus. The second, tetanotoxin, causes, first, tremors; later, paral^'sis and convulsions. The third, muriate of toxin, has not been designated by a special name ; it produces also well-marked symptoms of tetanus, but, besides, excites the salivary and lachrymal glands to increased functional activity*. The last, sjMsnwtoxin, produces severe clonic and tonic spasms, which prostrate the animal at once. Besides meat-emulsion, the contused brain-substance from horses and cattle was used ; also cows' milk mixed with carbonate of lime. It seems that the culture substance determined, to a certain extent, tlie kind of toxin which was produced ; thus, in cultures grown in brain-substance, besides the tetanin, tetanotoxin was found in greatest abundance ; old cultures, in which the tetanus bacilli were dead, produced none of these toxic substances. The same author has very recently been successful in isolating tetanin from the amputated arm of a patient the subject of tetanus. The disease had developed a few days after a severe crushing injury of the hand and forearm. The first symptoms manifested themselves in the morning, and at 12 o'clock (noon) the operation was performed ; at 5 o'clock on the same day the patient expired suddenlj^ during one of the tetanic convulsions. The bacilli of tetanus were found in the serum taken from the oedematous portion of the forearm, in connection with other bacilli of different length, — staphylococci and streptococci. Serum containing these microbes injected under the skin of mice, guinea-pigs, and rabbits invariably produced tetanus. On the other hand, a dog treated in the same manner, as well as after injections of tetanin, remained well. A horse inoculated with a culture of bacilli in meat-emulsion showed no symptoms of tetanus, but an abscess formed at the point of inoculation. The infiltrated tissues of the amputated arm planted on sterilized meat-emulsion, solid blood-serum, and emulsion made of the flesh of fish, yielded, besides ammonia, only tetanin; no trace of tetanotoxin, spasmotoxin, nor the unnamed toxin which could be obtained from Rosenbach's bacillus. A moderate dose of tetanin injected into the subcutaneous tissue of a horse produced muscular contractions which lasted for a considerable length of time, but the 392 PRINCIPLES OF SURGERY. characteristic S3"mptoms of tetanus, as witnessed in horses suffering from tetanus, did not appear. ETIOLOGY. The clinical and experimental researches just quoted demonstrate that the bacillus tetani is found in the wound-secretions, the tissues, and, in some instances, in the blood of tetanic patients, and that tetanus in animals can be produced artificial!}^ bj' injections of wound-secretions of tetanic patients, or by using mixed or pure cultures, — facts which have firmly established tlie microbic nature of the disease. The essen- tial cause of tetanus is the bacillus first discovered b}' Nicolaier in earth, and by Rosenbach in the wound-secretion of a tetanic patient. Period of Incubation. — The period of incubation, both in man and animals, appears to be extremely variable, in some instances lasting only twent3'-four hours, while in otliers weeks ma}' elapse between the time of infection and the first manifestations of the disease. This may depend on one of three things: 1. The number of bacilli introduced may be so small that a much longer time is necessar}' before active S3'mptoms are produced than if a larger quantit}' had been introduced, as Watson- Cheyne has shown that in animals the injection of a limited number of the bacilli of tetanus produced no sj'mptoms. 2. The location of the infection-atrium and anatomical cliaracteristics of the tissues surround- ing it ma}- influence the time which is necessary to develop the disease. 3. Brieger's investigations have shown that tetanic convulsions in animals are produced by injections of tetanin, — one of the toxic ptomaines derived from cultures of the bacillus of tetanus ; and it is more than probable that the active S3'mptoms of tetanus in man are due not to the presence in the tissues of tlie bacillus, but to the toxic action of the ptomaines on the spinal cord; so that the duration of the period of incubation is further modified b}^ the capacity' of the infected tissues to yield the different ptomaines. The degree of virulence of the bacillus of tetanus must certainly play an important part, not onl}- in determining the duration of the incubation stage, but also the gravity of the disease. Specific Microbic Cause. — There can be no doubt that both the acute and chronic forms of tetanus are caused by the same microbe, and that the clinical difference depends upon the degree of virulence of the primar}' cause, on the one hand, and the degree of susceptibilit}' of the individuals to tetanic infection, on the other. In reference to the susceptibility to infection with the bacillus of tetanus, it has been shown b}^ reliable statistics that the colored races, under the same conditions, are attacked more frequently b}' tetanus than the Caucasians. Inoculation experiments have shown that the greatest ETIOLOGY. 393 difference exists among different kinds of animals in tliis respect, and there is no reason whiy tiie same difference of susceptibility to this dis- ease should not exist in the human species. As the natural habitat of the bacillus of tetanus is the soil, we can readily understand that the disease should occur more frequentl}' in some localities than in others, and why it is more prevalent in southern than northern climates. The excretions and cadavers of tetanic animals may infect the soil, where, under favorable conditions, the bacillus may multiply, and in this manner a greater or less portion of the surface soil becomes a nutrient medium, in which an immense culture is developed from which new cases can become infected. A Avarm climate is more favorable for the unlimited reproduction of the bacillus in the soil tlian northern countries ; hence the greater prevalence of this disease in the tropics. Infection -Atrium. — As the bacillus of tetanus is the essential cause of the disease, the remaining causes are accidental conditions, which result in the formation of an infection-atrium. We have no evi- dence that the bacillus can enter the tissues through an intact mucous membrane or unbroken skin. Idiopathic tetanus, so called, is a clinical form of tetanus where even the most thorough examination reveals no infection-atrium. As in cases of erysipelas, under similar circumstances, the local lesion may have been so insignificant as not to have attracted the patient's attention, or if he was cognizant of it at the time it maj- have completely disappeared at the time the first symptoms developed themselves. In t7'ismiis sive tetanus neonatorum infection undoubtedly takes place through the umbilicus. In a case of this kind Beumer found the tetanus bacillus in the tissues. There is hardly an operation, capital and minor, which has not furnished its quota to the long list of tetanic patients. It has been observed most frequentl}' after amputation, castra- tion, and extirpation of the th3'roid gland. Weiss reported 13 cases of tetanus occurring after extirpation of the thyroid gland. He attributes the frequency with which this disease follows the removal of this organ to irritation of peripheral nerves induced b}- the numerous ligatures. Middeldorpf observed paralj-sis of the facial nerve in some of these cases, — a circumstance which would indicate a central origin of the disease. lu 53 total extirpations of the thyroid gland for goitre made by Billroth, tetanus followed in 12 cases, while no cases occurred in 109 partial operations. Two cases became chronic, in Avhich the disease, at the time von Eiselsbei'g made the report, had lasted for six and nine j^ears. In 7 cases there was, besides the ordinar}- characteristic symptoms, an involvement of the muscles of the face, neck, larynx, diaphragm, and abdomen ; so that dyspnoea and even 39 i PRINCIPLES OF SURGERY. loss of consciousness occurred. In the fatal cases death occurred in from three to thirt}' da3's, and in 1 case after seven months. Quite a number of cases have been reported during tlie last few years where it occurred after abdominal section. Tetanus occurring after an operation must be the result of infection through the operation wound with the specific bacillus, which, without exception, takes place by contact. As the bacillus of tetanus is not a pyogenic microbe, it is not necessarj' that a wound through which infection has occurred should suppurate. When suppuration takes place it is in consequence of a mixed infection. It is a well-known clinical fact that punctured, lacer- ated, and gunsliot wounds of the hands and feet are most liable to be followed by tetanus. Before it was known that tetanus is a microbic disease, the frequency with which this disease complicated such injuries was explained upon the ground that the part injured was abundantly supplied with sensitive nerves, and that the irritation caused by the injury provoked the disease. As thousands of operations upon the hands and feet performed under antiseptic precautions have not resulted in a single instance in tetanus, this ex[)lanation is no longer tenable. The antiseptic treatment of wounds has greatly diminished the fre- quency of tetanus as a complication of operation wounds. Expe- rience has shown that the same treatment wliich prevents suppuration and other wound-infetitive diseases has also diminished the frequency of tetanus. Wounds of the hands and feet are so often followed by tetanus, because, in the first place, the implement or substance which inflicts the wound is frequently contaminated with infected earth or dust, and, in the second place, such wounds are often neglected ami exposed to subsequent infection from the same sources; and, lastl}', infected foreign bodies are often allowed to remain in the wound. In a number of instances animals were successfully infected by inserting under the skiii particles of foreign bodies removed from tetanic patients. Wounds of the hands and feet are no more liable to cause tetanus than wounds in any other jjart of the body, provided they are not exposed to greater 7'isk of infection. Infection through the uterus after abortion and during childbed has been repeatedly observed. Gautier has collected 74 cases of tetanus, 36 following abortion and 38 following confinement. Autopsies were made in 15 cases ; 3 pre- sented, on microscopical examination of the brain and cord, no appreci- able lesion ; in 1 case a retained putrefied })lacenta was found in the uterus ; in 5 suppurative metritis or salpingitis ; in 1 ovarian cyst. The other autopsies showed hj^perffimia of brain, cord, and meningitis; in 1 haemorrhage into the lateral ventricles. Ten patients recovered, — 5 after abortion, 5 after labor. SYMPTOMS AND DIAGNOSIS. 395 Frost gangrene is especially prone to be followed b}' tetanus. Of 3T5 cases of tetanus collected by Thamha^^n, the disease followed wounds of the fingers and hand in 27 per cent,; of the thigh and leg, 25 per cent.; of the toes and foot, 22 per cent.; of the head, face, and neck, 11 per cent.; of the arm and forearm, 8 per cent.; and of the trunk, 6 per cent. Of TOO cases collected b}' the same author, the disease was known to have fol- lowed a trauma in 603. As males are more frequently exposed to injury than females, the disease is correspondingly more frequent in that sex. The largest number of tetanic patients are found among persons from 10 to 30 years of age, although no age is entirely exempt. According to Larre}', Cullen, and Dupu^-tren, the disease can be caused, and is always aggravated, by drafts of cold air. That the disease is never caused b^- exposure to cold requires no argument ; that drafts of cold air aggravate the disease when it exists is unquestionable, as every peripheral irritation cannot fail in aggravating the muscular spasms. SYMPTOMS AND DIAGNOSIS. The ptomaines of the bacillus of tetanus act upon the brain and spinal cord in a somewhat similar manner as strychnia. If the spinal cord is injured str3'chnia acts only upon the parts supplied with nerves from the intact portion of the cord. If the posterior roots of the spinal nerves are divided it produces no spasms in toxic doses. If in an animal the brain and medulla oblongata are removed the effect of str3'chnia upon the muscles is not impaired. Injection of hydrate of chloral arrests the spasm produced bj' strychnia, and, consequently, chloral must be con- sidered as the most efficient antidote to strychnia. Even the most acute cases of tetanus begin insidiously. The patient, perhaps, complains of a sensation of chilliness and a feeling of soreness about the region of the neck, and shooting pains and stiffiiess in particular muscular groups. The first symptom which announces the onset of this dreadful disease is difficulty in mastication. The patient discovers, accidentall}-, that he is unable to open the mouth sufficiently to drink or grasp the food. On inspection nothing abnormal is found, but on trying to separate the teeth the masseter muscle on each side becomes rigid and prominent. This spasm of the muscles of mastication is called trismus. It is the first group of muscles affected by the central lesion produced bj^ the ptomaines of the tetanus bacillus. If other causes of this condition, such as inflammator3- lesions in the phar3'nx and the alveoli of the maxillar3' boneo, can be excluded, the existence of trismus is almost a pathogno- monic symptom of tetanus. The patient next complains of difflcult3' in swallowing, as the muscles of deglutition become affected. The next muscular groups to become involved are the muscles back of the neck 396 PRINCIPLES OF SURGERY. and the extensors of the spine, giving rise to retraction and fixation of the head and overextension of the spine, — conditions which, when well developed, produce what is called opisthotonus. In well-marked opis- thotonus the bod}' rests on the occiput and heels when the patient is in the dorsal position. If the bod\' is bent in an opposite direction, from contraction and rigidity of the anterior pectoral aud abdominal muscles, the condition is called emjjrosthotomis. Contraction of muscles on the side of the chest and abdomen gives rise to X)leurosthotomis. Orthotonus means tonic spasm and rigidity of all the voluntary muscles, — a con- dition frequentl}' present in advanced cases of tetanus. The face of tetanic patients presents a characteristic mask-like appearance from the contraction and rigidity of the facial muscles. The muscular spasms are clonic, and are always aggravated b}^ the slightest causes, as walking in the room ; touching the bed-clothes or the body of the patient ; drafts of air ; sudden, unexpected noises. The affected muscles are rigid from tonic contraction, but this state of rigidity is increased by the parox3^smal clonic spasms. In acute cases the temperature soon rises to 40^ to 41° C, and the pulse is correspondingly increased in frequency. The temperature curve shows but little change during twenty-four hours. The sensorium usu- ally remains unaffected throughout the entire course of the disease. As the patient finds it difficult to clear the mouth, the profuse salivar}^ se- cretion escapes from the mouth. Respiration is impeded in proportion to the number of the respirator}^ muscles affected. In severe cases early dyspnoea and cyanosis are present. Special senses remain intact. The pain is mostly excruciating, extending from the necli and back in the direction of the nerves, leading to the affected muscular groups. The pain is always aggravated with the increased convulsive movements, resulting from the action of exteimal irritants. In consequence of deficient food-suppl}^ the intense pain, and loss of sleep, rapid emaciation and loss of strength appear as early and con- stant symptoms. Approaching exhaustion is announced b}' profuse clamm}^ perspiration, coldness of the extremities, and a rapid, feeble, and intermittent pulse. As soon as the intercostal muscles are affected res- piration becomes more and more embarrassed, and when finally the diaphragm is thrown into a tonic spasm respirations and pulse cease, general cyanosis follows, and death may ensue during the first spasm of the diaphragm. Should, however, the patient rail}' from this attack, he will be almost certain to succumb to the second or third attack. Wunderlich has seen the temperature shortly before death risf to 42° or 43° C, and the same has been observed in animals dying from tetanus by Billroth, Fick, and Ley den. A post-mortem rise in tempera- CLINICAL FORMS OF TETANUS. 397 ture to 44.7° C. has been recorded b}' "Wunderlich, and he attributed this strange phenomenon to paralj'sis of the central heat-moderators. In chronic tetanus the disease commences very insidiously, and the gi'aver symptoms, such as a ver}' high temperature, feeble and intermittent pulse, spasm of the intercostal muscle and diaphragm, are absent. The tem- perature is normal or onl}' slightly- elevated. Trismus is alwaj'S present, to which may be added spasm and rigiditj^ of the muscles of the back . of the neck and the extensors of the spine. The trismus makes it diffi- cult to administer food in sufficient quantity, and, on this account, pro- gressive emaciation is one of the prominent features of this form of tetanus, as the disease, as a rule, lasts from six to ten weeks. The dis- appearance of S3'mptoms is as gradual as their onset. In the differential diagnosis it is important to distinguish between tetanus and strychnia poisoning, hj-steria, cataleps}', hj'drophobi'a, cerebro-spinal meningitis, and basilar meningitis. With few exceptions it is possible in tetanus to establish the fact of infection, and the clinical history shows that differ- ent muscular groups become involved successively in regular order, first trismus, then rigidit}' of the muscles at the back of the neck, and, finally, opisthotonus. In acute cases the disease is attended b}- a continuously high temperature. In strychnia poisoning the maximum sj-mptoms, opisthotonus or orthotonus, are developed suddenly, as soon as a toxic dose of the drug has been absorbed. The convulsive movements in h3'steria are not limited to an}' definite muscular groups, and the pulse and temperature are normal. The same can be said of cataleps3\ In hj'drophobia, as we shall see subsequently, the spasms are limited to the muscles of deglutition, the stage of incubation is longer than in tetanus, and infection is always caused by the bite of a rabid animal, usually a dog. In cerebro-spinal meningitis muscular spasm and rigidit}' are limited to the extensor muscles of the spine ; so that, even if the disease has caused well-marked opisthotonus, trismus is absent. Tubercular meningitis is usually ushered in by intense headache, vomiting, and photophobia, and if tonic muscular spasms set in thej- affect the muscles at the back of the neck almost exclusively. Trismus is never present. CLINICAL FORMS OF TETANUS. Acute Tetanus. — The stage of incubation, as a rule, is shorter than is the chronic form of the disease. Trismus develops graduall}^ but after it has once been established the extension of the disease to other muscular groups is rapid. A high temperature and rapid, feeble pulse are always present. Respiration is mechanically embarrassed b}' the successive implication of the diflTerent muscular groups which are con- cerned in the function of respiration, the last one to become affected 398 PRINCIPLES OF SURGERY. being the diaphragm. The disease may prove fatal in twentj'-fonr hours, and the duration is seklom prolonged for more than a week. Chronic Tetanus. — The disease not only commences insidiously, but the symptoms appear gradually and never develop to the same extent as in acute tetanus. Tliemo.st marked feature is trismus, which may be fol- lowed by a mild degree of opisthotonus. The muscles of respiration are not implicated, and if death result it is from marasmus and exhaustion and not from apna>a. The duration of the disease is seldom less than six, nor more tlian ten, weeks. Trismus. — Tetanus in which only the muscles of mastication are affected is called trismus. With the exception of the infantile form, trismus is a chronic and comparatively benign affection. Tetanus Neonatorum. — Tetanus occurring in infants during the first week after birth is clinically characterized as trismus, and proves fatal almost without exception in a few days. Infection takes place through the umbilicus before or after separation of the cord. It is a disease that occurs much more frequently in tropical than northern climates, for reasons which hnvo been heretofore explained. Tetanus Hydrophobicus, or Head Tetanus. — This is a form of tetanus which was first described by E. Rose, in 1870. In the cases which have been reported, it followed liead injuries, especiall3' wounds of the face. Besides trismus, it is characterized by paralysis of the facial nerve on the injured side. During deglutition, the muscles which are concerned in this act are thrown into spasm, and on this account the disease bears a strong resemblance to hydrophobia. Klemm has collected up to date 24 reported cases of this disease. Most of them i-ecovered, and in those that died the disease passed into the typhoid form of tetanus. PROGNOSIS. The most important element in prognosis is the type of the disease. The more acute the onset and the more intense the symptoms, the greater the immediate danger to life. If death does not occur within two weeks the prospects of an ultimate recovery are good. Of 280 cases which comprise the Calcutta statistics of this disease 75 per cent, proved fatal. This list represents about the average mortalit}^ of this disease. The greater the excitability of the motor centres of the spinal cord, and the more rapid the successive involvement of different muscular groups, the greater the danger of an early dissolution. In acute cases death is alwa3's preceded b}^ great dyspnoea, and death usually occurs during an attack of convulsions, in which the intercostal muscles and the diaphragm take part. Chronic cases terminate, as a rule, in recovery after an illness lasting from six to ten weeks. PATHOLOGY AND MORBID ANATOMY. 399 PATHOLOGY AND MORBID ANATOMY. The absence of gross pathological changes is characteristic of tetanus. The only constant lesion found is a h^^persemic condition of the medulla oblongata and the spinal cord, to which special attention has been called b}' Leyden, Joffrey, Ilunvier, and Robin. As all of the peripheral manifestations of tlie central lesion point to an increased excitability of the nervous centre, we would expect that the principal lesions are to be found in the gra^' substance of the cord. In 1857 Rokitansky described tetanus as an ascending neuritis. He found a connective-tissue proliferation, in the form of a semi-fluid, adhesive, gra3-ish substance, between the medullary elements of the nerves leading from the infected district. In some cases he found extensive destruction of the nerve-tubes, and their space occupied by the products of granular degeneration, — colloid and amyloid corpuscles. Lockhart-Clark and Dickinson found, as the most constant patho- logical lesion, inflammatory softening of the gray substance of the cord and dilatation of the vessels. Michaud and Benedict found cell prolifera- tion into the anterior cornua of the cord and great vascularit}'. Elischer i-egarded the central lesion as a myelitis with vacuolation in the ganglia- cells. Tyson found in 2 cases destruction of the central canal of the cord, with disintegration of the posterior cornua. Aufrecht narrowed the morbid anatomy of tetanus down to atrophy' of the anterior horns, in the cervical portion of the spinal cord. Schultze was never able to discover any evidences of myelitis. The hyperemia of the cord, which is so constantly found, may be the result of a passive congestion; at present this cannot be accepted as proof of inflammation, because in most cases the anatomical and clinical evidences do not sustain this supposition. The view that tetanus is essentiall}' an ascending neuritis, as was claimed by Rokitansk}^, is no longer tenable, since it is not supported by the results of recent investigations. It is left for future research to furnish more reliable information concerning the pathology and morbid anatomy of tetanus. At present we can onl}- surmise that the ptomaines of the bacillus act upon the gray matter of the cord, where minute lesions are produced, w^hich must account for the clinical mani- festations of the disease. TREATMENT. The prophylactic treatment of tetanus has in view the prevention of infection by the usual antiseptic precautions in the treatment of wounds and local lesions which might become the necessar}- infection-atrium. As tetanus follows more frequently injui'ies insignificant in tliemselves than large wounds or major operations, it behooves the surgeon to treat the minutest lesions with the greatest care, and in strict accordance with 400 PRINCIPLES OF SURGERY. antiseptic principles. Foreign bodies slioiild be carefull}^ searched for and removed. Even the most recent accidental wounds should l)e treated as infected wounds, and should be rendered aseptic by a thorough primar3' disinfection. The antiseptic treatment must be continued until the wound is completel3Miealed, and during this time the injured part must be kept at rest. Wounds of the lower extremities must be treated by confining the patient to bed, and wounds of tlie upper extremities demand, in their treatment, fixation of the limb upon some kind of a splint or, at least, suspension in a sling. In acute cases of tetanus the most that can be expected from treat- ment is palliation. The excruciating pain is often only relieved by inhalation of chloroform. The administration of chloroform should be conducted by the phj'sician in attendance or .a reliable assistant, and should only be carried to the extent of relaxing the contracted muscles, and repeated as often tvs necessary to procure rest. Morphia in doses of 4 to ^ grain, with ^^^ grain of atropia, should be given hypodermati- cally every three or four hours until the desired effect is reached. In less severe cases the internal use of hydrate of chloral and potassic bromide, each in doses of from 15 to 20 grains, can be given every three or four hours with excellent effect. Woorara, which has been quite extensively used in the treatment of the disease, is absolutely contra- indicated, as its paralytic effect on the heart cannot fail in producing anything but a deleterious effect. All patients suffering from tetanus should be kept in a quiet, dark room, and all kinds of excitement must be carefully avoided, as bodily and mental rest are important elements in the treatment. As mastica- tion is impossible, the patient must be nourished with liquid food, which he can sip through an elastic tube. If swallowing is impossible, a small elastic tube is introduced through one of the nostrils into the stomach, and food is administered at regular intervals by this method. In chronic tetanus warm baths are grateful to the patient, and exercise a decided influence in ameliorating the symptoms. The surgical treatment of tetanus has j^ielded no better results than tlie internal use of drugs. In all cases the infection-atrium should be carefulh^ examined, and, if neces- sary^, the wound or local lesion should be thoroughly disinfected, as this treatment may be the means of preventing further infection from this source. Scars should be excised and foreign bodies removed. Under the belief that tetanus is an ascending neuritis, nerve-section, or neurotomy, has been practiced for the purpose of preventing further extension of the inflammation by interrupting the continuity of the nerve; but the results, as could be expected, were disappointing, and the operation has fallen into well-deserved desuetude. When nerve-stretching TREATMENT. 401 was the rage in the treatment of all kinds of nerve affections it was also applied in the treatment of tetanus, but the results were no better than after neurotom}-. Nocht reported 24 cases of tetanus treated b}' this method, and of this number onl}- 4 recovered, — the average percentage of recoveries in all cases of tetanus not treated by surgical resources. Amputation is only indicated in cases where the local conditions which gave rise to tetanus make it necessary- to resort to this operation. as CHAPTER XVI. Hydrophobia. Hydrophobia, lyssa, canine madness, and rabies are S3'nonymous terms used to designate a nervous disease caused by the bite of a rabid dog or other animal, attended witli violent spasms if the patient attempts to swallow water or other liquids, and by embarrassment of respiration from spasm of the laryngeal muscles. This disease never occurs spon- taneously in man, but is always the result of inoculations with the virus of a rabid animal. Although this disease never originates elsewhere than in the dog and animals belonging to the same species, the wolf, fox, and jackal, the virus of rabies is capable of being communicated to all warm-blooded animals. It has been estimated that in man the disease is derived in nine out of ten cases from dogs ; sometimes it is contracted from cats, and sometimes, but ver}- rarel}', from foxes or wolves. The specific virus of hydrophobia appears to be generated in the glandular appendages of the mucous menil)rane of the mouth and throat, and is transmitted by the saliva of the rabid animal. For this reason it has been observed that inoculation is more apt to take place from a bite on an uncovered part of the body, as, for example, on the hands or face, than from a bite inflicted through the clothes, as in the latter case the greater portion of the saliva is deposited in the clothing. Not every person bitten by a rabid dog necessarily contracts the disease, as statistics have shown that about one-third of the animals and human beings bitten by mad dogs escape all danger. This partial immunity is explained in part by the virus being diluted, and being wiped from the teeth of the rabid animal by clothing ; and also bj^ well-ascertained facts proving the absence of susceptibility to its action in certain individuals, both in animals and in man. Renault's careful experiments proved that one-fourth of the inocu- lated creatures escaped the effects of the inoculations, which were mortal in the other three-fourths. As in civilized countries the disease is con- tracted almost exclusively from rabid dogs, it is necessary to call atten- tion to the symptoms which cliaracterize the disease in this animal, in order that it may be recognized in time, so that the infected animal can be isolated and kept in close confinement until the result shall prove or disprove the correctness of the diagnosis. It is a great mistake to kill (403) 404 PRINCIPLES OF SURGERY. an animal suspected to be rabid, until b}^ careful observation continued for some length of time, or from the result of the disease, a positive diagnosis can be made, and thus a great deal of unnecessary fear may be avoided. HYDROPHOBIA IN THE DOG. The name " hydrophobia," meaning literally a dread of fluids, is a proper designation for the disease as it occurs in man, because a peculiar dread of fluids is the most characteristic symptom of this disease in the human being. This symptom does not exist in the dog ; hence, in this animal we should speak of the disease as rabies, in man as hydrophobia. Fleming, who is an acknowledged autliority on everything that pertains to hydrophobia, makes the following statement in reference to the ability of rabid animals to take fluids: " The many hundreds of rabid dogs seen by Blaine, Youatt, and others did not evince any marked aversion to fluids. On the contrary, the rabid animal is generally thirsty, and if water be oflfered will lap it up with avidity, and, at the commencement of the disease, will always swallow it. When, at a later period, the con- striction about the throat, wliich is symptomatic of the malady, renders swallowing difficult, the animal does not the less endeavor to drink, and lappings are as frequent and prolonged as deglutition is retarded. Even then we see the suflering creature, in despair, plunge its entire muzzle into the vessel, and gulp at the water as if determined to overcome the spasmodic closure of the tliroat by forcing down the fluid. Tantalus did not experience a greater torment with regard to water than does the unlucky dog." The excessive sensibilit}' to pain and the action of tlie mildest external irritants so characteristic of hydrophobia in the human being are absent in the rabid dog. The animal is almost insen- sible to pain; he will dash himself against the bars of his kennel, tear them when his mouth is lacerated and bleeding, and he has been known to seize a red-hot poker in his mouth and hold on to it, apparently unconscious of suffering. Rabies in the dog must be suspected when the animal becomes dull, morose, mopes, and avoids his master and companions. During the commencement of the disease the animal is exceedingly restless, and is alwa^'S on the move, prowling, snapping, and barking at imaginar^^ objects. During the first two or three daj-s there is rarely any tendency on the part of the animal to bite, nor to paroxysms of uncontrollable fury. The danger in tliis stage to man and other animals comes from lick- ing rather than biting, for there is a propensity to extraordinar}' demon- strations of affection. After a time, however, a paroxysm of maniacal fury comes on, generally provoked by the sight of another dog. When this has subsided the animal again becomes controllable, but manifests HYDROPHOBIA A MICROBIC DISEASE. 405 a strange disposition to wander from place to place. He is now most dangerous. With a slinking and troubled aspect, his head and tail down, his eyes suffused, and foam at his mouth, he walks or trots along, snapping and biting at real and imaginary objects. He is only aggressive when attacked, and then his fury seems unbounded. When tired out from inadequate nourishment and the ceaseless wanderings, he drops exhausted in some out-of-the-wa}', solitary corner, and, after a rest, starts off again on his lonely journey, seemingl}- impelled by some irresistible force, and is finally killed or dies of exhaustion. The duration of the disease in the dog never exceeds ten days, and in the majority of cases the animal dies on the fourth or the sixth day after the appearance of the first symptoms. From a stud}- of the symptoms in this animal we can readil}^ distinguish three stages : 1. Prodromal. 2. Irritation. 3. Paralytic. During the prodromal stage the most noticeable changes refer to the altered habits of the animal, while the stage of irritation culminates iu attacks of ungovernable rage, provoked bj- real or fancied causes. The last, or paralytic, stage precedes death, which takes place from exhaustion. The period of incubation in the dog is variable ; it is usually from six to twelve v.eeks, but ma}' extend to a much longer period. Frank, from a study of 200 observed cases of rabies in the dog, found that the aver- age period of incubation was three months ; the extremes, six and seven days, and eleven months. HYDROPHOBIA A MICROBIC DISEASE. Raynaud and Lannelongue discovered that rabbits could be success- fully inoculated with saliva from rabid animals. Pasteur corroborated these observations by his own experiments, and cultivated from the blood of the infected rabbits in veal-bouillon a micro-organism which in its shape resembled the figure '• 8 "; this microbe was surrounded by an envelope of a gelatinous substance. In the cultures these rods are said to have become converted into chain cocci. Fowls and guinea-pigs were not found susceptible to inoculations with cultures of this microbe. After Pasteur had regarded these micro-organisms as the cause of h3"dro- phobia, he produced the same disease in rabbits by inoculations with saliva from health}- persons. Vulpian also succeeded in producing, by inoculations of normal saliva in rabbits, a disease which proved fatal in two days ; and witli a small quantity of blood taken from the dead animals the disease could be communicated to other rabbits. The dis- ease thus produced was probably the same as that described by Stern- berg. This observer caused marked septicaemia in rabbits by injecting subcutaneously his own saliva in small doses. Injections of 1.25 to 1.75 406 PRINCIPLES OF SURGERY. cubic centimetres, with few exceptions, caused death, usually within fort3'-eight hours. The constant and characteristic lesion found was a diifuse cellulitis, or iuflannnatory oedema, extending in all directions from the point of injection, attended with an abundant exudation of bloody serum, swarming with micrococci. Hsemorrhagic extravasations in the connective tissue, and in various organs, were of frequent occur- rence, and changes in the liver and spleen, such as are common in rapidly- fatal septic diseases, were generally found. The disease could be com- municated by dipping a hypodermic needle into the blood of a rabbit just dead from the result of an injection of saliva; inoculating a healthy rabbit, a rapidly-fatal septicaemia was produced. Gibier found, in the brain of hydrophobic animals, round, shining granules, which stained slowly and imperfectly in aniline dyes. Fol stained the brain-substance, according to Weigert's method, and discovered in the hollow spaces of the neuroglia groups of micrococci. The same microbe he found also in the nerve-fibres, between the sheath and axis-cylinder. Bab^s stained the specimens according to Gram's method, and found cocci in the cells, especially those of the surface of the brain. The cocci looked like diplococci, and w^ere alwaj's found aggregated in flat clusters. Fol and Babes claim to have succeeded in obtaining a culture of the microbes found in the brain. The former used for nutrient medium a filtrate of triturated brain and parenchyma of salivary gland. Of 8 dogs, rats, and rabbits inoculated with the first culture, 5 died of well-marked hydrophobia ; of 8 dogs inoculated with the second culture, four died. The inoculations were alwa^^s made by infecting the brain through an opening in the skull. The microbes in the cultures corresponded in shape and size with those found in the brain of hydrophobic animals. The third series of cultures produced only negative results. The microbes in these cultures were more readily stained than most of the first two cultures. Babes cultivated the microbe upon gelatin and coagulated blood-serum, to which was added brain-substance obtained from rabbits. The cultures grew slowl}', and appeared as gray spots. Successful inoculations were made with the second and third generations. The microbe of hydrophobia exists, but so far it has not been discov- ered. That hydrophobia is a microbic disease can no longer be doubted. At the present time we can safely assert, without fear of contradiction, that the essential cause of this disease is a specific virus, which can only be reproduced within the living organism. As a small quantity of this virus introduced into the tissues can result in the most serious conse- quences, there exists no doubt that it possesses the properties pertaining to living organisms, more especiallj^ the capacity of reproduction after CAUSES. 407 its entrance into the body. Tliat tlie disease is not caused by preformed ptomaines, communicated from the saliva of rabid animals, is shown by the variable and, on the whole, long stage of incubation which precedes all true infective processes. Another convincing proof of its microbic origin is the well-established fact that the disease can be artificial!}' pro- duced b}' implanting fragments of brain- or cord- tissue, taken from animals dead of rabies, into health}' animals. Furthermore, the blood and secretions of a rabid animal, its flesh and viscera, even the cooked flesh of a rabid ox, when eaten, would seem to be capable of conveying the disease. A pupil at the veterinar}' school of Copenhagen inoculated himself with the virus by cutting his finger slightl}', while examining the body of a dog that had died of rabies on the evening before ; the student died of hydrophobia in six weeks. The clinical S3-mptoms, as well as the pathological conditions found in tlie brain and spinal cord of h3-drophobic patients, bear such a strong resemblance to tetanus that it appears probable that the microbe possesses analogous pathogenic prop- erties, and that the actual development of the disease follows the action of its ptomaines upon the central nervous system. The latent stage of the disease, or the long duration of the period of incubation, depends either upon the slow growth of the microbes or that these reach the place slowly from where the}' exert their specific pathogenic properties. CAUSES. The microbe of hydrophobia does not penetrate the intact skin or healthy mucous membrane; hence its entrance into the tissues takes place through an infection-atrium, usually a punctured wound made by the bite of a rabid animal. As the microbe pre-exists in the saliva of the rabid animal, inoculation takes place at the time the wound is inflicted. Infection, however, can take place by the deposition of the infected saliva upon a surface from which absorption can take place. This can occur from the licking of a wound or abraded surface by an infected dog, as happened in one of my cases. A lady of rank and fashion had a pimple on her face, from which she had scratched off the head. Hydrophobia was thus contracted, and she perished by this terrible disease. SYMPTOMS AND DIAGNOSIS. Great diversity of opinion exists as to the length of the period of incubation in man. In the 2 cases of hydrophobia that have come under my own observation, the time of infection and the onset of the disease could be accurately fixed, and in both of them the stage of incu- bation lasted forty-tivo days. In 106 cases of hydrophobia in human beings of all ages, collected by Bonley, 23 occurred within two months 4()p^^^^m ^c-"^ ,*>- ^f 0^^ -^tf T^' .^^ J'***«i.i,iu I m... ili Fig. 90.— a Blood-vessel from Medttlla Oblongata in a Case of Hydrophobia. Large Numbers of Round Cells are Seen in its Sheath. x350. (CocUes.) toms point mainly to the medulla oblongata, and after death well-defined vascular lesions can be detected in this structure by means of the microscope. Similar lesions, but less marked, can be found in the spinal cord, and still to a lesser degree in the other parts of the nervous system. The most prominent condition is an accumulation of leucocytes around the vessels in the substance of the cord and medulla oblongata. Where the local lesion is most advanced the vessels are surrounded by several layers of leucocytes, which would indicate that the microbe of hydro- 41-2 PHINCIl'LES OF SURGERY. pliobiii or its ptomaines protliicc an alteration of the capillary wall of suflicient intensit3' to entitle the i)roeess to be called intlammation. An increase of leucoc3tes is evident everjAvliere, so much so that the collec- tions which can be found in ditferent parts have been called miliary abscesses. As the leucocytes show no evidences of even approaching transformation into i)us-corpuscles, these aggregations of leucocytes do not deserve the name of abscesses. Klebs is of the opinion that the mi- crobe of hydrophobia does not enter the circulation directly, but invades in preference the lymphatic vessels, as he found general lymphatic en- gorgement in a recent case. The same author also discovered, particu- larly in the submaxillary gland, deposits of finely granular, strongly re- fractive corpuscles of a faint, brownish color, closely pncked together in Fig. 91.— From the .Salivary Gland in a Ca.se of Hydrophobia. In the Middle is the Portion of a Duct; abundant Round Cells around it as well as the Glandular Structures shown in Outline. x350. (Coates.) clusters and rows, which he regards as possibly the vehicles for the transportation of the specific virus. Well-marked evidences of leuco- cytes have been found by many in the salivarj^ glands. There is hypersemia and oedema of the substance of the brain, medulla oblongata and cord, and of their membranes ; deep-red injection of the mucous membrane of the phar^'nx and epiglotis, and sometimes recent swelling of the tonsils, follicular glands of the tongue, pharyngeal follicles, and of the lympiiatic glands in the neighborhood of the jaw. The stomach and intestines show decided injection, and often hsemor- rhagic extr:ivasations. The lungs are charged with blood, with frequent points of c:i[)illary haemorrhage, and sometimes emphysema as a result of the dyspncea. In the kidneys, also, there are signs of irritation in the form of dilatation of vessels and haemorrhasfe. According^ to Bol- TREATMENT. 413 linger, the anatomical picture bears the strongest resemblance to that seen in cases of death from asphyxia or thirst. The conditions found, post-mortem, furnish an illustration that here an intense irritant is cir- culating in the blood, and the intensit}- of it ma}- be judged from the fact that all these ver}' marked appearances, although nearl}- all of them recognized onl}" b}- the use of the microscope, occur in the short space of three or four da^'s. TREATMENT. As hydrophobia is an absolutely- fatal disease, the treatment resoh^es itself into prophylactic measures to prevent the disease, and means of palliation after it has developed. Prophylactic Treatment. — Tlie most effective prophylactic measures consist in preventing the spread of the disease, among animals, by the killing or strict isolation of animals which present symptoms of rabies. If animals, which are suspected of being rabid, are known to have bitten persons, the}' sliould not be killed at once, but should be kept in close confinement unknown to the injured person, until, by observation or the course of the disease, a positive diagnosis can be made. As soon as a positive diagnosis of rabies can be made, then the animal should be killed to prevent any further possibilitj' of infecting other animals or persons. If a person is bitten b}' an animal wliich presents suspicious symptoms, no time should be lost to prevent infection by removing or destroying the virus. (a) Excision of Wound. — As the virus of hydrophobia appears to be slowly dirt'used in the tissues, thorough local treatment of the wound ma}- prove successful in preventing infection, even if resorted to several hours or days after inoculation has occurred. As soon as possible after the bite has been inflicted, a constrictor should be applied on tlie proxi- mal side of the wound and medical aid summoned without delay. In the meantime an attempt should be made to remove the virus from the wound by suction. In recent cases the simplest and safest treatment consists in excising the tissues in the immediate vicinit}- of the puncture, and after thorough disinfection close the wound with sutures. (bj Cauterization of Wound. — The same object is accomplished, but with a lesser degree of certainty, by cauterization. Tlie most efficient caustic is the actual cauter}'. With the knife-point of a Paquelin cautery the wound is deeply- cauterized, and the resulting eschar is protected against infection with pus-microbes by an antiseptic dressing. Of the chemical caustics the most valuable are caustic potassa, nitric acid, sul- phuric acid, and nitrate of silver, their efficiency being estimated in the order named. The authority- for excision and thorough cauterization, as prophylactic measures, is to be found in the fact that, of 134 collected 414 PRINCIPLES OF SURGERY. cases, in which bites of mad clogs were cauterized, 68 escaped and 42 died, — a degree of immunity far above the average, which is 33 per cent. (Bonley.) (c) Prophylactic Inoculations. — Pasteur has shown, by a long series of inoculations, made first in monkeys, rabbits, and guinea-pigs, and later exclusively in rabbits, that if the virus of hydrophobia is introduced into the brain of these animals the disease is invnriably produced after a fixed period of incubation. As the period of incubation in successive inoculations in the same animal is shortened, we must take it for granted that the virulence of the material is increased. In the rabbit the first inoculation under the dura mater is followed by a period of incubation of fourteen days' duration, which, in successive inoculations in the same animal, is reduced to seven days. Back inoculations in dogs produce in these animals fatal rabies in the same length of time. Pasteur made an additional important discovery, as he found that the spinal cord of the inoculation rabbits, increased in virulence by successive inoculations, is again diminished in its virulence by preserving it in dr}' air, gunrding at the same time against contamination with other micro-organisms. This discover}' led to a method b}- which the virulent action of such prepa- rations can be accurately graded, inasmuch as the action of the spinal cord, in the drying-room, in 7 to 8 days is reduced from its highest degree of virulence to nil. By using the spinal cord of rabbits treated in this manner in different strengths, at first weak and then gradually stronger preparations, it was found possible to render animals immune to the action of inoculation material of the highest potency. By this method Pasteur succeeded in creating absolute immunit}' against the strongest hydrophobic virus in 50 dogs. The success of these prophylactic inocu- lations in animals enabled Pasteur to resort to the same method of treatment in persons bitten by rabid animals, as the long stage of incu- bation made it possible to carry out this treatment before the actual development of the disease was expected. The first human being sub- jected to this treatment was on 5\\\y 5, 1885, and from that time until the close of the year 1889 2682 persons bitten by rabid animals, or animals that were suspected of being mad, with the result that of this large number only 31 died, equiA'alent to 1.15 per cent., while the general mortality in persons under similar circumstances without such prophy- lactic inoculations has been at least 16 per cent. The danger is alwaj^s greatest when the bite is inflicted by rabid wolves. Pasteur collected 100 cases of persons bitten b}' rabid wolves, and of this number not less than 82 died. Pasteur had an opportunity to submit to his treatment 38 persons bitten by rabid wolves, and of this number only 3 died, — a mortality of 7.89 per cent. TRlEATIVIENT. 415 The following tables represent Pasteur's work for four 3'ears : — Table A. Table B. Table C. Total. Yeabs. 5 11 1= i s >>1 -< S2 u 73 s •ti ■2 ^< g ft 2^3 13 s 1? c t- 1886 . . 1887 . . 1888 . . 1889 . . 231 357 402 346 3 2 6 2 1.30 0..56 1.49 0.58 1926 1156 972 1187 19 10 2 2 0.99 0.86 0.21 0.17 514 257 248 297 3 1 1 2 0.58 0.39 0.40 0.67 2671 1770 1622 1830 25 13 9 6 0.94 0.73 0.55 0.33 Total . . 1336 13 0.97 5241 33 0.63 1316 7 0.53 7893 53 0.67 The bites have been divided into three categories, — 1. Those of the head and face ; 2. Those of the hands ; 3. Those of the limbs and ti'unk, — with the following result : — Tables A and B. Table C. Total. 5 S is ■6 S ^'2 ilS ^ 1. Head and face 2. Hands 3. Limbs and trunk .... 593 3768 2216 14 26 6 2.36 0.69 0.27 79 619 618 1 3 3 1.27 0.48 0.48 672 4387 2834 15 29 9 2.23 0.66 0.32 Total 6577 46 0.70 1316 7 0.53 7893 58 0.67 Table A comprises those persons bitten by animals determined to be rabid by experiments in rabbits, made in the laboratory, or by the death of other animals, or persons, bitten by the same animal. Table B comprises those persons bitten by animals demonstrated to be rabid by the examination of a veterinarj' surgeon, or by the clinical signs shown during life. Table C comprises those persons bitten by animals suspected to be rabid. These results must convince the most skeptical of the practical utilit}^ of Pasteur's prophylactic treatment against hj'drophobia, and, although the method will not be perfect until the microbe of this disease is discovered and mitigated (pure cultures are emplo3-ed), this crude method must be viewed as a great boon to a class of patients otherwise exposed to the risks of contracting the most terrible and hopeless of all 416 PHINCIPLES OF SURGERY. diseases. Pasteur institutes have sprung up in different parts of the civilized world, and the accumulated experience of all those engaged in this kind of work bears strong testimony in favor of the proph}' lactic inoculations against hydrophobia as taught and practiced by Pasteur, At the bacteriological laboratory in Cuba 306 persons liave been treated by the " double intensive " plan. Of these only 2 died after going through the full course, — a mortality of 1.63 per cent. All these cases were bitten by dogs proved experimentally and clinically to be rabid, or, at anjf rate, suspected. That the inoculations were conducted with due conservatism is indicated by the fact that only 306 persons were treated out of 700 applicants. Some of the failures Pasteur attributes to the long intervals between the prophylactic inoculations, and in grave eases he now advises that successive inoculations should be made with cord- substance twelve, ten, and eight days old, during the first twentj^-four hours ; on the second da}^ with material six, four, and two da3"S old ; on the eighth da}- with material one day old, to be followed by two similar series of inoculations. By following this energetic plan of prophjdactic treatment he has been able to secure protection even in the most urgent cases ; that is, in cases where the stage of incubation had nearly terminated. Palliative Treatment, — The nature of the disease should, under no circumstances, be disclosed to the patient, as the people, high and low, educated and ignorant, are only too familiar with the terrible suffering caused by this affection and its absolute certaint}' of a fatal termination in a few days. In one of my cases the patient had been made acquainted with the character of the ailment, and begged piteously that his life might be terminated by the administration of chloroform, knowing well that the intense suffering would continue to the last moment. As light, draughts of air, and noise of every kind increase the suffering by exag- gerating convulsive spasms, these aggravating causes should be elimi- nated from the patient's room, and only a limited number of persons should be admitted to render the necessary" assistance and carry out the directions of the attending phj'sician. As the saliva of hydrophobic patients contains the specific virus, those placed in charge of the patient should protect themselves against inoculation by preventing the contact of the saliva with abraded surfaces, or, still better, b}^ covering an}^ abrasions which may exist with a coUodiura dressing. Thirst is quenched by administering water per rectum. Medicines b}' the mouth should not be given, as every attempt at swallowing brings on violent spasms of the muscles of deglutition and the respiratory muscles of the larynx. Mor- phia combined with small doses of atropia should be given subcutaneously in such doses and at such intervals as will procure rest. The subcu- TREATMENT. 417 taneous administration of quinine and woorara has been advised, but both of these remedies are more harmful than useful, and neither of them either add anj-thing to the duration of life or alleviation of sufter- ing. The onlv reraedj' which can be relied upon to afford prompt relief is chloroform by inlialation. Ether should never be used, as the hyper- semic condition of the brain and spinal cord which is present in every case of hydrophobia sufticientl}' contva-indicates its use. The inhalation of, chloroform must be conducted b}^ an assistant or a competent, re- liable nurse, and should never be carried beyond the point wlure relief is afforded, and it siiould be repeated as often as the paroxysms return. 27 CHAPTER XVII. Surgical Tuberculosis. Tubercular lesions furnish a most excellent illustration, clinicall}' and under the microscope, of the origin, course, termination, and tissue changes of what is kncnvn as chronic intlnmniation. A histological description of a tubercular nodule is a description of tlie pathology of chronic inflammation. Tuberculosis in all its forms is caused by a specific microbe, the action of which upon the tissues produces his- tological and vascular changes which are characteristic of chronic inflammation. Of all the microbic diseases, with the exception of sup- puration, tuberculosis is of the greatest interest and importance to the surgeon. Of the greatest interest because the tubercular lesions which come under his care are more clearly understood from a bacteriological stand-point tlian most of the other surgical diseases, and of the greatest importance on account of their great frequenc}'. That large class of ill-defined lesions which were grouped under that indefinite and vague term scrofula, in the text-books of but a few years ago, haA'e been shown b}"- recent research to be identical with the recognized forms of tuber- culosis,, etiologically, clinicall}^ and anatomically. In this chapter I shall aim to give a brief description, from a bacteriological and clinical stand-point, of such localized tubercular lesions which, by general consent, are regarded as surgical affections and requiring surgical procedures in their successful treatment. HISTORY OF THE MICROBIC ORIGIN OF TUBERCULOSIS. The first inoculation experiments with tubercular products were made by Kortum in 1789, and Cruveilhier in 1826. In 1834 Erdt suc- ceeded in producing numerous nodules in the lungs of horses b3' inocu- lating them with tubercular pus, and Klencke, in 1843, produced tuberculosis in rabbits by intra-venous injections of tubercular matter. The results obtained from the crude inoculation experiments which were made years ago )iy Villemin pointed strongl}^ towaixl the infec- tiousness of tuberculosis. Villemin's experiments consisted in the subcutaneous insei'tion, behind the ear of rabbits, of fragments of tubercular tissue or fluid taken from tlie cavity of a tubercular luno- recently removed from a patient who had died of pulmonary phthisis. (419) 420 PRINCIPLES or SUIIGERT. The first nnimal thus infected was killed three and a half months after inoculation. The lungs and most of the internal organs were found diffusely infiltrated with miliary tubercle. His numerous later experi- ments yielded similar results, and led hini to the following conclusions : " Phthisis of the lungs (like tubercular diseases in general) is a specific infection. Its etiology depends on an inoeulable agent. It can be readil}^ communicated from man to animal by inoculation." Yogel repeated the experiments of Yillemin on horses without success. BifH, Verga, and Sangalli experimented on mules, cows, sheep, dogs, cats, mice, and chickens with negative results. The experiments of Langhans led him to the conclusion that tubercle could not be com- municated in the manner described b}^ Villemin. He claimed that the inoculation material acted only the part of a foreign bodj', the inflam- mation following its insertion into the tissues differing in no way from the ordinar}' forms of inflammation. Among those who made successful inoculation experiments, and adopted the doctrines advanced by Yillemin, may be mentioned Hevard and Cornil, Hoffmann, Cohn, Behier, Empis, Mantagazza, Bizzozero, Lebert and Wj^ss, Klebs, Koester, Waldenburg, Bijuen, Simon, Sanderson, W. Fox, Papillon, Nicol, and Laveran. Hevard and Cornil were able to propagate them. They inocu- lated witli genuine tubercular material, but failed with cheesy products. Marcet inoculated 11 guinea-pigs with the sputa of phthisical patients, and in 10 of them the experiment proved successful. Cohnheim injected tubercular material into the anterior chamber of the eye in rabbits, and succeeded in producing the disease artificiallj' in this manner.. Hueter produced tulierculosis of the iris b}" inserting into the anterior chamber of the e3'e in rabbits fragments of tubercular tissue. Toussaint showed that true tubercle, both in man and animals, reproduces itself indefinitely with absolutely constant and identical properties, and that it is quite capable of being transmitted from animal to animal without losing its virulence. Krishaber and Dieulefoy experimented on monkeys, and the results obtained led to the conclusions : 1. That human tubercle, when inocu- lated, kills a monke}^ in nine out of ten cases, with lesions analogous to those met in man. 2. The effect of the inoculation varies according to the substance employed ; the gray granulation is most, and the pulmonary parenchyma least, infectious. Schliller and Lentz made successful inoculations with blood taken from tuberculous rabbits. Lippl, Schwenniger, Tappeiner, and Weichselbaum succeeded in pro- ducing the disease in animals by inhalation. Successful feeding experi- ments were made by Chaveau, Aufrecht, and Bollinger. Since Yillemin announced the inoculability of tuberculosis, diligent search was made HISTORY OF THE MICROBIC ORIGIN OF TUBERCULOSIS. 421 to discover and isolate a specific micro-organism which should be characteristic of this disease. The first cultivation experiments were made bj- Klebs in 1877. He found, b}' examining fresh specimens of tubercle of human beings, that they invariabh" contained bacteria. He cultivated them in egg-albumen and Bergmann's culture fluid, and found, by experiment, that the cultures produced the same effect in causing disease b^^ inoculation as the tissues from which they were grown. Injections of the culture under the skin, into the muscles, lungs, pleural and peritoneal cavities, caused death of the animals from tuberculosis. Cultures made in a similar manner from scrofulous glands and lupus-tissue produced the same effect in animals. Max Schiiller repeated the experiments of Klebs with the same results. He described the specific microbe as round and rod-shaped bacteria, the rods bulbous at both ends, composed of two, seldom more, spherical bodies. He found these microbes in great abundance in tubercular joints and tubercular foci in bone. He produced the disease artificial!}' in animals which were previously inoculated by making contusions of joints. Other workers in the same field advanced theories, found and described microbes, which were supposed to bear a direct etiological relationship to tuberculosis, but nothing definite was known on the subject until the father of modern bacteriolog}", Robert Koch, in 1882, announced to the profession his great discovery. He had found and demonstrated the true and essential cause of tuberculosis, the bacillus of tuberculosis, and, in his first publication, brought such convincing- proof of the correctness of his claim that, with few exceptions, it brought conviction even to the minds of the most skeptical. He had not only found the bacillus, but showed that it was present in all tuber- cular lesions. He had isolated and cultivated the bacillus from tuber- cular tissue ; and, finall}', he had furnished the crucial test — had produced tuberculosis, artificiall}', in animals bj'^ inoculation with pure cultures. A number of pathologists wlio inoculated animals with non-tubercu- lar material claimed that they had produced patiiological conditions analogous to those found in animals which had been infected with the virus of tuberculosis. Fragments of sponge implanted in the abdominal cavity produce a condition which resembles tubercular inflammation, and it has been asserted that powdered glass has a similar property. Sehot- telins. Wargunin, Weichselbaum, and Martin have emploAcd various substances b}- wa}' of experiment, such as powdered cheese, brain- substance, h'copodium-seed, Cayenne pepper, and pulverized cantharides. They caused these to be inhaled in the form of a fine spray, with the result that the}' were almost invariably able to produce, in different ani- mals, an eruption of nodules in the lung and sometimes in other organs. ■122 PRINCIPLES OF SURGERY. With Liaiburger cheese Weichselbaum produced an eruption in the lungs and kidneys of dogs, after fifteen inhalations during seventeen days, which, liistologicall}', could not be distinguished from the products of genuine tuberculosis. Further ex})erimentation soon showed that these were instances of pseudo-tuberculosis ; tluit, while the gross appearances of the lesions resembled true tuberculosis, inoculations with this material never reproduced the disease, while inoculations with tubercular tissue could be doue through a series of animals without impairing the potency of the virus or varying the constancy of the results. Koch's discovery did not lead to such energetic search for the bacillus of tuberculosis among surgeons as physicians, because, as Konig asserts, the symptoms and signs of the tuberculous affections coming under the observation of surgeons are so characteristic that, for practical purposes, a correct diag- nosis could be made in the majority of cases without a knowledge of their microbic nature and the improved methods for making a positive diagnosis derived therefrom. Koch himself, in the publication above referred to, demonstrated the presence of the bacillus in lupus, the so- called scrofulous glands, tubercular joints, etc. He called attention to the fact that in these affections the bacillus can be constantly found in giant cells and between the epithelioid cells, while it is more difficult to find it in chees}- products, unless caseation has taken place quite rapidl}-. Koch examined 19 cases of miliary tuberculosis, in which bacilli were found in every nodule ; 29 cases of phthisis, in every one of which bacilli were found most numerous, with the exception of the sputum, in recent caseous foci and in the walls of cavities undergoing speedy de- struction. He also found them constantly in tuberculous ulcers of the tongue, tuberculous pyelo-nephritis, and tuberculosis of the uterus and testicles ; also in 21 cases of tuberculosis of Ij^mphatic glands. Further, in 13 cases of tuberculosis of joints and in 10 cases of tuberculosis of bone ; in 4 cases of lupus, in which only a single bacillus could be seen in the giant cells ; in 17 cases of Ferlsucht in cattle. Finally, in animals inoculated with tubercular virus : 2*73 guinea-pigs, 105 rabbits, 44 field- mice, 28 white mice, 19 rats, 13 cats, besides dogs, chickens, pigeons, etc. Examinations of sputa and organs in various other non-tubercular aflTections for bacilli resulted, without exception, negatively. Weichselbaum, Meisels, and Lustig found tubercle bacilli in the blood in cases of acute miliary tuberculosis, both during life and after death. Schuchardt and Krause examined 40 cases of tuberculosis of bones, joints, tendon-sheatlis, and the skin in Volkmann's clinic, and never failed in finding bacilli, although in some specimens careful and prolonged search had to be made. Schlegtendal examined 520 specimens of pus from tuberculous sup- DESCRIPTION OF BACILLUS TUBERCULOSIS. 423 purations, and found bacilli present in about 75 per cent, of the cases. Mogling found the bacillus never absent in tuberculous pus from 53 patients. The literature on the etiological relation existing between tlie bacillus of tuberculosis and the atfections of the skin, glands, bones, and joints, which have heretofore been grouped under the head of scrofula, is immense ; but the foregoing quotations will suffice to show the regu- larity with which the bacillus can be found in the tissues of the so-calle-d scrofulous affections, as well as in all recognized clinical forms of tuberculosis. DESCRIPTION OF BACILLUS TUBERCULOSIS. The tubercle bacillus, with the exception of the bacillus of septi- caemia in mice, is the smallest of the known bacilli. The length of each rod varies from one-fourth to three-fourths of the diameter of a red blood-corpuscle. The thickness corresponds to that of the bacillus of sepsis in mice. The rods are either straight or, what is more common, bent or curved near the centre. In cultures and in the tissues they occur singly, in pairs, or in bundles. In a state of fructification the bacilli contain from two to six spores. In stained rods the spores appear as clear, minute, ovate spaces, :is the}' are not affected b}^ the coloring material. BAciLLT^'coNTAmiNG In some bacilli the spores form slight projections on ^xochf ^'^^^^ A*^-"*- the sides of the rod. Reproduction bj- spore for- mation also takes place in the tissues within the animal body. In badly-stained specimens, and on superficial examination, the spores im- part to the bacillus the appearance of a chain coccus; but, examined closely, it is seen that the protoplasm of the bacillus is continuous, and the apparent interruptions are due to the presence of the spores. The bacilli of tul)erculosis are non-motile, and consequently possess no power of locomotion, and cannot penetrate into the tissues without assistance. In the tissues they are found in the interior of giant cells and within and between epithelioid cells. They are constantly found in places where the tuberculous process is commencing or actively progressing. In the beginning they are isolated and in the interior of cells ; later, they be- come more abundant and form groui)s. In cheesy deposits they are either entirely absent or few in number. The virulence of caseous material is due mostly to the presence of spores, which may remain in a latent condition and yet retain their power of reproduction under more favorable conditions for an indefinite period of time. As soon as giant cells appear, they contain bacilli in their interior, as a rule. In some giant cells only one bacillus can be found, and then it occupies a part of the cell which contains uo nuclei. / 42 J: PRINCIPLES OF SURGERY. In giant cells with numerous bacilli the latter arrange themselves around the periphery in the interior of the cell, while the centre contains few or none. The first inoress of bacilli into the diseased tissues probably takes -^ 1 Fig. 93.— Giant Cell with One Tubercle Bacillus. Section from Lupus of Skin. 700:1. {Fluegge.) place by wandering cells, which transport the non-motile microbe. In many inoculation experiments such bacilli-containing cells have been found in the blood and tissues. Fig. 94 —Giant Cell. Miliary Tuberculosis. 700:1. (Fluegge.) Staining. — The peculiar behavior of the bacillus of tuberculosis to different staining material enabled Koch not only to discover this microbe, but also to differentiate it from all other microbes. While the aniline dyes and other nuclear staining material showed no micro-organ- DESCRIPTIOX OF BACILLUS TUBERCULOSIS. 425 isms in tubercular products, the bacillus came plainly into view if a small quantity of alkali was added to the aniline solution. Later experience proved that the same effect is produced if, instead of an alkali, anilin, tolnidin, turpentine, carbolic acid, or ammonia is added. All of these substances aid the penetration of the staining fluid into the bacillus. Of especial advantage is the discover}-, also made bv Koch, that the staining fluid is fixed more permanentl}' l\y treating the sections stained with alkaline aniline d^-es with nitric or muriatic acid, a procedure which removed the staining from the cells, nuclei, and all other bacteria, while the tubercle bacillus alone remains ,_>. stained. The preparation is further \V ^ # \if/^^^^ * /'N.\ completed bv staining once with one V ^fe^^i M /Ji v\ ^ of the ordinary aniline d3'es, which r\ ! X^~" j^ it\| stains the cells and nuclei and other VTL bacteria, so that the tubercle bacil- ,// 2A /\ lus, for instance, appears red, the nuclei and other bacteria blue. ^^^ Most of the bacilli in Fig. 95 "^^^J contain spores, the majority of them ^^^^i--^??'^,'^" ^^t^^X^^'r^'''^"'' c^''^'" i ' J J Phthisical Sputum. Double Sstain- slightly curved or bent: they lie ing, after ehklich's method, xiooo. ^ J > J (Baumgarten.) free, — that is, outside the cells. Where they appear to be within the cells, a close examination shows them to be either upon or underneath the cells. For section-staining Ehrlich's method is the best: — Saturated alcoholic solution of methyl-violet or fuchsin, . 11 parts. Aniline water, 100 " Absolute alcohol, 10 " Sections are left for twelve hours in this solution. Treat the speci- mens with l-to-3 solution of nitric acid a few seconds ; wash in alcohol (60 per cent.) for a few minutes; after-stain with diluted solution of vesuvin or methylene-blue for a few minutes; wash again in 60-per-cent. alcohol ; delndrate in absolute alcohol ; clear with cedar-oil ; mount in Canada balsam. The examination of fluids for bacilli can be done rapidl}' and most satisfactorily by Gibbes' method : — GIBBES' MAGENTA SOLUTION. Magenta, 2 parts. Aniline oil, 3 " Alcohol (specific gravitj- 0.830), 20 " Distiller) water, 20 " Stain cover-glass preparations in this solution for fifteen or twentj' minutes ; wash in l-to-3 solution of nitric acid until the color is removed ; 4*26 PKINCIPLES UF SURGERY. rinse in distilled water ; after-stain with inetli^'lcne-blue, methyl-green, iodine-green, or a watery solution of cr^^soidin, live minutes; wash in distilled water until no more color comes away; transfer to absolute alcohol fur five minutes; dr}-, and preserve in Canada balsam. Cultivation. — The best culture medium for the bacillus of tubercu- losis is solid, sterilized blood-serum of the cow or sheep, with or without the addition of gelatin, at a temperature of 37° to 38° C. (98.6° to 100.4° F.). The bacillus grows very slowly, and only between the tem- peratures of 30° and 41° C. (86° and 105.8° F.). In about a week or ten days the culture appears as little, whitish or yellowish scales and grains. Cultivations can also be made in a glass capsule or solid blood- serum, and the api)earance of the growth studied under the microscope. The scales or pellicles are then seen to be made up of colonies of a perfectly characteristic appearance. The growth ceases after three or four weeks. The blood-serum is not liquefied unless putrefactive bacteria contaminate the culture. Frankel figures, in his " Atlas der Bacterien- kunde^^^ a luxuriant culture of the bacillus of tuberculosis upon glycerin- agar. Nocard and Roux have found that coagulated blood-serum is improved for the growth of the bacillus by adding peptone, soda, and sugar. A further addition of 6 to 8 per cent, of glycerin favors the growth of tlie bacillus still more, while, at the same time, it prevents the formation of a dry crust upon the culture medium, which otherwise forms by evaporation. They also made successful cultivations upon agar-agar bouillon, to which was added 6 to 8 per cent, of gl3'cerin, kept at a temperature of 39° C. (102.2° F.). Koch has cultures 3 years old which have passed through 40 genera- tions and still retain their virulence, showing plainly the longevity and tenacity of the bacillus of tuberculosis. INOCULATION EXPERIMENTS. Long before the discovery of the bacillus of tuberculosis by Koch, genuine tuberculosis was produced artificially^ in animals by inoculation with the products of tubercular inflammation. Hueter inoculated the anterior chamber of the eye in rabbits with lupus-tissue, and produced typical tuberculosis of the iris. Schiiller introduced fragments of lupus- tissue directly into the veins of animals, and in this way caused pulmo- nar}' tuberculosis. Koch produced tuberculosis in animals susceptible to this disease by implantation of tubercular tissue in various localities and by inoculation with pure cultures, the experiments yielding, almost without exception, positive results. The same author inoculated the anterior chamber of the eyes in 18 rabbits from 5 cases of lupus, and in INOCULATION EXPERIMENTS. 427 all of them tuberculosis of the iris was produced, and, if life was pro- longed for a sufficient length of time, was followed by tuberculosis of the lymphatic glands of the neck, lungs, kidneys, liver, and spleen. Similar results were also obtained in 5 guinea-pigs. Cornet has made numerous experiments, in Koch's laboratory, on animals, to ascertain the inoculabilit}- of tuberculosis through abrasions of the skin, or a pure culture of tubercle bacilli is applied to a cutaneous abrasion ; the result in viost, if not all, cases is a local tuberculosis in the adjacent lymphatic glands, and, later, a general miliar}- tuberculosis. The same author made, more recentl}^ a long series of experiments on dogs, to ascertain the dili'erent avenues through which tubercular in- fection is known to take place. Tubercular sputum and pure cultures inserted into the lower conjunctival sac in healthy dogs produced tissue hyperplasia at the seat of inoculation, and was followed by infection of the cervical glands on the corresponding side. Some of the glands underwent caseation, and the presence of bacilli could be demonstrated in all of the pathological products. lu other animals the tubercular material was introduced into the nasal cavity. The cervical glands, especially those on the corresponding side, became enlarged and caseated. Infection through the mouth, by depositing the tubercular material in a depression made with a blunt instrument between the canine teeth, re- sulted also in tuberculosis of the glands of the neck. Infection of the external meatus of the ear, without creating an infection-atrium intention- ally, was followed by infection of the lymphatic glands behind the ear and along the neck on the same side. Cutaneous tuberculosis in the form of an ulcerating lupus was produced by shaving the skin on one side of the nose and iiice, and scratching it Avith a finger-nail infected with a pure culture. Injection of pure cultures into the healthy vagina of bitches resulted in local tuberculosis and secondary infection of the inguinal glands. Inoculations of other parts were followed by the same train of SA'mptoms. — local tuberculosis at the seat of infection, followed by dissemination of the process along the course of lymphatic channels. 'IMie lungs were found aflected only in two of the animals. These ex- periments show conclusivel.y that the bacillus of tuberculosis, introduced through superficial peripheral infection-atria, seeks the lymphatic chan- nels, through which it is extensivel}^ disseminated before general infec- tion takes place. Cornil and Leloir implanted lupus-tissue into the peritoneal cavity of guinea-pigs, and in 5 cases out of 14 experi- ments produced peritoneal and general tuberculosis. Pagenstecher and Pfeifter took the secretion of the conjunctiva from patients suffering from lui)us of this structure, and injected it into the anterior chamber of the eye in rabbits. After five to six weeks nodules could be seen on the 428 PRINCIPLES OF SUKGKRY. surface of the iris, which, on exauuiuition, were found to be in every respect identiciil with tuberculosis of tliis organ. Doutrelepont inocu- lated the peritoneal cavity in 50 guinea-pigs, and in 8 rabbits the anterior chamber of the e^'c with the same material, with the result that in all of the animals local tuberculosis was produced at the point of inoculation, and in 3 of the guinea-jjigs and in 1 rabbit the local disease was followed by general tuberculosis. Inoculations with material from so-called scrofulous glands produce the same etfect as when lupus-tissue is used, and we are, therefore, forced to conclude that these glands owe their existence to the same cause. Arloing prepared an emulsion from a scrofulous (tubercular) gland, caseous in its centre, which was taken from a boy aged 14. This was injected beneath tlie skin of 10 rabbits, and the same number of guinea- pigs. Visceral tuberculosis developed in all of the guinea-pigs, but the rabbits remained health}', except that 2 showed yellow, caseous granula- tions at the seat of inoculation. Some glands excised from the neck of a 3'oung woman produced tuberculosis both in rabbits and guinea-pigs. The patient died three weeks after the operation from miliary tubercu- losis. From these experiments he inferred that either scrofula and tu- berculosis were nearly allied affections, but caused by different agents, or they were derived from the same virus, of which the activity was modi- lied in the scrofulous form. That the number of bacilli Injected has a great deal to do with the result has recently been satisfactorily demonstrated by Bollinger. He found that infectious milk from a tuberculous cow, which produced local tuberculosis by intra-peritoneal injections, lost its virulence if diluted from 1:40 to 1:100. The sputum of phthisical patients was found much mure virulent, and had not lost its power to produce tuberculosis on being diluted 1:100,000, on being injected into the abdominal cavit}', or the subcutaneous connective tissue. Feeding experiments with sputum diluted 1:8 yielded negative results. Pure cultures remained virulent when diluted 1:400,000. All the experiments proved that the more con- centrated the material and the greater the number of bacilli, the more rapid and intense was the development of the lesion caused by the injec- tion. It was estimated that about 820 bacilli were necessarj^ to produce tuberculosis in guinea-pigs. Intra-peritoneal injections did not always produce peritoneal tuberculosis, and in cases where this did not occur tlie organs aftected Avere the lymphatic glands, spleen, lungs, liver, kid- neys, and genital organs, in the order of frequency named, showing con- clusivel}^ that localization does not invariably take place at the point of primarj- infection. Direct intra-venous infection by injections of pure cultures, sus- INOCULATION-TUBERCULOSIS IN MAN. 429 pended in distilled water, is the most eflfective way in which diffuse miliary tuberculosis can be artificially produced in animals with unfail- ing certainty. Koch succeeded also in producing the disease in rabbits, guinea-pigs, rats, and white mice, by inhalation. A pure culture, sus- pended in distilled water, was used with a hand-spra^', and the cages in which the animals were kept were filled with the infected spray. The animals were killed after twenty-eight da3's, and all of them showed unmistakable signs of pulmonar}^ tuberculosis. INOCULATION-TUBERCULOSIS IN MAN. The opinion that tubercle is capable of inoculation was held by ancient writers, and Laennec, himself, after a nick from a saw while making a necropsj- on a phthisical subject, thought that he witnessed an example of inoculation in a small tubercle in the skin, but twenty 3'ears afterward this distinguished clinician was in good health, though finally he died of phthisis. Schmidt made a number of experiments to ascertain the effect of inoculations of superficial abrasions of the skin with the virus of tuber- culosis. In guinea-pigs he made abrasions in the skin, to which he applied tubercular material and covered the point of inoculation with collodium. All of his experiments failed in producing tuberculosis, while in the control animals, in which the infectious material Mas intro- duced into the subcutaneous tissue, or into the peritoneal cavity, tuber- culosis developed without a single exception. He believes that the results of these experiments are only corroborative of the assertion previously made b}' Bollinger and Koch, that the susceptibility of the cutis for tubercular infection is slight. A sufficient number of authen- ticated cases, however, have been reported during the last few 3'ears, to prove that in man tuberculosis is not infrequently contracted b}' the absorption of tubercular material through small wounds and superficial abrasions of the skin. Yolkmann, a number of 3'ears ago, made the state- ment that tubercular infection never takes place through a large opera- tion wound, or at the site of severe injuries, but that localization of the bacillus is likely to take place in parts the seat of very slight contusions, or what ma}- appear at the time as an insignificant injur}-, He explained this by assuming that the active tissue changes which take place during the process of regeneration after a severe trauma prevent the infection. In studying the cases of inoculation-tuberculosis, which will be referred to below, it will be seen that the infection-atrium was always caused by a trivial injur}-. A very interesting case of inoculation tuber- culosis came under my own observation during the last year. The patient was a strung, healthy young woman, with a good family history, 430 PRINCIPLES OF SURGERY. who wfis emplo3'ed in a rag establishment in sorting rags. Two months before she came under my care she noticed a small sore on the dorsal side of the right index finger, near the metacarpo-phalangeal joint. The place ulcerated, and the granulation tissue which appeared melted rapidly awa}', forming a deep excavation, which had the extensor tendon for its floor. Two weeks later a nodule appeared in the course of the l3-mphatic vessels, near the elbow-joint, over the anterior aspect of the arm, which was soon followed by the formation of three other nodules between this point and the primary seat of infection. General health not impaired in the least. Jnllamed foci neither painful nor tender on pressure ; presented distinct evidences of (luctuation. All the foci were excised and presented the characteristic appearances of tul)ercular tissue. The primary focus, after excision, left such a large defect that it was found impossible to close the wound by suturing, and consequently the surface was covered with Thiersch's grafts taken from the arm. Primary union of all the sutured wounds and speedy, definitive healing of the defect at the primary seat of infection. There can be no doubt whatever that in this case infection occurred through a small wound of the index finger, by handling contaminated rags, which was followed b}^ dissemination of the bacilli through the lymphatic vessels in direct communication with the primary infection- atrium. I have had also under treatment a well-marked case of exten- sive subcutaneous tuberculosis of the hand, in the person of the mother of several children who had died of pulmonary tuberculosis. The disease originated near the tip of the index finger, at the site of a former abrasion, in which a papillomatous swelling formed. This ulcerated and healed partl}^, when the disease commenced to spread along the subcu- taneous connective tissue, and when the patient came under my observa- tion it had extended almost over the entire dorsum of the hand. A number of fistulous openings existed, which discharged dail}' only a few drops of thin, serous pus. The subcutaneous tissue was transformed into a mass of granulation tissue, which was removed with a small spoon through multiple incisions, and the wound surfaces were freely iodo- formized. The process of repair was slow, but satisfactory. Martin du Magny has collected the clinical material of cases of inoculation-tuber- culosis, and in his comments upon the cases asserts that the sputum of phthisical patients and animal excretions were the usual carriers of the bacilli ; consequently the affection is most frequentl}^ met with among physicians, nurses, butchers, and teamsters. The external appearances, manifested at the point of inoculation, consist in the formation of a red nodule in the skin, which increases slowly in size and forms miliary abscesses, in which papillomatous proliferation takes place, and around INOCULATION-TUBERCULOSIS IN MAN. 431 which a new zone of infiltration forms, which in turn again suppurates and becomes papillomatous. The centre heals with the formation of a flat cicatrix, while the destructive process progresses slowlx* in a peripheral direction. Hanot has collected 6 cases, 1 of which came under his own observa- tion. In this case the patient was in the third stage of phthisis, and died soon after from a tubercular ulcer on the arm of at least two years' standing, while the history of cough only dated from the last two montlis, which would show that the cutaneous lesion preceded the pul- monary', and was the cause of the phthisis. In the cases which he collected the sources of inoculation were necropsies on tubercular patients, handling old bones, pricking the hand with a fragment of porcelain from the broken spittoon used by a phthisical patient, and in 4 of the cases the tubercular character of the cutaneous lesion was verified by finding the bacilli. Eiselsberg has observed 4 cases of inoculation-tuberculosis dur- ing the last few j'ears. The first case was a girl 16 j-ears old, in whom the disease developed in the track of a perforation of the lobe of the ear made preparatorj^ to the wearing of an ear-ring, and which was kept from closing by the insertion of a thread. The tubercular product appeared in the shape of a hard swelling the size of a hazel-nut. The second case was a young man who injured himself with the point of a knife above the external epicondyle of the humerus. Eighteen days later a swelling, the size of a pea, appeared at the site of injurv, with an ulcerated surface covered by pale, flabb}^ granulations. In the axilla of the same side one of the h'mphatic glands was found enlarged to the size of a hazel-nut. The third case concerned a woman 50 years of age, who was supposed to have infected herself b}^ washing the clothes of a person the subject of a tubercular abscess of the spine, and who with her fingers scratched an acne pustule on her face. At this point, six to eight days later, a pain- ful swelling, the size of a pea, formed, which subsequently became indu- rated, and opened spontaneously in six weeks. At the end of three months the place of inoculation presented an ulcer with indurated mar- gins. In the fourth case the inoculation followed in the track made b}- the needle of a h^^podermic syringe, in a girl 20 years of age. The swelling which appeared opened after six weeks, and a small quantity of pus was discharged. Four months subsequently the fistulous opening communicated with an abscess-cavit}', the size of a silver dollar, lined by a wall of granulation tissue. In all of these cases no evidence of tuber- culosis could be detected iu any of the internal organs, and the local dis- ease could be traced in every instance to some antecedent lesion, through which the infection had evidently taken place. The diagnosis in all cases 432 PRINCIPLES OF SURGERY. w:i.s bused on an examination of the granulation tissue for the bacillus of tuberculosis, which was always found present. Another ease of tubercular infection through ear-rings is related from Vienna in a girl, 14 years of age, of a perfectly healthy family', who wore ear-rings left to her b}' a friend who had died of pulmonary tuber- culosis. Soon ulcers appeared on the lobes of both ears, the cervical glands became swollen, and percussion and auscultation revealed infil- tration of the apex of the left lung. Tubercle bacilli were found in the ulcers and sputa. This case is onl}' another instance of inoculation- tuberculosis, where, from the point of infection, the disease extended along the lymphatic sj^stem, and, finall}^ S3'stemic infection from the entrance of bacilli into the general circulation. In the cases of inoculation-tuberculosis cited above, infection occurred through some slight lesion, puncture, or abrasion, which fur- nished the necessar^^ infection-atrium for the entrance of the bacillus into the tissues, but a number of cases have been reported by reliable observers where infection took place through a larger wound or granula- tion surface. Middeldorpf reports the case of a health}^ carpenter, who opened his knee-joint by the cut of an ax, and dressed the wound with a soiled handkerchief. The wound healed kindly, but later the joint be- came swollen, tender, and painful. Resection was performed, and on examining the capsule it was found very much thickened. In the gran- ulation tissue tubercle bacilli were found. Wahl amputated the arm of a boy suffering from gangrene, the result of an injury, and discharged the patient with the wound completel}^ healed, except a small granula- tion surface from which the drainage-tube had been removed. At first the wound was dressed by a girl suffering from tuberculosis. The wound soon showed all the characteristic appearances of fungous disease, and the lymphatic glands became infected from this source. I have seen in numerous instances large wounds made for the removal of tubercular glands become infected a week or two after the operation, after the superficial wound had apparently healed. In such cases the overlying cicatrix is subsequentl}^ completely destroyed by the granulations under- neath. The energetic use of the sharp spoon and free iodoformization are the only resources in finall}' eflTecting the healing of such wounds. Konig has seen 16 cases of inoculation-tuberculosis, following operations for tubercular disease of bones and joints, and 2 such cases have been described by Kraske. Czerny reports 2 cases in which tuberculosis fol- lowed in wounds treated by Reverdin's method of skin-grafting. In both instances the patients were healthy, and the skin-transplantation was made during the treatment of extensive burns. The skin was taken from limbs amputated for tubercular affections. In both cases HISTOLOGY OF TUBERCLE. 433 tuberculosis of the adjacent joint occurred, and in 1 of them tul)ereulosis of the granulating surface. A number of cases of inoculation-tubercu- losis following circumcision are on record, in which the infection often occurred in the practice of orthodox Jews, Avho performed the operation in accordance with tlie directions laid down in the Mosaic laws. The loose connective tissue of the prepuce, richly supplied with lymphatics, is an admirable surface for al)sorption, and, when infectious material is brought in contact with it, furnishes the most favorable conditions for the production of local lesions and the transportation of microbes along the lymphatic channels to more distant parts. Lehmann has observed 10 cases of inoculation-tuberculosis in Jewish boys, caused b}' sucking the wound after ritual circumcision b}^ a phthisical person. Ten da^^s after the circumcision the wound became the seat of ulceration, and the inguinal glands began to enlarge. Four of the children died of tubercular meningitis, and 3 died after a prolonged illness caused bj' multiple tubercular al)scesses. Hofmokl has reported a similar case, and Weichselbaum detected the bacillus of tuberculosis in the circumcision wound. Elsenberg has described 3 cases of tubercular infection after circum- cision. All the cases were infants, and the disease appeared primarily in the w^ound or cicatrix, and, later, in the inguinal glands. Local treat- ment b}' scraping proved successful. The diagnosis was corroborated 1)3' microscopical examinations of the granulation tissue. Willj' Me^'er re- lates a case in which circumcision was performed according to the rules of the Jewish Church eight days after birth b}' an old man, and in which four weeks after the ceremony an induration appeared at the frenulum, and the inguinal glands about the same time began to enlarge. S^'philis was suspected, and the little patient was put on a specific course of treatment. The inguinal glands suppurated, and another small ab- scess formed in the right gluteal region. The diseased tissue about the glans penis was then excised. Microscopical examination of the granu- lations revealed the presence of miliar}- tubercles and bacilli in great abundance. The above cases furnish abundant and convincing proof of tlie possibility of the transmission of tuberculosis b}^ cutaneous inocu- lation through superficial abrasions, small wounds, and granulating sur- faces, and this subject is deserving of the most careful attention of surgeons in the matter of prophylaxis, diagnosis, and treatment. HISTOLOGY OF TUBERCLE. A tubercle-nodule is an aggregation of cells primarily invisible to the naked e^ye, tlie product of a minute focus of inflammation, caused by the presence of the essential cause of tuberculosis. When the nodule 434 PRINCIPLES OF SURGERY. becomes so large that it can be recognized without the aid of the micro- scope, it alread}'^ consists of a confluence of a number of minute micro- scopic nodules, Lfennec described four varieties of tubercle : 1. Miliary tubercle, where the visible product of tubercular inflammation appears as nodules the size of a millet-seed, of a gra^ash color, and usually arranged in groups. 2. Crude tubercle, where the miliary nodules have become confluent and have undergone caseous degeneration. 3. Granular tubercle, where the nodules are extremely' small, nearly the size of a millet-seed, and scattered uniformly through a whole organ. They are not arranged in groups and have no tendency to become confluent. In the centre thej' become transformed into yellow tubercle. 4. Enc3'sted tubercles, or such as are constituted of a hard mass of crude tubercle in the centre surrounded by a firm fibrous capsule. These varieties only represent ditterent phases of the same process and different stages of inflammation produced by the same cause. The anatomico-pathological basis of tubercle was created by Vircliow, and has been firmly established through the laborious researches of Langhans, Wagner, Klebs, Schuep- pel, Rindfleisch, Koester, Friedlander, Fox, Baumgarten, and many others. The specific-cell theory has had many able advocates, and has been the subject of many animated discussions, but it has at last been abandoned as fallacious and unscientific. There are no specific tubercle-cells. Lebert's tubercle-corpuscle is a thing of the past, and is only re- ferred to as a landmark in the history of tuberculosis. Reinhart showed that these cells, which were regarded by Lebert as characteristic and pathognomonic of tubercle, could be found in all products of chronic inflammation, and their presence was only an evidence that a certain amount of inflammation existed. When we speak of a tubercle, we mean a nodule or granule, which is composed of leucocytes derived from the capillary vessels damaged by the bacillus of tuberculosis, or new cells derived from tissue proliferation of pre-existing cells acted upon by the same cause. The anatomical character of the nodule consists not in the presence of any particular cell-element, but in the peculiar arrange- ment of the cells; and this feature is the only reliable anatomical guide in making a diagnosis by the use of the microscope. The product of tubercular inflammation occurs either in the form of submiliary, micro- scopic granules, visible miliary nodules, or a cheesv infiltration, which may occupy an entire organ, as a lymphatic gland, or large, isolated foci, as in bone. Every tubercular product commences as submiliary nodules, which, when tliey become confluent, are transformed into visible gray miliar}' nodules, which again coalesce after the}' have undergone caseous degeneration from cheesy masses, which may be either small and circum- scribed or large and diffuse. HISTOGE>fESIS OF TUBERCLE. 435 Yircliow defines tubercle as a nodule representing a heterogeneous growth, a product originall}- necessarilj' of a cellular nature, taking its starting-point from the connective tissue or from other mesoblastic struc- ture, as morrow, fat, or bone. He asserts that the microscopic or sub- miliarv granule contains oil of the essential histological elements of tubercle, and by aggregation forni;^ the ordinary milinrv nodiilo of Lfennec. When the nodules become confluent the}- ma}- form masses the size of a walnut, surrounded by a common zone of embr3'onal tissue. The yellow tubercle, the crude tubercle of Lfennec, is a more advanced stage of the gray, the histological elements of the latter having under- gone caseation. HISTOGENESIS OF TUBERCLE. Colberg asserts that tubercles in the lungs originate from the nuclei of the capillar}- vessels and the connective tissue, the epithelial cells lining the alveoli never being primarily affected. Bastian observed tubercle-nodules upon the small vessels in cases of basilar meningitis, but refers their origin not to proliferation of the nuclei of the endo- thelial lining of the vessels, but to new cells springing from the endo- thelial cells of the perivascular 13-mphatic sheaths which surround the vessels of the meninges of the brain. Kuauff demonstrated the lymphoid character of the adventitia bj' examining the capillar}' vessels of the visceral pleura in dogs which had been exposed for a long time to an atmosphere impregnated with coal- dust. He found the pigment lodged in small masses close to the walls of small arteries and veins. Examining the same vessels in other dogs not thus treated, he found upon the outer surface of the adventitia opaque, whitish-gray nodules, surrounded by round and oval cells con- taining nuclei, also lymph-corpuscles. The same structures, which he named lymph-nodules, are also found around the same A'essels of the pleura in man, and Knaufi' looks upon these lymphoid structures as the starting-point of tubercular inflammation. Klebs maintains that the endothelial cells of lymphatic A'essels are the most frequent location for tlie formation of the primary tubercle- nodule. He observed that in eases of tubercular ulceration of the intes- tines the peritoneum is reached through the lymphatic vessels. Silver- stained preparations of inoculation-tuberculosis in rabbits showed that the most recent products occurred in the interior of the lymphatic vessels at points of intersection. In some places the nodules extended into the tissues between the lymphatic vessels, but their centre always corre- sponded to the location of a lymphatic vessel. At some points the nodules were seen to branch out, but these projections, in reality, were within the lymphatic vessels, as the net-work of lymphatic endothelia 436 PRTNCTPLES OF SURGERY. could be seen above and underneatli the tubercular product. Toward the centre of the nodule no endothelial cells could be distinguished, and this fact led him to the belief tlint the endothelial cells are directly con- cerned in the production of the new tissue. In the mesentery he saw the tubei'cles ndhere to the outer wall of the c:ii)illary vessels, and, as the spindle-shaped cells of the outer coat appeared to be pushed apart by the new tissue, he regards the adventitia as a genuine lymphoid struc- ture. Rindtleisch traces the beginning of the process in miliary tuber- culosis of the lungs to a proliferation of the endothelia and the external connective-tissue la3'er of the capillary Ij'raphatic vessels. Edward Smith believes in the epithelial origin of tubercle. Manz studied the development of tubercle in the choroid in patients suffering from general miliary tuberculosis. So constantly does this disease show itself in this structure that von Graefe, Cohnheim, Frankel, and Bouchut recommend ophthalmoscopic examination as a diagnostic measure in cases of sus- pected pulmonar}' or general tuberculosis. Manz traces the commence- ment of the disease in the choroid to cell-pullulation in the tunica adven- titia of the small vessels. The process is, however, not limited to this structure ; the non-pigmented stroma-cells ma}' also assist in furnishing material for the new product. Bart, on the other hand, asserts that the vessels, in cases of tuberculosis of the choroid, are not primarily affected ; according to his observations, the process depends exclusivel}^ on a degeneration of the stroma-cells, as the remaining tissue did not appear affected. Cohnheim, Ziegler, and others maintain that the leucocytes furnish most of the material in the building up of the tubercle-nodule. Experiments on animals, as well as microscopic examinations of pathological specimens, have suflicientl}' demonstrated the fact that the tubercle-nodule is nothing more nor less than a circumscribed inflamma- tory pi'oduct, the histological elements of which are composed of new tissue, formed by proliferation of fixed tissue-cells which have come in contact with the bacillus of tuberculosis or its ptomaines. The specific pathogenic effect of the bacillus consists in its power to cause a chronic inflammation of the tissues in which it has localized or with which it has been brought in contact. The tissues affected are the cells which are nearest the essential microbic cause, irrespective of their embryological origin, their histological structure, or physiological function. In cases of inoculation-tuberculosis the primar}^ nodule develops at the point of insertion of the virus from connective-tissue proliferation, and from here the bacilli enter the lymphatic channels, and the secondary nodules are composed of cells derived from the endothelial, l3^mphoid, and connective- tissue cells which compose these structures. If the bacilli are injected HISTOLOGICAL STRUCTURE OF TUBERCLE. 437 directly into the circulation or gain entrance into the ])lood-current from some tubercular focus, they become implanted upon the wall of distant capillar}' vessels, and the nodule which forms at the seat of implantation consists of cellular elements formed b}' the tissues of the vessel-wall. As aoon, however, as bacilli reach the extra-vascular tissues, they, in turn, furnish tlieir part of the material for the further growth of the nodule. If the tubercle bacillus becomes implanted upon a mucous sur- face, as the bladder, intestines, nose, larynx, uterus, etc., if such surface is susceptible to tubercular infection, the epithelial cells take an earl}' and active part in the inflammator}' i)rocess. From the manner of en- trance into and diffusion tlirough the tissues, it is apparent that the mesoblastic tissues, the connective-tissue and endothelial cells, being the first to become infected, furnish the greatest amount of material in most tubercular lesions; but all tissues, when infected, take part in the process. HISTOLOGICAL STRUCTURE OF TUBERCLE. The essential histological elements which make up a primary tubercle- nodule are: (a) leucocytes; (6) giant cells; (c) epithelioid cells; (d) reticulum. Leucocytes. — One of the conA-incing proofs of the inflammatory nature of tuberculosis is the presence of leucocytes in the tubercle- nodule. The bacillus of tuberculosis appears to exercise only a mild pathogenic effect on the capillary wall, and the primar}' inflammatory product is always scanty. As the colorless blood-corpuscles can onl}' escape, in considerable number, through inflamed capillary walls which have undergone alteration from the action of some specific microbic cause, it is evident that its migration into the para-vascular tissues, where it forms a part of the tubercular product, can onl}^ occur after such alteration has taken place from the action of the bacillus upon the cement-substance of the endothelial lining of the capillary vessels. The leucoc3'tes are found scattered among the other cellular elements, and are found in greatest abundance toward the periphery of the nodule. The leucocytes invariably undergo degenerative changes, and are never trans- formed into other forms of cells found in the tubercular product. The}^ have been described as lymphoid corpuscles. Although constantly pres- ent, they are most numerous when the process is acute. Giant Cells. — A great deal has been said and written concerning the origin and diagnostic value of the giant cells in the tubercle-nodule. The}^ resemble the giant cells found in some forms of sarcoma, and appear to be simpl}' certain cells which have outgrown others by taking up a greater amount of nourishment in the shape of leucocytes which have undergone fragmentation. 438 I'KINCIPLES OF SUliGEUY The uianl cells, or, ns Klebs calls tliem, macrocytes^ are finely gran- ular, and contain multiple nuclei, which usually occupy the periphery of the cell, or are arranged in a crescent at one end. In tubercular lesions artificially produced in animals the giant cells contain numerous bacilli, which occupy, as a rule, the peripheral zone of the cells. In tuberculosis in man the bacilli in these cells are never so numerous, and as central degeneration of the cells appears they disappear in this portion of the cell, while some may still be found in the periphery. During the progress of the disease the giant cell becomes more and more fibrous toward the peripher}^ at the expense of the protoplasmic part in the centre. The protoplasm evidently is transformed into or secretes the fibrous margin. ^..^. Fig. 96.— Giant Cell fkom Centre of Tubercle ok Luno. x 450. {Hamilton.) A, granular protoplasmic centre ; B, peripheral more-formed part ; C, crescent of nuclei ; D, endothelium-like cells ; E, two vacuoles within the giant cell. If caseation does not take place the bacilli disappear, and the whole cell mass, including the giant cells, is converted into a cicatricial mass. The first evidences of degeneration appear in the centre of the giant cells, and, according to Weigert, the}' consist of strnctund and chemical chano-es which are indicative of coagulation necrosis. In a recent tubercle-nodule the giant cells occupy the central por- tion, around which the epithelioid cells and leucocytes are arranged. The vacuoles are necrotic foci within the cells. The giant cell found in tubercular tissue has its prototype in normal tissue. Giant cells were first discovered in normal tissue (mar- row of bone) by Robin, who called them myeloplaques. They were sub- sequently accurately described b}' Virchow. In a normal condition they HISTOLOGICAL STRUCTURE OF TUBERCLE. 439 are constantly found in bone and the placenta. They are also found occasionally in fat-tissue, especially in cases of rapid emaciation. Kun- drat has found them in iuflamed serous membranes, and Strieker and Heitzmann iu the inflamed cornea. They are always found around for- eign bodies, becoming encysted in the tissues. Friedlander found them present in the aveoli of the lungs in cases of chronic pneumonia. Heubner found giant cells in endarteritis, Baumgarten in gummata, Buhl and Jacobson in granulating wounds, and finall}- Jdhne and Pflug in actinomycotic foci. The histological source of these cells in tuber- cular affections has been traced to epithelial cells by Zielonko and Weigert ; to endothelial cells by Kundrat, Klebs, Herrenkohl, and Zie- lonko ; to connective tissue or endothelial cells by Yirchow, Fleming, and Ziegler. Schueppel and Rindfleisch believe that they invariably originate within blood-vessels or hmphatics, where these authors regard them as the first step toward the development of tubercle-nodules. Ziegler claims to have seen giant cells develop from white blood-corpus- cles. Hering, Aufrecht, Woodward, Schueller, and Treves are of the opinion that what appears as giant cells in tubercular tissue are not cells, but onl}- represent spaces which correspond to transverse sections of lymphatic channels, the protoplasm representing the coagulated Ij-mph within these vessels, and what appear as nuclei being enlarged, swollen endothelial cells. Giant cells possess amoeboid movements, and by virtue of these they are capable of taking up in their protoplasm fine particles, such as microbes, pigment material, and blood-corpuscles, which have undergone fragmentation. The giant cells in tubercular lesions are hyperplastic, epithelial cells, and consequently are derived from the same histological source as these. Epithelioid Cells. — Cells intermediate in size between the giant cells and the leucocytes are found in everj- tubercle-nodule in which the cells liave not been destroj'ed b}' caseation. These cells were first described b}- Rindfleisch, and were called b}' him epithelioid cells from their struc- tural resemblance to epithelial cells. Klebs calls them platycyies. They are about two or three times larger than a white blood- corpuscle, and in shape they are eitlier round or somewhat elongated. In structure they are finely granular, and contain one large and often a number of small nuclei. Thej' form the bulk of all recent nodules, are scattered between the giant cells, and are often arranged in layers around them. The histological source for these cells was supposed to be the leucocyte b}- Schueppel, Ziegler, and Treves; the endothelial cells of the Ijmph-spaces by Aufrecht, Hering, and Woodward ; the endothelial cells of the blood-vessels and lymphatics or connective-tissue cells by Rind- fleisch and nearlv all of the modern authors. The endothelioid cells 440 PRINCIl'LES UF SI UGEKV. represent the embryonal colls, the product of proliferation from any of the fixed tissue-cells in a tubercular lesion, and they remain as such until they are destroyed by degenerative changes from the continued action upon them of the bacillus of tuberculosis or its ptomaines, or until, on cessation of the primary cause, they are transformed into tissue of greater durnbility. Reticulum. — Schueppel lirst called attention to tlie reticulated structure of tubercle by his description of the reticular arningement within tubercles of lymphatic glands. The reticulum, according to most authors, (ionsists of the pre- existing connective tissue pushed asunder by the new cells. According to Wagner, Schueppel, Brodowski, Tliaon, and Ziegler, it is made up of Fig. 97 Section from Mucous Membrane of Pharynx, showing Epithelioid Cells WITH A FEW Small Giant Cells. X 350. (Birch-Hirschfeld.) protoplasm. Buhl taught that the giant and e[)itiielioid cells secrete a substance at their periphery which, on becoming firm, is formed into a structure resembling connective tissue. According to his researches only the marginal zone is supplied with loose, read^'-formed, connective tissue of the organ. Wahlberg maintained that the principal reticulum consists of protoplasm which is traversed by a net-work of connective tissue. The reticulum is always more marked in the periphery of the tubercle-nodule, where, from pressure, it is condensed into a fibrous capsule (Fig. 98, C). Arrangement of the Cells in a Recent Tubercle-Nodule. — The earliest evidence of the formation of a tubercle-nodule, as witnessed under the microscope, is the appearance of small cells which resemble ordinary HISTOLOGICAL STKUCTUKE OF TUBERCLE. Ul embryonal cells, which are the product of tissue proliferation from a mesoblastic matrix, usually the connective tissue, and its embryological and histological prototype, the endothelial cells of blood-vessels and lymphatics. From these cells the epithelioid and giant cells are, later, developed. Some of the central cells, b^- appropriation of a superabund- ance of food furnished by leucocytes in a state of fragmentation, become hj'perplastic, and are transfunned into giant cells ; these occup}- the //I w Jjj: Fig. 98.— Fully-Developed RsTicrLAR Tcbeecle of Lvng. x 4.50. (Uamilton.) A, A, A, giant cells ; B, vacuole in one of these : C. peripheral capsule of fibrous tissue ; D. reticulum of the tubercle : E, large enilothelium-like cells lying on the reticulum and within its meslies ; F, smaller " lymphoid " cells occupying the same situation ; G, peripheral fibrous-looking border of the giant cells. centre of the nodule. Around these cells the smaller or epithelioid cells arrange themselves, and between them and in the periphery of the nodule are found the smallest cells, — the leucocytes. Gaule and Tizzoni distinguish three zones in a tubercle: (1) an external, composed of small round cells; (2) a leper, epithelial, or middle zone, containing the reticulum ; (3) a central space containing a giant cell. The structure of a tubercle is not always typical, and hence the division into zones is based more on theoretical "rounds than actual 442 PRIXCIPLES OF SURGERY. observation. The giant cell is not an essential histological element of tubercle, but an accidental product. In some tubercles giant cells can- not be found, wliile in others they are numerous. Giant cells can only develop I'rom I'pithelioid cells if tlie local conditions are favorable for hypernutrition ; tiiat is, if the leucocytes in a condition of fragmentation are witliin their reacli. If they are present tliey always mark the loca- tion of tlie starting-point of the tultercuiar infection, as only the older epithelioid cells undergo this change. Tlie number and size of the epithelioid cells are also subject to great variation, and are modified by the nutritive conditions within and in the immediate vicinity of the nodule. If cell proliferation is active the epithelioid cells appear densely packed in the reticulum, nutrition is greatly impaired, and the new cells undergo degenerative changes before they attain their average size. The leucocytes are scattered among the giant and epithelioid cells, and, as they reach the part through the inflamed wall of the capillaries in the immediate vicinity, they are most numerous in the periphery of the nodule and along the course of the atfected vessels. GROWTH OF THE TUBERCLE-NODULES. The typical tubercle-nodule is microscopic in size. Tlie growth of the swelling depends on the formation of new tissue, migration of leuco- cytes, and confluence of nodules into larger masses. The bacillus of tuberculosis, when brought in contact with fixed tissue-cells susceptible to its pathogenic action, incites tissue proliferation, which always takes yjlace bj' karyokinesis. Baumgarten's investigations leave no doubt that phatycytes constitute the entire mass of the forming tubercle. He has also observed karyokinetic figures in tubercular tissue in cells derived from the connective tissue, endothelia, and epithelia. The tubercle bacilli are found in the interior of giant and epithelioid cells and between them. Each tubercle-nodule increases in size by the growth of new cells from pre-existing tissue, and as the primary cause, the bacillus of tuberculosis, multiplies in the tissues, bacilli are conveyed into the surrounding tissues by leucocytes or the plasma-current, and new centres for tubercle formation are established, which, later, become confluent, forming masses of considerable size, the numei'ous foci of caseation corresponding to the centre of a nodule. The growth of tubercle is favored by local and general conditions which diminish tissue resistance, while retardation takes place in consequence of degenerative changes in tlie cells of which it is composed, or, if the cells are converted into tissue of a higher type, from disappearance or suspension of activity of the primary cause. PATHOLOGICAL VARIETIES OF TUBERCLE. 443 PATHOLOGICAL VARIETIES OF TUBERCLE. Several varieties of tubercle have been described, according to the histological structure of tiie tubercle or the structure or condition of the cells of whicli it is composed. Reticulated Tubercle. — This is tlie ordinary form of tubercle usually met with, and tlie most important anatomical feature is the presence of a well-detined reticulum, comi)osed of pre-existing connective tissue and a delicate iiet-worli of brandling giant cells, in the meshes of which are found the epithelioid cells and leucocytes. Fibrous Tubercle. — In contradistinction to the reticulated or lymphoid tubercle, a few years ago the tibrous tubercle w-as described, distinguished by its pearl-like, light-gray appearance, but possessing the same inherent tendency to caseation. It is said to be found most fre- quently in dense, librous tissue, and quite often in newl^'-formed connective tissue. Histologically it is composed of nodules of dense connective tissue, the cells of which have undergone rapid growth, containing, fre- quently, more than one nucleus. A further development only takes place in the interior of the nodule, as here caseation occurs, the caseous focus being surrounded bj'^ a firm capsule of connective tissue. The description of fibrous tubercle by Langhans differs materially from the above. According to investigations of this author, the fibrous tubercle has for its favorite location the so-called parenchymatous organs, as the lungs, liver, spleen, kidnej-s, testicles, epididymis, and brain. The larger nodules are composed of three zones. The central zone consists of a few connective-tissue fibres, free oil-globules, and cells in a condition of fatt}' infiltration. The middle zone is composed of connective tissue. As the cells of this zone are not numerous, it presents the appearance of a capsule ; in reality, however, it is not a capsule in the proper sense of the word, but a matrix of tissue proliferation, from which the central part of the tubercle is the oti'spring. Both Langhans and Schueppel, like nearh' all of the modern pathologists, regard fibrous tubercle not as a distinct special anatomical form, but as an ordinar}^ tubercle in which the epithelioid cells in the peripheral zone have been converted into con- nective tissue. Fibrous tubercle differs from the ordinary cellular variety onl>- in so far that it contains a larger amount of connective tissue. If in a tubercle-nodule at the time the young cells are yet vigorous the primary microbic cause ceases to act, degenerative changes fail to take place and the embryonal cells are transformed into connec- tive tissue. The cicatricial condition starves out remaining embryonal cells ; at the same time an impermeable wall of connective tissue is thrown around the primary depot of infection, which effectually guards against the escape of active bacilli or their spores into the surrounding tissues. 444 I'RINCirLlvS OF SURGf:RY. Hyaline Tubercle. — Chimi described another variety of tul)crcle — tlie hyiiline tubercle. The first si)eeimen in which lie found tiiis variety was taken from the liver of a tuberculous child 4 years of age. The nodules in the brain, lungs, and bronchial glands in the same case pre- sented the ordinary structure of lymphoid tuljcrcle. The clear hyaline structure of those found in the liver gave them a very i)eculiar appear- ance. The clmuge is believed to be due to a hyaline degeneration of the reticulum, and reseniltles most closely the hyaline degeneration of the capillaries of the brain. Chiari conjectures that it may be regarded as a benign change opposed to caseation, which tends to infection. Hyaline degeneration of any pathological product must now be considered as one of the earliest phases of coagulation necrosis, and, if a considerable area of the nodule undergo this change rapidl}' and simultaneously, the structures will present a hyaline appearance ; but if the hyaline product continue to be acted upon by the same causes, caseation will follow, and the hyaline tubercle becomes a chees}- tubercle. CASEATION. The gray or miliarj- tubercle is transformed into the yellow, crude, or cheesy tubercle hy a process which is called caseation, or tyrosis. The exact nature of this process remains unknown. The cheesy material is composed of the products of cell necrosis. Early death of cells is the most characteristic pathological feature of tul)ercle, Avhich distinguishes it from all other forms of chronic inflamination. Two causes can be advanced to explain this peculiar and almost pathogno- monic form of degeneration, which occurs, almost without exception, in every tubercle if a sufficient length of time has elapsed : 1. Inadequate blood-supply. 2. Specific action of the bacillus of tuberculosis or its ptomaines. Caseation alwa^'S commences in the centre of a nodule, consequently at a point most remote from the vascular supply, and in cells Avhich have been exposed longest to the deleterious effect of the primary microbic cause. Tubercle is a non-vascular product. From causes which, as j'et, are not known, the tubercular product is not supplied with new blood-vessels. The angioblasts are transformed into epithelioid cells that have lost their power of vessel formation. Nodules which have priinarilj^ an intra-vascular origin are rendered avascular by closure of the vessel from intra- and peri- vascular cell proliferation. If the primary starting-point is outside of the vessels, the rapidly accumu- lating cells exert pressure upon the surrounding vessels, and thus diminish the 1)lood-sn[)ply to the part affected. The new cells require an adequate blood-supply for their further development, and if this fail to take place, as is the case in eveiy tubercular product, they necessarily CASEATION. 445 suffer from malnutrition, and undergo degenerative changes at an early stage of their existence. A deficient blood-supply, in the absence of other causes, would result in fatt}' degeneration of the new vessels ; but caseation is something different from ordinary- fatty degeneration, and the bacillus of tuberculosis, or its ptomaines, must be regarded as its immediate and essential cause. Caseation is preceded by coagulation necrosis, which is one of the results of the specific action of the bacillus on the tissues. The coagulation necrosis commences in the giant cells, and in the epithelioid cells in the centre of the nodule, and caseation follows as soon as the dead cells have lost their histological identity, and appear under the microscope as a debris in which no distinct cell forms can be identified. Caseation is attended by softening, which can be readily recognized in tubercular masses the size of a hazel-nut to that of a walnut, composed of numerous confluent nodules with as man}' caseating foci. In such masses the small, chees}- cavities become confluent and form spaces of considerable size. Caseation proceeds from the centre of each nodule toward the periphery, layer after layer of epithelioid cells being destro^'cd and changed into cheesy material. The part of a tubercle- nodule which has undergone caseation contains few, or no, bacilli, and 3^et inoculation experiments show it to be highly infectious. The cheesy material does not furnish the proper nutrient material for the growth and development of the bacillus, which dies from starvation, while the spores, being more durable and possessing greater power of resistance, remain in an active condition for an indefinite period of time in the dead material, and it is due to their presence that infection takes place from cheesy foci, and that successful inoculations can be made with cheesy material. While the disease has become arrested in the centre of a nodule, with the appearance of caseation, its growth in a peripheral direction pursues the same relentless course. The bacilli multiply in recent tubercular tissues, and are carried beyond tlie peripheral zone into the surrounding tissues, where new, independent foci of infection are thus established, which, in the course of time, pass through the same series of pathological changes as the primary nodules. It is a well- known clinical fact that acute miliary tuberculosis is not a primar}- affec- tion, as in all such cases a careful post-mortem examination will reveal the presence of a cheesy focus in a lymphatic gland, the lungs, testicles, a joint, or bone, or some other organ, from which the infection occurred. Weber found chees}'^ foci in 16 cases of tuberculosis of serous mem- branes. The cheesy mass may lie latent so long as it is solid, but as soon as it liquefies the spores which it contains can be taken up by the blood-vessels and prove a cause of general infection. 446 PRINCIPLES OF SURGERY. CALCIFICATION. One of nature's meiiiis in i)rc'venting the local extension of tubercle and in guarding against regional and general infection is calcification of the tubercular product. This can only occur as a secondary condition in tubercles that liave undergone caseation. Calcification implies the removal of the cheesy material and the substitution for it of inorganic, calcareous material. It is a process which greatly resembles petrifaction. Arrest of the tubercular process by caseation and calcification frequently takes place in the lungs, and, occasionally, in the lymphatic glands. CHAPTER XVITI. Clinical Forms of Surgical Tuberculosis. It is but a few years since it was thought impossible that any other organ than the lungs should be the seat of tuberculosis. The different forms of surgical tuberculosis that will be described below were not cor- rectly understood until quite recently, and consequently a rational sur- gical treatment was out of question. Most all of the localized tubercular processes were included under the general term scrofula, and were regarded as local manifestations of a general dyscrasia, and treated in accordance with this view of their patholog3^ The discovery of the bacillus of tuberculosis has rendered the word scrofula obsolete, and has assigned to the tubercular processes in the various organs and tissues of the body their correct etiological and pathological significance, and paved the way for their successful surgical treatment. There is hardly a tissue in the body which ma}' not become the primar}' seat of tuber- cular infection, or which escapes when diffuse dissemination occurs through the medium of the general circulation. The frequency of tubercular affections is something appalling. At least 1 person out of every 7 dies of some form of tuberculosis. Most of the large hospitals contain from 25 to 50 per cent, of patients afflicted with this disease. The ravages of the disease are to be seen everywhere, in the shape of disfiguring scars of the neck, deformed limbs, and bent spines. Health resorts, frequented for years by tubercular patients, have become infected to such an extent that there is great danger of the whole population becoming exterminated by this disease. The sources of infection in such places have become so numerous that it is unsafe to breathe the air, to drink the water, or to eat the food prepared in houses which for 3'ears have been hot-beds for the bacillus of tuberculosis, and by persons car- rying the microbe upon ever}- square inch of their surface. That whole communities and nations, where this disease has been prevalent for cen- turies, have not been completely depopulated long ago is owing to the fact that many persons possess, from the time of their birth, a degree of resistance to infection that even direct infection b}' inoculation would prove harmless. The bacillus is not the sole, but the essential, cause of tuberculosis. (447) 448 PRINCIPLES OF SURGERY. HEREDITARY AND ACQUIRED PREDISPOSITION. Almost every uuthor recognizes, as an iniportiint element in the etiology of tuberculosis, the existence of a hereditary or acquired pre- disposition. Little is known in reference to the real nature of such a predisposition. A weakness of the lymphatic vessels in scrofulosis was recognized b>' Sylvius as early as 1695, by Portal in 1690, and still later by Bell, Percival Pott, Hufeland,and Broussais. Fox is of the opinion that a disposition to tuberculosis is created by certain anatomical or physiological defects in the Ijniphatic system. The cause of scrofula was ascribed by Virchow to a weakness or imperfection in the arrange- ment of the lymphatic system ; by Hueter to a dilatation of lymph- spaces ; and by Billroth to a constitutional anomal}'. Mordhorst regards a slugiiish circulation, the consequence of superficial, imperfect respira- tion, by causing ca[)ilhiry stasis and favoring inflammatorj^ exudation, a potent factor in producing that peculiar vulnerability of the tissues in scrofulous subjects. Rokitansky placed great stress on the importance of an imperfect circulatory and respirator}' apparatus as a predisposing cause of tuberculosis. In 1871 Friedlixnder suggested that in cases of tuberculosis there might be present, and active, a fusion of the scrofu- lous and tubercular diathesis, — a view which was indorsed b}^ Charcot in 1877. Aufrecht claims that the disposition to the origin of tubercle may be found in the lymphatic vessels. Riedel defines the hereditary predisposition to tuberculosis as consisting in a [)eculiar defect in the anatomical arrangement of the tissues, especially' of the Ij'mphatic glands, which furnish a favorable soil for infection. Schiiller believes that the noxae of tuberculosis excite a slow form of inflammation, with a tendenc}^ to speedy retrograde metamorphosis of the new material. Quincke recognized a close relationship between scrofula and tubercu- losis, when he says : " Scrofulous persons are especially predisposed to tu- berculosis; tuberculosis hardly ever occurs except in scrofulous persons." Ziegler w^as aware that pulmonary phthisis is the most frequent cause of death in scrofulous patients. Whittier, in comparing the etiology of tuberculosis with sypliilis, makes use of the following very positive language : — " There is no such a thing as a predisposition to either disease. Eitlier a man has syi)liilis, or he has it not. One m.in is not more pre- disposed to either disease than another. Syphilis affects one individual more than another because it^ virus finds a better lodgment upon mucous membrane. Tuberculosis finds, also, fortuitously, a better nidus in one case than another. The virus of tuberculosis is lodged, in one case, and not coughed up, just as in syphilis the virus is secreted and not washed off." And again: "From an}' chancre, plaque, gumma, or HEREDITARY AND ACQUIRED PREDISPOSITION. 449 other deposit of syphilis, re-absorption ma}' take place at any time, and re-infection with syphilis ; or, hetter, re-appearance of external signs. So from an}- caseous nodule, wherein the tuberculous virus is locked up in temporary innocence, absorption may take place under favoring cir- cumstances, and a new outbreak of tuberculous symptoms appear, the quantity of virus thus set free determining, to a great extent, perhnps, the virulence of the symptoms. While the virus is thus locked up, the disease is latent ; when set free, it is manifest." W3'nne Foot say-s : " Tubercles are small-celled overgrowths of lymphatic tissue that have preserved such uniformity of size, color, and shape as to have long- suggested the probabilit}' of their lymphatic origin," Wilson Fox regarded tubercle as an overgrowth or hyperplasia of lymphatic tissue resulting from irritation of the lymphatic elements. Savor}', in speaking of the relation of scrofula to tubercle, remarks : " It appears to me that there is nothing sufficient to warrant the patho- logical distinction which it is now the fashion to make between scrofula and tul)ercle." And further : " Tubercle may be said to be the essential element of scrofula." According to Rokitansk}-, the most frequent seat of tubercle in children is in the lymphatic glands, Virchow maintained that scrofula constitutes the basis of tubercle, and that in man tubercu- losis depends in general on scrofula. He asserts, further: " On account of the histological identit}' of the scrofulous and tubercular new growths, it is often impossible, in a given tubercular lesion, to determine how much is inflamniator}^ and how much is tubercular." From the above quotations it becomes apparent that nearh' all of the older authors recognized, if not the identit}', at least a close relationship between scrofula and tuberculosis. The identity of scrofula and tuberculosis was established not upon anatomical or pathological rt'searchos, but was deflnitel)' settled by the discovery of the same cause in the local lesions of both. The demonstration of any definite anatomical defect, heredi- tary or acquired, which acts as a predisposing cause to tubercular infec- tion, has so far not succeeded. Only a few years ago Formad made some interesting studies concerning the histological structures of tissues that are known to be prone to tubercular infection, and he believed that the changes constantly found were such that favored the arrest of migrating cells. It is more probable that the hereditar}^ or acquired predisposition to tuberculosis, which must now be recognized as nn important element in the causation of the disease, must be regarded rather as a diminution of the power of resistance inherent in the tissues to the action of the specific microbic cause than any characteristic anatomical cell defects. From a clinical stand-point, it is important to remember that in the causation of tuberculosis we must recognize a combination 29 450 PRINCIPLES OF SURGERY. of etiological factors, viz.: (1) local or general conditions, resulting fi'om hereditary or acquired causes, wiiich diniinisli tlie resisting capacity' of tlie tissues to the action of the bacillus of tuberculosis, which must be regarded as the predisposing cause; and (2) the presence in the tissues of the essential cause of the disease — the bacillus of tuberculosis. The predisposing cause can under no circumstances result in tuber- culosis without action of the essential cause, and the bacillus of tubercu- losis is most certain to produce its specific pathogenic effect in tissues debilitated by hereditary or acquired causes. The different avenues through which infection takes place will be referred to in the further discussion of the subject which heads this chapter. TUBERCULAR ABSCESS. Pathological Anatomy. — The effect of the bacillus of tuberculosis on the tissue is to produce a chronic inflammation, which invariabl}^ results in the production of granulation tissue. The embr3'oual cells furnish, as it were, a wall of protection for the surrounding healthy tissue. The characteristic pathological feature of ever}' tubercular product consists in the tendency of the cells of which it is composed to undergo early degenerative changes, which are caused by local ana?mia and the specific chemical action of the ptomaines of the tubercle bacilli, and consist in coaguhition necrosis, caseation, and liquefaction of the cheesy material into an emulsion, which has always been regarded as pus, until recent investigations have sliown tliat it is simpl}' the product of retrograde tissue metamorphosis, and not true pus. I believe that it can now be considered as a settled fact that the bacillus of tuberculosis is not a pyo- genic microbe, and that in the absence of other microbes it produces a specific form of chronic inflammation, which invariably terminates in the formation of granulation tissue; and that when true suppuration takes place in the tubercular product it occurs in consequence of secondary infection with pus-microbes. The so-called tubercular, or cold, abscess contains a fluid which macroscopically resembles pus, but which, when examined under the microscope, shows none of its histological elements. If the ])acillus of tuberculosis meets with sufficient resistance on the i:)art of the surrounding tissues, it finally exiiausts the nutrient material in the granulations and dies, or remains in a latent condition ; the granu- lation material is converted into cicatricial tissue and the local lesion is cured. The cases in which the tubercular product is removed by cica- trization terminnte most frequently in spontaneous cure. If, on the other hand, bacilli in sufficient number are present to destroy the granu- lation cells, congulation necrosis, caseation, nnd liquefaction of the in- fected tissue take place; a spontaneous cure is still possible if a part TUBERCULAR ABSCESS. 451 of the fluid portion is absorbed and the solid debris becomes encapsu- lated. The same favorable termination is expedited under similar cir- cumstances if the primary lesion has healed, and the iiillammatory l^roduct is removed b}' operative interference under the strictest anti- septic precautions, or if, at the same time, the primary focus can be completely removed bj' extending the operation to the i)rimary lesion. Secondary infection of a tubercular product with pus-microbes without a direct infection-atrium is possible, and if the primary- lesion is located in an unimportant organ, and in such a place where the inflammator}^ product can be earlj- reached or can be disehnrged spontaneous^^, a cure is often effected, as the suppurative inflammation may destro}- all of the tissues inhabited b}- the bacillus, and the whole nidus, with the microbes it contains, is eliminated permanently from the bod}'. Such a course is not infrequently observed in cases of tuberculosis of the lymphatic glands of the neck. If, however, the tuberculnr process affects important organs or ports deeply located with extensive infection of tissue, and secondary infection with pus-microbes takes place, then the patient incurs the danger of septic infection and local and general dissemina- tion of the tubercular process from the breaking down of the protective wall of granulation tissue. That the bacilli do not grow in a tubercular abscess has been definitely settled by Schlegtendal. He examined 520 specimens of fluid from tubercular abscesses, and found bacilli present in only 75 per cent. Garre has also made an extended series of observa- tions to ascertain the presence of the bacillus in cold abscesses. Accord- ing to this author, many tubercular ulcerations and abscesses are the result of a mixed infection, as has been claimed by Hoffa for some cases of empj-ema complicating pulmonary or pleural tuberculosis. In cold abscesses, and in the liquefied cheesy material of tubercular cavities in bone, no pus-microbes could be fovmd ; not even in cases that pursued a rapid course. Cultivations of such material remained sterile, while inoculations produced tvpical tuberculosis. Such specimens, examined iinder the microscope, showed none of the morphological elements of pus, Init were seen to consist of an emulsion composed of fat-globules and detritus of broken-down tissue suspended in serum. Garr^ believes it is possible that, in many cases of suppuration fol- lowing in the course of a tubercular process, pus is the result of a mixed infection, and that the pus-microbes disappear before the examination is made. The walls of the tubercular cavit^^ contain the typical structure of the tubercular lesion and the primary and essential cause of the in- flammation, the bacillus tuberculosis. The infection follows the migra- tion of the abscess in whatever direction that may take place. If an additional infection from without take place, following either a spon- 452 PRINCIPLES OF SURGERY. tiineoiis discharge or after incision, the superficial granuhitions 'are destro^'ed by the suppurative process which is initiated, exposing the patient to the additional risks of septic infection and a more rapid local and general dissemination of the tubercular process. Symptoms and Diagnosis.— The tubercular abscess is called a cold abscess because it lacks the characteristic clinical phenomena which attend the development of an acute or hot abscess. There is but little, if an}', rise of the local temperature, and, unless the abscess has reached the skin, looks rather preternaturall_y pale than red, and the abscess itself is always painless and not tender on pressure. The pain, if l)resent, is referred to the priniar^^ seat of the tiibercular inflammation. Fluctuation is usually well mnrked,as the tissues around the abscess are not much infiltrated. The most important clinical feature of a cold abscess is its tendency to wander from the place where it originated to distant localities by gravitation ; hence the name given to it by German writers, senkxmgs absce.'tii. Thus, in tubercular spondylitis, the abscess raa}^ appear in the lumbar region, and is then called lumbar- abscess; it may follow the iliac muscle and appear in one of the iliac regions, and is then called iliac abscess ; or, finally, it ma}^ follow the psoas muscle and appear above or below Pou part's ligament, when it constitutes a psoas abscess. In tuberculosis of the hip-joint the abscess appears posteriorly underneath the gluteal muscles, if perforation of the capsule in this direction take place ; or it appears anteriorlj' a considerable distance below the hip-joint, if perforation of the capsule take place in an oppo- site direction. As the contents of the abscess carry the original cause of the disease, infection of the tissues takes place along the whole course of the abscess, which is alwaj^s lined with infected granulation tissue. Although the primary cause of a tubercular abscess is most frequently a tuberculosis of a joint or bone, it can also develop in the course of any localized form of tuberculosis, and it is quite frequently met in the course of tuberculosis of the lymphatic glands. The diagnosis must be made with special reference to the nature and location of the primar}^ lesion. In tuberculosis of the spine the fixed pain in the region of the affected vertebrae, radiating from here in the direction of the nerves on each side, is an important S3mptom, and this symptom is always aggraA'ated by flexion and ameliorated by extension of the spine. In coxitis the pain in the beginning of the disease is usually referred to the inner aspect of the knee-joint, but is always increased b}^ motion in the hip-joint. In cold abscess, caused by glandular tuberculosis, the clinical history will point to a chronic inflammation of the glands which preceded the forma- tion of the abscess. As soon as the abscess reaches the skin that struc- TUBERCULAR ABSCESS. 4.53 ture becomes inflamed, red, and more and more attenuated b^' pressure and inflammation, until spontaneous perforation takes place at a point subjected to greatest pressure. If a tubercular product become the seat of a secondary infection with pus-microbes, the subsequent symp- toms, local and general, are those of suppurative inflammation. The temperature, which was normal, or nearl}- so, increases and presents the daily curves indicative of suppuration, while the abscess, which has been painless heretofore, becomes painful and tender on pressure ; in fact, a chronic inflammation has been supplanted by an acute one, with a cor- responding change of the clinical picture. If any doubt remain as to the character of the swelling and the nature of its contents, this can be dispelled at once b}' resorting to an exploratory puncture. In cold abscess the fluid removed presents the appearance of serum in which minute particles of broken-down tissues are suspended, while in an abscess caused b^^ a mixed infection it presents the macroscopical and microscopical appearances of pus. Prognosis. — The danger attending tubercular abscess must be esti- mated exclusively b}- the extent and location of the primary disease and the presence or absence of tuberculosis in other organs. If the general health remain unimpaired, even an extensive local tubercular disease may be amenable to a spontaneous cure or successful surgical treatment. On the other hand, a tubercular abscess developing in the course of an insignificant and unimportant local lesion occurring in an anaemic person, the subject of incipient multiple foci in difl^erent organs, must be regarded as a formidable condition, with little or no prospects of a favorable ter- mination. I have learned to regard pronounced anaemia as an unfavor- able symptom in the different forms of surgical tuberculosis, as it is often an exp)ression that general infection has occurred. Another important matter to be taken into consideration, in making a prognosis in cases where general infection can be excluded, is the possibility of eradicating the primary lesion b^^ operative interference. Where this can be done, the chances of successful treatment of the local disease are much better; at the same time, the removal of all the infected tissues is the best guarantee against general infection. Other things being equal, the prognosis is lietter in patients without a hereditary history- of tuber- culosis, and in young persons tiian those advanced in years. Treatment. — The surgical treatment of large tubercular abscesses is always fraught with danger from the fact that, even if conducted under strict antiseptic precautions, it is not alwaj's possible to prevent infec- tion Avith pus-microbes. Large tubercular abscesses were a " nole me tangere^^ to the older surgeons, as it was well known evacuation by incision would be followed within a few days bj- hectic fever, profuse 45 i PRINCIPLES OF SURGERY. sweating, diarrhoea, and other symptoms of septic infection. The early advocates of tlie antiseptic treatment hoped that the time had come when the surgeon had it in his power to prevent septic infection during the operation by resorting to the necessary antiseptic precautions, and to maintain an aseptic condition tlirougliout the after-treatment under an ellicient antiseptic hygroscopic occlusive dressing. If we remember that in cases wiiere the abscess originated from a primary lesion inac- cessible to direct treatment it may require months for the healing process to be completed, it is not surprising that even the strictest antiseptic precautions in the hands of the ablest surgeons have failed in protecting the abscess-cavity against septic infection for such a long time. In a number of tubercular abscesses originating from a tubercular focus in the vertebra, in the hip- and knee-joints, I have succeeded in preventing infection, and the patients were cured after several months of the most careful and watchful treatment; but in a greater number of eases infection occurred at the time of operation, or weeks or months later during change of the dressing, or in consequence of a slipping of the dressing. In abscesses in the gluteal or inguinal regions, especially in children treated by incision and drainage, it is almost next to im- possible to maintain an aseptic condition for weeks and months, and the most careful and laborious efforts in this direction will often result in failure. (a) Evacuation by Aspiration followed by Antiseptic irrigation and Subcutaneous lodoformization. — The frequency with which failures have occurred after incision and drainage, in the hands of the most enthu- siastic followers of the antiseptic treatment, has again aroused the fear of surgeons in attacking large tubercular abscesses by incision and drainage, and the subcutaneous evacuation with subsequent disinfection of the abscess-cavit^' has again come into favor. That iodoform exerts an inhibitory effect on the groMth of the bacillus of tuberculosis is now generally accepted. Its use in the treatment of tubercular affections is almost universal. It has been extensively^ used for injection into tuber- cular abscess, after evacuation b}^ aspiration, since Bruns advocated this treatment, in 1887. It was first used dissolved in ether in the proportion of 1 part to 20. The ethereal solution has the advantage of bringing the drug in contact with everj^ part of the interior of the cavity by the distention which takes place from the expansion of the ether when exposed to the bod}- -temperature, but the injection is usually followed by considerable pain. Bruns used a suspension of iodoform in glycerin and alcohol. Recently the following formula was suggested by Krause : — TUBERCULAR ABSCESS. 4:55 lodoformi subt. pulveris, 60.0 Mucil. gummi arab., 23.0 Glycerini, 83.0 Aquae destillatae, q. s. ad 500.0 (Ten-per-cent. iodoform mixture.) The evacuation of the abscess is to be done with an ordinary trocar under strict antiseptic precautions. Tiie surface of the abscess is thor- oughly disinfected in the usual manner, and the instruments rendered aseptic by boiling. The trocar is inserted in such a manner that a track, at least an inch in length, is made underneath the skin before the instru- ment is plunged into the abscess-cavity, in order to make the wound, after the removal of the instrument, as nearly as possible subcutaneous. As tubercular abscesses usually contain shreds of dead connective tissue and masses of broken-down granulation tissue, the evacuation is often attended by a considerable difficulty, as these substances block the open- ing of the instrument and thus prevent evacuation. The simplest pro- cedure to overcome these difficulties is to introduce through the canulaa small hook made b}' bending an aseptic wire, and to extract with it any substance which interferes with the escape of the fluid contents. Gentle, uniform pressure is of great value in expediting the escnpe of the con- tents and in preventing the entrance of air. lodoformization of the abscess-cavity is not to be done until complete evacuation of solid de- tached particles has been effected by means of irrigation with a 3-per- cent, solution of boracic acid. This can be readily done by inserting the glass tip of an irrigator which holds the solution into the canula. A sufficient quantity of fluid is allovved to flow into the cavity until this is distended as much as before the evacuation of the fluid, when, by gentle pressure, it is forced out thi'ough the canula. By filling and emptying the cavity alternately in this manner a requisite number of times, com- plete evacuation of the fluid and loose solid contents is ett'ected, and the cavity is now ready for lodoformization. Whatever formula for the solution is selected, not more than half a drachm of the iodoform should be injected at the first time, and in children even less. If this dose does not produce any unpleasant symptoms, it may be increased the next time the operation is repeated. There seems to be very slight danger of iodoform intoxication, not even a symptom of tliis being observed in 109 cases thus treated by Bruns, of TUbingen. The injection is made with an ordinary but perfectly aseptic syringe, the nozzle of which must fit accurately into the outer end of the canula. If the ethereal solution is used, the iodoform will become diffused over the entire inner surface of the abscess-cavitN' ; but if a non-evaporating medium for the mixture is used, this must be done bj- gently kneading and rubbing the parts 456 pRiNCiPL?:s OF surgery. over the abscess after the camihi is witlulrawn. Tlie injection containing the iodoform is, of course, intended to remain in the cavity. The punc- ture in the slcin is closed with collodium, and the walls of the abscess are kept in contact b}' compress and bandage. Absolute rest is to be en- forced for some time b^- splints or confinement in bed, according to the location of the abscess. The operation is to be repeated in the course of a week, or as soon as the abscess-cavity has partially refilled. The treatment of tubercular abscesses by subcutaneous evacuation, with sub- sequent iodoformization, should be adopted and repeated, from time to time, in all cases where the primary lesion is inaccessible to radical surgical treatment, and ma}' yield good results in cases which heretofore had been subjected to heroic surgical treatment from the beginning. It ma}' also prove useful as a preparatory treatment in cases which subse- quently require operative treatment. (b) Incision and Removal of Primary Focus. — In all cases where, from the anatomical location of the [trimary lesion, it is possible to remove the tubercular product b}' operative interference, and the patient is free from other tubercular affections, a radical operation is absolutely indicated. In such cases the abscess-cavity is laid freely open in a direction wliich will secure most ready access to its interior with least injur}' to surrounding parts. After the abscess has been opened, its con- tents are waslied away by irrigating with an aqueous solution of iodine, after which the granulations lining the cavity are scraped out with a sharp spoon, and the primary lesion is removed in a similar manner. In dealing with such cavities it is important not to forget that the granula- tions contain tubercle bacilli, and, if they are not thoroughly removed, the principal object of the operation — removnl of the primary cause — has not been accomplished, and a return of the disease is to be expected. If the abscess communicates with a primary focus in the bone, it is advisable to resort to ignipuncture of the bone after the cavity has been cleared of the granulations with the sharp spoon. The wound is to be closed in the usual manner, leaving only a small opening at the most dependent point for drainage. The scraped surfaces are now in the same conditions for primary union as a recent aseptic wound, and, if kept in accurate apposition by the antiseptic dressing, which answers at the same time the purpose of a compress, primary union throughout is frequently ob- tained. Abscesses which have opened spontaneously, or during the treatment of which infection has occurred, must be treated on the same principles as acute abscesses. As far as can be done, the suppurating granulations should be removed with the sharj) spoon and efficient tubular drainage established, and by frequent antiseptic irrigations an attempt is made to prevent septic infection. Landerer has recently called TUBERCULOSIS OF THE INTERNAL EAR. -457 attention to the value of balsam of Peru in the treatment of tubercular affections. He claims that this drug acts beneficiall}' by stimulating the tissues to renewed activit}', thus neutralizing, at least to a certain degree, the pathogenic effect of the bacilli. Sayre, of New York, has used this remed}' for more than thirty j-ears in the treatment of tubercular joints, and his results have certainl}- been extrerael}- satisfactor}-. In the treat- ment of open, suppurating, tubercular cavities, the balsam of Peru should be tried as a local ai^plication. As a fluid for irrigation under the same circumstances, nothing can surpass the efficac}' of a strong aqueous solu- tion of tincture of iodine. (c) General Treatment. — Patients suffering from suppurating tuber- cular cavities require nutritious food, ale, porter, or some of the substantial wines ; out-door air will often prove the best tonic. Change of residence to the sea-shore or some mountain resort has often been known to effect a cure when recovery was despaired of as long as the patients lived in localities less favorabl}' located. In the way of medication the treatment must be purely symptomatic. Appetite is restored b3' the use of bitter tonics ; anaemia is treated by the administration of some mild prepara- tion of iron, as the S3'rup of iodide of iron, tincture of chloride of iron, albuminate of iron, or citrate of iron. If codliver-oil is given it should be administered pure, and not in emulsion, and never upon an empty stomach. The pale Norwegian oil is the best. The best time to give the oil, without disturbing the digestion, is an hour or an hour and a half after each meal, in doses of from a teaspoonful to a tablespoonful, according to the condition of the digestion and the age of the patient. TUBERCULOSIS OF THE INTERNAL EAR. That an ordinary otitis media with perforation of the tympanum may occasionally be transformed into a tubercular lesion by the entrance of tubercle bacilli there can be no doubt. Habermann has recentl}' investigated this subject by examining, post-niorteni. 18 tuberculous subjects, in whom either otorrha^a or deafness, without active discharge, had been observed during life, and in 9 of these he could demonstrate the presence of tubercular lesions in the auditor3- canal. In 1 case he found, in the left auditory- apparatus, tuberculosis of the entire middle ear where the tjnnpanum was intact. In another tubercular subject, a man 38 3'ears of age. in whom tuberculosis of the ear was observed a year and a half before death, the post-mortem revealed extensive tul)ercul()sis of the cochlea, in the internal auditor}' canal, and in the superior semicircular canal, while the other semicircular canals and the vestibule were destroyed b\' caries. Infection with the bacillus tuberculosis of granula- tions in the middle ear through a perforation in the tympanum can 458 PRINCIPLES OF SURGERY. occur in persons otherwise in perfect lieiiltli. Tlie diagnosis in such cases can be readily made by removing fragments of granulation tissue for microscopic examination. If they are found to contain tubercle bacilli a positive diagnosis has been made, and no time should be lost in resorting to a radical operation. The removal of the infected granula- tions with a sharp spoon, followed by irrigation with a warm 3-per-cent. solution of boric acid and iodoformization of the cavity, are the measures to be emplo3-ed in removing the infected focus and in preventing exten- sion of the disease into other parts of the ear, the mastoid cells, or the meninges of the brain. TUBERCULOSIS OF THE IRIS. Inoculations of the anterior chamber of the eye with tubercular material have shown the extreme susceptibility of the iris to tubercular infection. That this structure should occasionally become the seat of primary infection is evident from a case recently reported by Griffitho The patient was a female child 7 months old. The eye had been affected for one month ; there was an enlarged gland in the neck on the same side, but there were no other physical signs of tubercle ; no history of heredit}'. A yellowish nodule grew from the periphery of the iris of the right eye, and numerous millet-seed-like bodies from its surface ; the pupil was closed, but thei'e was no acute inflammation. The local disease increased rapidly in extent. The eye was enucleated after tliree weeks' treatment. The disease was found to be confined to the iris and ciliary body. Under the microscope the new growth showed the characteristic structure of tubercle. In 32 recorded cases, in which microscopic and bacteriological tests left no doubt as to the tubercular nature of the disease, only 1 eye w^as affected in 29. The average age of the patients was 12 years; youngest 4 months, oldest 51 years. In 10 cases bacilli was searched for, but only found in 4 ; in 1 of the remaining 6 cases, however, the inoculation test was successful. A number of patients recovered completely and permanently after enucleation. If the tubercle is located on the anterior surface of the iris, a diag- nosis can usuall}- be made witiiout much difficult}' at an early stage, as the inflammatory product can be seen and carefully examined through tlie transparent cornea. If some doubt exist at first as to the nature of the swelling, this is soon set aside b^- the progress of the disease. The primar}' nodule soon becomes surrounded and covered by an eruption of miliar}^ tubercles. The disease here, as elsewhere, shows its charac- teristic clinical feature, — progressive extension, affecting all the struc- tures contiguous to or continuous with the part primarily affected, irrespective of their anatomical structure. Glandular infection on the TUBERCULOSIS OF THE SKIN. 459 same side is an early and quite constant occurrence. Even if the disease is correctl}' diagnosticated at an early stage, complete removal by iridec- tomy is impossible, as parts of the iris wliicli present a perfectly normal appearance may alread}' be infected and lead to an almost certain recur- rence of the disease. Enucleation of the affected eye is onlj^ justifiable if the disease affect only one e^-e, and if the surgeon can satisf}' himself that the patient is not suffering at the same time from tuberculosis in other organs inaccessible to successful surgical treatment. TUBERCULOSIS OF THE SKIN. All forms of primary- tuberculosis of the skin are the result of direct inoculation with tubercle bacilli. Considering the frequency with which abrasions occur in the exposed portion of the skin, and the innumerable sources of infection with the virus of tuberculosis, it is somewhat strange that primar}- tubercular lesions of the skin are not of more frequent occurrence. Baumgarten believes that this is due to the slow growth of the bacillus and the dense structure of the deeper portions of the skin, — conditions which enable the superficial wound to heal before the tubercle bacilli have penetrated the tissues to a sufficient depth. Considerable confusion exists at the present time in reference to the nomenclature of primary tubercular affections of the skin. We find descriptions of what is called tuberculosis of the skin, tubei'culosis verrucoaa cutis, and lupus, all of which affections have been proved to be tubercular in their origin and manifesting the same clinical tendencies. It is time that these imma- terial and unimportant distinctions should be set aside, and these different affections should be included under one head, as ^jrimary tuberculosis of the skii}, since all of them present the same histological structure, and all of them are caused by direct inoculation with tubercle bacilli. Riehl and Paltauf have described an affection of the skin, under the name of tuberculosis verrucosa cutis, in which the bacillus of tuberculosis is constantly found, and whicli they attributed to local affection, because all of the patients they examined were persons handling animal products. Riehl has also shown the tubercular nature of papillomatous allections occurring upon the hands of pathological anatomists by finding the bacillus in the tissues. Anatomical and Clinical Proofs of the Tubercular Nature of Lupus. — Lupus vulgaris, and probabl}- the other varieties of this affection of the skin, are nothing more nor less than cases of cutaneous inoculation- tuberculosis. It is well known that lupus occurs most frequently in parts of the bod}' most exposed to injury and infection; that is, in the skin not protected by the hair or clothing. Lupus attacks most fre- quently the nose, face, ej-elids, ears, and hands, localities where abrasions 460 riilNCIPLES OF SURGERY. occur most frequently, and parts upon which floating microbes are too liable to become deposited, and where direct inoculation with soiled hands, handkerchiefs, and towels is most likely to occur. I shall quote from a number of reliable authorities at sufficient length to prove that lupus and tuberculosis are identical affections. From a clinical stand- point Hebra, brought the different varieties of lupus under one common head. He separated it entirely from syphilis, but otherwise did little to fix its pathological siguilicance. He adopted the classification of Fuchs and the older French and English authors, who taught that it was one of the manifestations of scrofula, and that anatomicall}^ it was composed of granulation tissue. Yirchow classified it with the granulomata, but denied its identity with scrofula. Rindfleisch described it as a proliferation of epithelial cells, — as a sort of phthisis cutanea. Hueter, who, in his pathological views, was generally far ahead of his time, affirmed that it was a form of fungous inflammation, the specilic cause of which, when introduced into the organism, produced miliary tuberculosis. Volkmann included it among the affections which auatomicall}' are represented by granulation tissue. Friedlander Avas the first to take a positive stand in asserting that lupus is a tubercular affection of the skin, and showed its histological identity with other recognized forms of local tuberculosis. He demonstrated the presence of miliary tubercles in it. The absence of caseation in lupus, which was regarded by some authors, among them Baumgarten, as an evidence of its nun-tubercular character, has been explained bj^ Schiiller as being due to the soil present in and around the nodules. He also calls attention to the fact that Cohnheim and Thoma have seen caseous foci in lupus, and consequently asserts that the absence of caseation is no proof of the non-tubercular nature of lupus. Neisser accepts fullj' and pleads strongly in favor of the tubercular nature of lupus. Rassdnitz collected 209 cases of lupus, and found that in 30 per cent, of all the cases it was associated with other evidences of tuberculosis. He placed, also, great importance on the observations that lupus is prone to develop in the scar left after healing of a localized tuberculosis in lymphatic glands, and that lupus is often observed u[)on t!ie nose or ej'elids in cases of chronic nasal or conjunctival ca- tarrh. In 10 to 15 per cent, of his cases lupus could be traced to heredi- tary predisposition. Demme observed miliary tuberculosis in 2 of his cases after scraping lupus. Pontoppindau asserted that, in his expe- rience, in 50 to 75 per cent., patients suffering from lupus manifested ad- ditional evidences of tuberculosis. Quinquaud saw in 3 cases of lupus pulmonary tuberculosis appear as a final cause of death. Of 38 cases that came to the personal knowledge of Bessnier, 8 of them suffered TUBERCULOSIS OF THE SKIN. 461 from pulmonary phthisis. Of 2 patients treated by Aubert, 1 died of acute pulmouaiT tuberculosis and the other of tubercular pleuritis after scarification. Renoward was able to ascertain the existence of pulmonar}' phthisis in 50 per cent, of his cases of lupus. Block met with tuberculosis in other organs, before or after the development of lupus, in 114 out of 144 cases. Bender examined 374 cases of lupus. In 159 of these an accurate history could not be obtained. In 99 of the latter number symptoms of other antecedent or co-existing tuberculous lesions existed. In 77 of the cases tuberculosis in an etiological or clinical aspect was present. Leloir observed several cases in which, after years, a lupus of the face gave ris.e to a pseudo-erj'sipelatous swelling of the face, which disappeared after a time, to be followed by swelling of the submaxillary l3'mpliatic glands, which remained stationar3\ Soon after the aflection of the lymphatic glands had appeared, febrile disturbances, gastric S3'mp- toms, and evidences of pulmonary infiltration followed. In all of these cases Leloir believes that the virus of tuberculosis had left the primary' location, and had migrated through the lymphatic vessels and glands into the lungs. In 10 out of his 17 cases the tubercular nature of lupus was clinically manifest. Sachs ascertained that, of 105 cases of lupus which he collected, in 86 per cent, the patients had co-existing tuberculosis in other parts of the body, or a hereditary predisposition to tuberculosis could be shown to exist. Experimental and Bacteriological Evidences of the Tubercular Nature of Lupus. — If the clinical and anatomical proofs which have been advanced to establish the tubercular nature of lupus point unequivocally in that direction, the crucial test is furnished b}^ the inoculation experi- ments and liacterioiogical investigations that have been made with the same object in view. Koch, in his paper on the etiology of tuberculosis, states that he produced a pure culture of the bacillus tuberculosis from a case of lupus which resembled in ever}- respect the cultures obtained from recognized tuberculosis, and with the fifteenth generation from this source, one 3'ear after the first cultivation, he inoculated 5 guinea-pigs bv subcutaneous injection and produced typical tuberculosis in all of them. Doutrelepont found in 7 cases of lupus tlie bacillus tuberculosis invarial)l3' present, in greater or less number, either within the cells or dispersed in small groups between them. He never found them in the interior of giant-cells, but in their immediate vicinit3'. In a second communication the same author reports 18 additional cases of lupus, in each of which the presence of the bacillus could be demonstrated in the tissues. Demme detected the bacillus in 6 cases of lupus. Pfeiffer found it in a case of lupus of the conjunctiva. Schuchardt and Krnuse 462 PRINCIPLES OF SURGERY. discovered the bacillus in 3 cases of lupus affecting, respectively', the face, ears, and leg. In examinations made of 11 cases of lupus by Cornil and Leloir, and 4 bv Koch, for the especial purpose of showing the identity of lupus and tuberculosis, the bacillus was found in every instance. In the artificial tuberculosis of animals, produced by implanta- tion of lupus-tissue, the specific microbe was shown to exist by P:igen- stecher, Pfeiffer, Koch, and Doutrelepont. To proA'e that lupus and tuberculosis are identical, it became necessary to furnish tlie necessary experimental i)roof, and to show tlic uniform presence of the bacillus of tuberculosis in the lupus-tissue, all of which has been done with almost infiillible positive results. The inocuhition experiments with lupus- tissue have already been referred to, and from them it can be learned that, with few exceptions, the}' were followed by positive results ; that is to say, implantation of lupus-tissue into subcutaneous tissue or the peritoneal cavity, in animals susceptible to tuberculosis, gave rise to local tuberculosis at the point of implantation and to dissemination of the process in a manner characteristic of tuberculosis in man. A diffuse tuberculosis of the skin and mucous membranes, occurring as a sort of secondar}' localization in patients suffering from advanced tuberculosis, has been recently described by Pantlen, Bizzozero, Baumgarten, Chiari, Hall, Janisch, Riehl, Vidal, and Finger. As such cases occur in conse- quence of auto-infection in persons debilitated by the ravages of the primary disease in the lungs, it is not surprising that the skin affection should extend more rapidly than in cases of primary tuberculosis of the skin. Pathology and Morbid Anatomy. — As every case of tuberculosis of the skin is caused l)y the entrance of tubercle l)acilli from without througli some infection-atrium, the primary' pathological changes occur at the point of inoculation. As soon as the bacilli reach the vascular layers of the skin, a nodule forms which contains the histological ele- ments described in the section on the Histology of Tubercle. By the formation of new nodules, a more diffuse cellular infiltration of the tissue between them, the lesion tends to spread, and, by confluence of the infiltrated portions, a dense and more or less extensive area of nodular infiltration maybe formed. If the continuit}' of the epidermic la3'er of tlie skin has been restored after infection has occurred, and the cell pro- liferation has been abundant, the swelling may resemble a papillomatous growth, and, on account of the increased vascular supply, an excessive production and exfoliation of epidermis over the infiltrated area occur. Tliese are the cases of inoculation-tuberculosis which have been described as tuberculosis verrucosa cutis. The nodules undergo disintegration near the centre, and the epidermis at a corresponding point becomes TrBERCULOSlS OF THE SKIN. 463 macerated and detaclied, leaving at first a minute defect, which secretes a serous fluid. As soon as the underl3Mng granulation tissue has been exposed to infection from without, infection with pus-microbes occurs, and the destruction of tissue is hastened b}' the suppuration inflammation which follows, as the granulation cells are rapidly desti'03^ed bj'' the pus-microbes and their ptomaines, and are eliminated as pus-corpi;scles. Ulceration now takes the place of the papillomatous growths, and the defect increases in size as rapidly as granulation tissue is produced b}' the action of the bacillus tuberculosis. New nodules are produced in the immediate vicinity of the ulcer, which are again dissolved bj' retro- grade tissue metamorphosis of its cellular constituents and purulent liquefaction. It is not uncommon to find, at some places, efforts at repair, and even partial cicatrization and epidermization ; but the disease pursues its relentless course in other directions, .and, after what appears as health}'^ new tissue, becomes again infected and the process of destruction is repeated. In some forms of tuberculosis of the skin the infection remains superficial, and only the more superficial portions of the skin undergo pathological changes characteristic of tuberculosis ; while in other cases the process extends deeper and deeper, until muscles, fascia, and bone are destroj'ed b}^ the disease, in the manner of its exten- sion from tissue to tissue resembling the clinical behavior of malignant tumors. In this manner the whole nose, e^yelids, and the greater portion of the face are frequently* destro3'ed before the patient is relieved from his sufferings b}' a merciful death. Microscopical examination shows the lesions to consist in the formation of granulation tissue, in which the typical structure and histological elements of tubercle can be readily recognized. Caseation is seldom found, probabl}' on account of the location of the tubercular product so near the surface of the skin, and also because the granulation tissue soon becomes the seat of a secondary' infection with microbes which prevent caseation. Inmost cases a well- marked reticulum is present between the new cells, and these are often groujied in masses around the blood-vessels. Symptoms and Diagnosis. — Tuberculosis of the skin is most fre- quently- met with in middle-aged persons, but no age is exempt from it, as I have seen it in children 5 years of age and in persons far advanced in 3'ears. It attacks most frequently the nose, ej^elids, cheeks, ears, and hands, but it may also develop upon the difl'erent parts of the trunk. The disease commences in the form of a small, red, vascular nodule ; is not painful nor tender on pressure. In the vicinity of this nodule new foci spring up, and by confluence may form a swelling of considerable size. To the touch these nodules impart rather a sensation of elasticity 464 PRINCIPLES OF SURGERY. than hardness, and if the swelling is large in size an obscure sense of fluctuation mi\y be felt. Before ulceration takes place the surface of the nodules is covered by a thickened epidermis, which can be scraped off in white scales. If no ulceration take place (lupus non-exedens), the nodules nia}' remain stationary in size for an indefinite period of time or undergo a spontaneous cure by cicatrization, during which the epithelioid cells are converted into connective tissue. Ulceration begins over the centre of the nodule, at a point where the nutrition of tiie tissues is most impaired by pressure, and extends from here toward the margins of the nodule, attacking the new nodules almost as fast as they are formed (luj^us exedens). Cicatrization and ulceration are often seen side by side. Ulceration is hastened by the secondary infection with pus-microbes, whicii invade the granulation tissue in the margins of the ulcer, occupying the tubercular zone. Repair b}' cicatrization and epi- dermization is more likely to occur if the infection remains superficial, but is usually entirely absent as soon as the tubercular process has ex- tended beyond the limits of the skin. The ditferential diagnosis as to tuberculosis of the skin, tertiary syphilis, and epithelioma is generally very diflficult, and sometimes almost impossible. There is very little difference between the histological structure of a tubercle-nodule and a gumma, and the most experienced microscopist is liable to make a mis- take if called upon to make a diagnosis exclusively by the use of the microscope. The histor}' of the case is of the greatest importance in making a differential diagnosis between tuberculosis and syphilis. If the patient is positive that he never contracted S3'pliilis, it is still possible that the lesion may be S3philitic, as the disease may have been inherited; if he give a history of primarj'^ and secondary S3'philis, the affection may still be tubercular; but a straight histor}' of tuberculosis or syphilis will go far in determining the nature of the local affection. If any doubt remain, this can be cleared up by the use of the microscope in the course of five weeks, either by the effect i)roduced by anti-sy])hilitic treatment or the result of inoculation experiments made by implantation of fragments from the inflammatory product into the subcutaneous tissue in guinea-pigs. The microscopic examination of fragments of tissue removed for this purpose must have in view the detection of the bacillus of tuberculosis, wdiich is constantl}' present in tubercular tissue. The specimen must be prepared by double staining according to Ehrlich's method, and if the affection is tubercuhir, the bacillus can be found b^' making a patient search for it ; if it is syphilitic, it will, of course, be absent. The bacilli, however, may be so few that even a careful search of stained specimens may result negativeh', and in such a case a positive TUBERCULOSIS OF THE SKIN. 465 diagnosis can often be made by observing the effects of a thorough anti- syphilitic treatment. For an adult, ^'g grain of sublimate with 15 grains of potassic iodide, dissolved in distilled water, is given four times a da}-, — after each meal and at bed-time. If the lesion is syphilitic, a decided improvement will be observed in the course of two or three weeks ; if tubercular, this treatment will make no decided impression on the local lesion. The most reliable diagnostic test in differentiating between tuberculosis of the skin and a syphilitic lesion consists in removing, under antiseptic precautions, a fragment of granulation tissue the size of a small pea, and implanting the same into the subcutaneous tissue of a guinea-pig. Tavel has been studying, in a systematic manner, the diagnostic value of implantations of tubercular material in animals, mainly- guinea- pigs. He found tliat fragments of granulation tissue, taken from a tubercular product and implanted into the subcutaneous connective tissue in the inguinal region in guinea-i)igs, invarinldy produces in this animal local, and later general, miliaiy tuberculosis, and death in from five to six weeks. The course of the disease thus artificially produced is typical ; at the point of inoculation a hard nodule appears first, the result of traumatic response on the part of the tissues around the graft. Next, a l3-mphatic gland becomes enlarged in the immediate vicinity of the inoculation and in the direction of the lymphatic stream. Often all of the inguinal glands are infected successively. At a later stage the axillary glands become affected At the necropsy it was always observed that, of the internal organs, the spleen becomes affected first, then the liver and lungs, but before death is produced almost everj' organ is the seat of miliary nodules. When the differential diagnosis between tuber- culosis and sj'philis cannot be made from a clinical study of the case or by the use of the microscope, inoculation experiments will alwa^^s furnish the desired information in from three to six weeks. If the lesion is tubercular, the infected guinea-pig contracts the disease, and dies in from five to six weeks ; if it is syphilitic, the implantation will prove harmless and the animal remains well. The differential diagnosis be- tween tuberculosis of the skin and epithelioma must be based on the primary location of the pathological product and the character of the infdtration. Tulierculosis commences in the vascular portion of the skin; hence, the primary nodule is sub-epidermal; while epithelioma starts in the non-vascular epidermis and inliltrates tiie deeper laj'ers of the skin later. The tultereular nodule is not hard, but somewhat elastic, to tlie touch. The carcinomatous infiltration feels almost as hard as cartilage, and forms a part of the e[)itlielial layer of the skin from the beginning. A tul)erculous ulcer of tlie skin is covered with flabby granu- 466 PRINCirLES OF SURGERY. Litions, and its margins, although infiltrated, do not feel as firm as the borders of an ulcerating epithelioma. Under the microscope the tubercle- nodule shows granulation cells in the meshes of a delicate reticulum, while in a section of an epithelioma a well-marked alveolated reticulum can be seen, the meshes of which are occupied by em])ryonal epithelial cells arranged in concentric htyers. Another microscoi)ic criterion is the absence of blood-vessels in tubercle-nodules, while carcinoma is a vascular structure. Prognosis. — Primary local tuberculosis of the skin may lead to glandular infection, and, after the last lymi)hatic filter has been passed, to general miliary tuberculosis. The tu])ercular product in exceptional cases becomes the starting-point of carcinoma. The local extension of the tubercular process is subject to many variations. In some instances the process commences during early life, and remains stationary for twenty or more years, when it suddenly commences to extend vei'y rap- idly, destroying all of the tissues which come in its way, irrespective of their anatomical structure. Tuberculosis of the face, manifesting such a tendency to rapid extension, may in a few months destroy nearly all of the soft tissues and a considerable portion of the superficial bones, so that the head looks more like a skull than the head of a living being. In other instances the ulceration keeps extending, while at otiier points the healing process is progressing with equal speed. In such cases the massive scars are often productive of the most hideous deformities. Recurrence of the disease in the scar-tissue is of common occurrence. The prognosis, as far as life is concerned, is favorable so long as the disease remains local and does not progress rapidly ; while life is threat- ened as soon as regional infection through the lymphatic glands takes place, or when ulceration extends rapidl}- without any tendency to repair by cicatrization and epidermization. Tuberculosis of the skin without ulceration is a more benign form of the disease than when ulceration has occurred, as in the latter case the destructive process is hastened by secondary infection with pus-microbes. Treatment. — About the only medicine that deserves any confidence in the treatment of tuberculosis of the skin is o.rsenic. This drug can be given in the form of F'owler's solution, in doses of from 3 to 10 drops after each meal, well diluted with w\ater. It is best to commence with the smallest dose and add 1 drop every week until the ph3siological effect is produced, when the use of the medicine is not suspended, but the dose is diminished. To be of any use, the medicine has to be con- tinued for weeks and months. If the patient is anaemic, it is combined with the tincture of chloride of iron, and, if the patient's appetite is poor, with one or more of the bitter tonics. If the patient is emaciated, pure TUBERCULOSIS OF THE SKIN. 467 codliver-oil can be given with good results ;in hour and a half after meals, in doses which will be tolerated by the stomach. If digestion is impaired this drug should be withheld. A well-selected, nutritious diet is indicated in all such cases, with plent}- of out-door exercise. Salt-water baths invigo- rate the peripheral circulation, nnd coiisecpiently favor the limitation of the disease and the process of repair. The surgical treatment of tuber- culosis of the skin is to be conducted upon the same principles as opera- tion for the removal of malignant tumors. The use of caustics often does more harm than good. The great object of the local treatment is to remove every jMrtivle of the infected tissues, for if this is not done a re- currence is almost sure to take place. If the patient object to a radical operation, and the tubercular process has gone on to ulceration, all irri- tating applications should be avoided and the ulcer protected b}^ a piece of lint spread with empl. h^drargyri or nnguent. hydrargyri 0x3-d. albi. Balsam of Peru can also be used with benefit as a local application. If a radical operation is decided upon, this should be done preferabl}' by ex- cision. Excision should be practiced exclusively in cases where the extent of the disease is limited. The incision should be made some distance from the visible margins of the infiltration, in order to include tissues which, although presenting macroscopicall}' a health}^ appearance, may already be infected with bacilli, conveyed there by migrating leu- cocytes. The greatest care must be exercised in removing the deeper portions of the infiammatory product, as this may send down projections at diflerent points which it is necessar}' to remove with the princi^Dal mass. Thiersch's method of restoring the excised skin places the surgeon in a position where he can excise an extensiA'e area of tegument, and yet obtain primary healing of the wound and perfect restoration of the skin under a single dressing. I have, on several occasions, removed tuber- cular foci from the face and temporal region the size of the palm of the hand, and, b}- covering the defect at once with large skin-grafts, saw the whole healing process completed in two weeks, with almost perfect restoration of the lost tissues. In cases where the disease is too exten- sive for excision, removal of the infected granulations is attempted by the vigorous use of Yolkmann's sharp spoon. Skin-grafting can be done after curetting in the same manner as after excision, but the knife always leaves a better surface for skin-grafting than the sharp spoon. If, after either operation, the result is not perfect, and the tubercular process returns at one or more points, the granulations are again removed with the sharp spoon and the defect covered with skin-grafts. Tuberculosis without ulceration demands treatment bj' excision, while in the case of ulcerating nodules the choice lies between the knife and sharp spoon, and 468 PRINCIPLES OF SURGERY. to the first preference should be given in all cases Avhere excision can be (lone with a fair prospect of removing all of the infected tissues. The constitutional treatment should be continued for several montlis after the local lesion has apparentl}' healed, as the disease is very liable to recur at the site of operation. The site of operation should bo carefully pro- tected against injur}" a long time after the process of repair has been completed, in order to guard against a return of the disease, from local irritation preparing the soil for the pathogenic action of latent bacilli which may remain incorporated in the scar-tissue. CHAPTER XIX. Tuberculosis of Lymphatic Glands and Peritoneum. tuberculosis of lymphatic glands. That most cases of cluoiiic inflammation of tlie lymphatic glands are in their origin, course, and final termination instances of local tuber- culosis, has been satisfactorily shown by clinical experience, microscopic examination, inoculation, and cultivation experiments. Manner of Infection and Dissemination of the Bacillus of Tuber- culosis. — The tubercle bacilli enter the lymphatic circulation through some abrasion or pathological defect of the skin or mucous surface ; any loss of continuity of surface may furnish the necessary portio invasionis for the entrance of the microbes from without. In tubercular ail'ections of the skin the point of inoculation becomes the centre of the primary nodule, because the bacilli are present in sufficient quantity and viru- lence to produce the necessary irritation ; but in tuberculosis of the lym- phatic glands the microbes enter the lymphatic channels usually before the}' have caused any visible lesions at the point of entrance. Yolkmann found tubercle bacilli in tiie skin of an eczematous fore- arm, and it is probable that many cases of tuberculosis of the cervical glands in children are caused b}* the entrance of tubercle bacilli through an eczematous patch on the face, ear, or scalp. In perhaps 95 out of every 100 cases of tuberculosis of the lymphatic glands the disease at- tacks the glands of the neck, — as the scalp, face, and mouth are parts of the body most frequentl}- the seat of slight injuries and superficial lesions, and also most exposed to tubercular infection. The lymphatic glands act as filters for the microbes which enter the body through the l3'mphatic channels. The pathological conditions which are produced in the interior of a lymphatic gland by the presence of pathogenic micrO' organisms are well calculated, for the time being at least, to limit the extension of the infection. The lymphadenitis which is produced blocks the lymph-spaces with the products of a specific inflammation, which, temporarily at least, mechanicall}- obstructs the way for the microbes toward the general circulation. Primary infection of a l^'mphatic gland by the bacillus of tul)erculosis in many instances attacks diff"erent por- tions of the gland from the very beginning, as a number of independent (469) 470 PRINCIPLES OF SUKGKRY. centres of tissue proliferation are established around each microbe, or around each colony- of microbes arrested on their way through the gland. These separate nodules soon become confluent and form a mass of considerable size, which soon implicates the entire parenclijma of the gland. Local dissemination of the bacillus of tuberculosis in the in- terior of the gland is accomplished l)y the assistance of the lymph- stream, as long as the microbes remain free, and through the medium of wandering cells as they have become attached to or have entered the protoplasm of the lymphoid corpuscles and leucocytes. Regional infection is not limited to the lymphatic glands, on the proximal side of the primary focus, as during the course of the disease we often observe that lymph-glands become involved whicli are not in the direct course of the lympli-stream. As tlie bacillus of tuberculosis is non-motile, we can onl}' explain its transportation in a direction opposite the lymph-current b}' its conveyance in such a direction b^^ migrating amoeboid cells. As the lymph-stream is impeded or perhaps completely arrested by the inflammatory product which has accumulated in the lymph-spaces, migration of leucoc^'tes in an opposite direction is easily explained. The usual course of infection along the lymphatic channels is, however, in the direction of the lymph-current. The course of the disease is almost characteristic. A l^'mphatic gland in the submaxillary or parotid region becomes enlarged, and from this centre the infection invades suc- cessively gland after gland, until the whole chain of lymphatics from the angle of the lower jaw to the clavicle has become involved. Another interesting feature is observed in reference to the regional diffusion of the tubercular process, as the course of infection usually corresponds to the location of the gland first affected. If the infection has involved primaril}^ one of the deep glands of the neck, the glands subsequently invaded belong to the deep lymphatics which follow the larger blood- vessels of the neck. If, on the other hand, the primar}^ depot is located in one of the superficial glands, the glands, which are being irrigated by' the lymph that flows through and from the gland, become the seat of successive infection, showing again that regional infection nsually takes place in the direction of the lymph-current. In extensive tuberculosis of the glands of the neck, the superficial and deep glands are affected at the same time, the infection from one set of vessels to the other being accomplished through the medium of communicating branches. As long as the infection has not extended along the entire length of the chain of lymphatic glands, the patient is protected against miliar}' tuberculosis ; but as soon as the virus has passed all of the lympliatic filters it enters the general circulation, and diflfuse miliary tuberculosis follows as an inevitable result. TUBERCULOSIS OF LYMPHATIC GLANDS. 4:71 Pathological Histology and Morbid Anatomy. — As soon as a sufficient number of bacilli lias entered tlie parencli> ma of a lymphatic gland, a karj'okinetic process is initiated wliich involves the parenchyma-cells, the cells of the reticulum, and the endothelial cells. The proliferating tissue- cells produce epitheloid and giant cells, -svhile the lymphoid elements are either the normal lymphoid corpuscles, ^vhich have remained unatiected by the inflammatory- process, or leucocytes. As the number of bacilli present is not great, the process is a very slow one, and the inflamma- torj' product undergoes very gradually the characteristic degenerative changes. The entrance of new bacilli from the infection-atrium is pre- vented b}' the obstruction in the lymph-spaces, caused by the accumula- tion within them of the products of inflammation, which arrests the lymphatic circulalion in the afferent vessels of the gland, through which primarily the bacilli entered. The bacilli found in the tubercular gland are, therefore, derived from the multiplication of the bacilli which origi- nall3'^ entered the gland from the primary infection-atrium. The cells that first undergo coagulation necrosis are those in the centre of each nodule, for reasons which have been previously mentioned. As the products of coagulation necrosis do not furnish the necessary nutritive material for the growth of the bacillus, the microbes gradually disappear in the centre of the nodule, while they can still be found within and between the cells in the surrounding granulation tissue. Cell necrosis is followed by caseation, and by this time nearly all of the bacilli have disappeared, but inoculation experiments with cheesy material have shown that spores remain in an active condition, and capable of reproducing the disease in animals. The numerous nodules which appear, often almost simultaneously, in the in- terior of the same gland become confluent, and in the course of time the entire parenchyma of the gland is destroyed, while the intact capsule of the organ still furnishes a v/all of protection against infection for the surrounding tissue. A single tubercular gland is seldom larger than a walnut, and the large masses found in the neck and other regions are composed of several glands so closely packed together as to give the appearance of a single gland. When the capsule becomes infected, the same processes are initiated here as in the parenchyma of the gland ; the connective tissue is transformed into granulation tissue, which undergoes coagulation necrosis and caseation in the same manner as the fixed tissue- cells of the i)arenchyma; and, finally, after perforation of the capsule has taken place, the inflammation extends to the paraglandular tissues, re- sulting in tubercular periadenitis. The cheesy material ma}- dry and shrink and become inclosed b}- a capsule of dense connective tissue, resulting in calcification ; or it undergoes liquefaction. If secondary infection with pus-microbes take olace, a not infrec^uent occurrence in 472 PRINCIPLES OF SURGERY. tuberculosis of the gltinds of the neck, :ui acute suppurative iullamuiation takes the place of the chronic process, and almost without exception re- sults in a rapi(ll3--spreading- suppurative [)eri;ulenitis. The connective tissue surrounding tlie gland becomes sw^ollen and (jL'dcmatous and large abscesses form, which, on being incised, give exit to pus whicli resembles the pus of an ordinary phlegmonous inflammation. The suppurative in- flammation results in extensive detachment of the cheesy glands, which at this time can be readily enucleated b}' the linger. If, however, the ab- scess is simpl}' incised, and the radical operation postponed for weeks or months, the removal of such glands is an exceedingly- difficult task, as the capsule of the gland will then be found intimately adherent throughout the surrounding tissues. Symptoms and Diagnosis. — Tuberculosis of the lyniphatic glands occurs most frequently in persons between 15 and 30 years of age. The regions most frequently affected are the cervical, parotid, sul)maxillary, axillar3^, and inguinal. Tuberculosis of the parotid, submaxillary, and cervical h'mpliatic glands is often preceded by eczema of the scalp, ears, or face, or by a catarrhal or tubercular inflammation of the mucous mem- brane lining tlie nose and pharynx. It is possible that in many of these cases the catarrhal inflammation creates the necessar}- infection-atrium for the entrance of the bacilli into the lymphatic channels ; or, what is more probable, that which has been regarded as a catarrhal inflammation is, in reality, a mild tu])ercular inflammation that may disappear after infection of the lymphatic glands has occurred. In the region of the neck, the first glands affected are usually the submaxillary, or the glands just behind, in front, or below the external meatus. Progi-essive infec- tion is the most characteristic clinical feature of tuberculosis of the lymphatic glands. Regional infection, as has been stated, usually takes place by the extension of the disease from gland to gland, until the whole chain in a region has become aftected. In a case far advanced, for in- stance, the glands first affected may l)e as large as a walnut; their size then gradually diminishes, so that those last infected may not be larger than a split pea. The degenerative changes are also most marked in the glands first affected; so that, while the primary foci show- well-marked evidences of caseation, and caseation with liquefaction, the glands last infected still present a normal pinkish color. The number of glands affected in one region varies from one to twent}' or more. If many glands are affected, the hyperplastic inflammation in their periphery'' usually results in their becoming matted together into a dense nodular mass. With the exception of the neck, it is seldom that more than one anatomical region is affected. In the cervical region it is not uncommon to find the glands on both sides affected at the same time. The infected TUBEKCULOSIS OF LYMPHATIC GLANDS. -473 glands increase gradually in size ; the}' are painless and not tender on pressure. At first they are movable, and appear loosely attached to the surrounding tissues. With the a[)pearance of periadenitis the swelling rapidly increases in size, and the gland becomes fixed and immovable. Liquefaction of the cheesy material is announced b}^ softening and per- ceptible fluctuation. Secondary infection with pyogenic microbes is followed by phlegmonous inflammation in the capsules and in the connec- tive tissue surrounding the affected glands. The course of the disease, so far as time is concerned, is extremely variable. The extension of the infection and the growth of the swellings may become arrested for months or3e:irs, when the disease may take a new start and pursue its t^'pical course. I recollect the case of a woman, 45 years of age, who had an enlarged gland the size of a hazel-nut in the upper cervical legion, which remained stationary for twenty years, when the swelling rapidly increased in size ; new glands became infected, and, when the glands were removed b^^ operation, it was seen that the first gland was composed of a thickened capsule, distended to its utmost b}' inspissated cheesy ma- terial. The capsule showed evidences of recent tubercular inflammation, and small foci of caseation were detected in the glands that had recently- become infected. When a true sui)puration takes place in a tubercular lymphatic gland, it does so in consequence of a secondary infection with pyogenic micro-organisms. A spontaneous and permanent cure is not infrequently effected by the substitution of an acute suppurative process in place of the prinuiry specific chronic inflammation, which destroys the entire soil of the bacillus tuberculosis and, at the same time, effects com- l)Iete elimination of the bacilli through the discharges of the abscess. While tuberculosis of the lymphatic glands often stands in a direct causa- tive relationship to and precedes general, diffuse, and pulmonary tuber- culosis, it is seldom observed as a secondar}' affection in the course of pulmonary tuberculosis. I have observed one case of tul)erenl()sis of the lungs with secondary infection of the lymphatic glands. The i)atient was a woman, 50 years of age, who had suffered for two years from well- marked t\'pical tuberculosis of the lungs, when the glands on both sides of the neck became infected, and continued to increase in numl)erand in size until she died, six months later. Frankel reports an interesting case ill which lymijhatic and pulnuMiary tuberculosis developed almost simul- taneously. Tiie patient was a woman, 51 years of age, who had given birth to two children, their father being the subject of advanced tuber- culosis, and both of whom died of tuberculosis. She had been in perfect health until her 49th 3"ear, when she was attacked simultaneously with pulmonary and glandular tuberculosis, from the continued effects of which she died in a few months. In exceptional cases glandular tuber- 47-4 PRINCIPLES OF SURGERY. ciilosis pursues an acute course. Delafield reports an exceedingly inter- esting case of this kind. The disease coninienced with enlargement of one of the cervical glands near the angle of the lower jaw, with a tem- perature of 40'^ C. (104^^ F.), and rapid extension to the proximal glands as far as the clavicle. Symptoms of pulmonary comi)lication were not present. Rapid emaciation and marked anjumia supervened, followed after six weeks l)y swelling of axillary and inguinal glands. Ophthalmic examination revealed the same conditions of retina and papilla as in leucaemia or Bright's disease. A few days after the beginning of the disease profuse diarrhoea and reduction to nearly normal temperature occurred. The diagnosis was between malignant lymphoma and tuber- cular adenitis. During the further course of the disease bronchial breathing in both lungs appeared. Heart, liver, and spleen appeared to be normal. Urine normal, but increase of temperature and respirations took place during this time. Death occurred in less than five months. At the autopsy the lungs wei'e found congested and (Edematous, with red hepatization of the lower lobes and a few miliary tubercles. The spleen contained many miliary tubercles the size of the head of a pin, and most of them in a state of cheesy degeneration. The mesenteric glands were much enlarged, and a few of them in a condition of cheesy degeneration and calcification. In the cheesy matter bacilli were found. All the cer- vical glands were affected with softening and cheesy degeneration in the centre. The calcification of mesenteric glands pointed to an earlier affection. The disease remained latent and recurred in the same glands, and, later, extended to the cervical glands. This case resembles the cases described by Hilton-Fagge and Pj^e-Smith. In reference to the dissemination in cases of acute miliary tuber- culosis, Weigert has pointed out that in some cases the bacilli are con- veyed through the lymphatic system successively until they reach the general circulation, while in others, and by far the greater number, generalization of the tuberculous process takes place more directly by the entrance of tubercular products through a vein, — an occurrence which is followed at once bj* rapid and extensive diffusion by embolic processes ; when the bacilli have reached the sj^stemic circulation, the intensity of symptoms and subsequent course of the disease depend on the number of bacilli which the blood contains. As regards the frequenc}^ of secondary infection of the lungs in cases of glandular tuberculosis, Frankel found it present in only 18 out of 148 cases. In making a differential diagnosis it becomes necessary to distinguish tubercular adenitis from simple adenitis, suppurative adenitis, syphilitic adenitis, carcinoma, lymphoma, lympho-sarcoma, and pseudo-leucfemia. Simple adenitis is the result of the entrance into the lymphatic TUBERCULOSIS OF LYMPHATIC GLANDS. 475 circulation of iioxjv that neither produce suppuration nur the Ibrnuilion of new tissue. A number of glands corresponding to the direction of the lymph-current from the infection-ntriiim. through \vhich the irritant gained entrance, enlarge, but tlie inflamniator}' swelling subsides shortly after the cessation of the primar\- cause, with perfect restoration of the structure and function of tlie atfected glands. Suppurative adenitis is an acute affection which terminates in the formation of pus in a few days. Syphilitic adenitis developing in the course of a primary syphilitic sore only attacks the glands contaminated with lymph coming from the infected area. The adenitis which accompanies secondary and tertiary syphilis is not limited to a single region ; nearly all of the external Ijanphatic glands are more or less enlarged, but especially those in the occipital and cubital regions. Carcinonia never occurs as a primary- lesion in the l3'mphatic glands, and when regional infection has occurred it is not difficult to locate the primary tumor. Lymphoma is a benign tumor of the lymphatic glands, and as such is always met with as a single tumor. Lymplio-sarcoma represents the primary malignant tumor of the lym- phatic glands, and gives rise to regional and general infection, the infec- tion in these respects resembling the clinical tendencies of tubercular adenitis. Lj-mpho-sarcoma, however, is a tumor, not an inflammatory swelling, and, consequently, the tissues of which it is composed do not undergo degeneration and necrosis at such an earh' stage, and the rapid tissue increase leads to the formation of large tumors, wdiile tubercular glands the size of an almond contain cheesy material. The unlimited growth which characterizes sarcoma is cheeked in the tubercular glands by necrosis of the cells which compose tlie swelling. In pseudo-leuc»mia the fixed tissue-cells of the parenchyma of the glands proliferate b}' being acted upon by a microbe as yet unknown ; but this microbe, unlike the bacillus of tuberculosis, is diffused more extensivelj- through the lymphatic system, involving one region after another luitil, after the disease has been once well developed, almost every lymphatic gland in the body has become infected. The supposed microbe of pseudo- leucaemia possesses the property of producing new tissue by its action upon the fixed cells, but the ncAV product does not undergo caseation. As the last and infallible diagnostic measures, must be mentioned the search for the bacillus of tuberculosis by the use of the microscope and inoculation ex[ieriments. Prognosis. — A tubercular lymphatic gland is alwa3's a source of danger. Even if the disease becomes latent, a recurrence may take place at any time, and lead to rapid regional and general infection, or general infection may take place directly- from an old cheesy focus by the entrance of bacilli or their spores into a vein. The prognosis is very 476 PRINCIPLES OF SURGERY. grave if the patient is ana,'inic, and the glands on both sides of the neck are aflected at the same time. Friinkel estimates the average duration of the disease from tiiree to four years. In the eases whicli lie collected the shortest time was two months and the longest thirty 3'ears. Sooner or later, pulmonary or diffuse general tuberculosis is almost sure to take place. A spontaneous cure is possible if secondar3' infection occur in cases whore onl}' a few of the glands have become infected, and suppu- ration results in the elimination of all the infected tissue. Suppuration only hastens a fatal termination if many glands are affected. Treatment. — As primary lymphatic tuberculosis, in most inf-tances, signifies the entrance of bacilli through a loss of continuity of tiie skin or a mucous membrane, or through the socket of a carious tooth, locali- zation occurring in one of the nearest glands to the portio invasionis, it must be regarded primarily as a local process amenable to timely surgi- cal treatment. The capsule of the lymphatic glands constitutes a very efficient barrier against infection of the paraglandular tissue for a long time, and perforation of the capsule can only take place after the disease has made considerable progress, and has been followed by extensive caseation and especially by suppuration. Early operative interference is as necessary in the treatment of tubercular adenitis as in the treatment of malignant tumors, and holds out more encouragement, so far as a pier- manent cure is concerned, ^y a thorough removal of the primary foci of infection, successive infection of proximal glands and general miliary tuberculosis are prevented almost to a certaint}^ if the operation is per- formed before the disease has extended beyond the capsule of the glands. If the operation is done at such a favoral)le time it is not attended by any great difficulties, as the glands can be readily enucleated, and, as suppuration has not taken place, the wound usually heals by primary intention. If, however, the tubercular inflammation has involved many glands, and has extended to the connective tissue surrounding them, the operation becomes one of the most formidable in surgery, on account of the close proximity of important vessels that are often imbedded in the mass. Under such circumstances complete removal is frequently impos- sible and earl}' local recidivation is inevitable, owing to imperfect re- moval of the primary microl)ic cause. Traumatic dissemination is very likely to follow all imperfect operations in which portions of glands or infected capsules are left behind, as the operation wounds are inoculated witli bacilli liberated during the operation. I have seen in a number of such cases, as early as a week after the oi)eration, the entire surface of the wound covered l\y a thick layer of granulation tissue, whicli showed all the histological evidences and possessed all the bacteriological prop- erties of tubercular tissue. As a testimony in favor of the operative TUBERCULOSIS OF LY.MI'HATIC GLANDS. 4 77 treatment of tubercular adenitis, I will quote from the paper of Schuell, who collected 56 cases of tuberculosis of the cervical glands that were treated by extirpation in the clinic at Bonn. In 37 of these cases he was able to learn the ultimate result. In 57 per cent, the operation was fol- lowed b}- complete recovery, in 27 per cent, the disease returned at the site of operation, and in i cases death resulted from pulmonary tubercu- losis. The largest number of cases were patients between 10 and 20 3'ears of age. FrJiukel reports 128 cases operated upon by Billroth, some of the operations being quite serious ; in 16 cases the internal jugular vein had to be tied. In 91 of the operations the wound healed b}' primar}- union, and in 25 the healing was retarded by suppuration. Erj-sipelas compli- cated the result five times. In one of these cases a large part of the tuber- cular mass was left, and it was noticed that the erysipelas had no effect on the tubercular process. Only in 49 of the cases operated on coiild the final result be obtained. Taking three and a half years as the time when the patient could be considered exempt from a recurrence of the disease, it was ascertained that in 24 per cent, no relapse followed the operation, a local relapse was observed in 14 percent., and re-appearance of the disease distant from the seat of operation in 4 per cent. The results of operation for tuberculosis of the Ij'mphatic glands have shown the necessity of earl}' operating, as dela}^ renders the operation more difficult, on account of the progressive regional dissemination of the dis- ease and the occurrence of pathological changes within and around the affected glands, which render their complete removal more diflicult ; while at tlie same time the danger of general infection increases with the local extension of the disease. If the glands have suppurated, or if the capsule has become perforated and tubercular periadenitis or sup- purative periadenitis has taken place, and many glands are simultane- ously affected, it ma^' not be advisable to resort to excision, as Avhen extensive connective-tissue infiltration is present it would be almost Impossible to remove all of the infected tissues. In such cases free incisions should be made, and the tubercular product be removed with a Volkmann spoon. The proximal glands which have not undergone such extensive secondary- pathological changes can be excised. The scraped surface is freely iodoforniized and the wounds are sutured and drained. In removing the glands of the neck it is always important to expose the infected area b}' a large incision. The operator should not only feel, but see, every gland he removes. Accidents are more liable to happen b}' removing the glands through a small than a large incision. As in cases of secondary carcinoma of the lymphatic glands the extent of the disease is onl}- ascertained after incision, so in 47S PHFNTIPLES OF SURGEHY. glandular tuberculosis the extent of the aion of infection can only be ascerlained after the external incision is made. Whole chains of small iilands which could not be felt through the skin are then exposed. In tuberculosis of the glands of the neck the region between the mastoid process and the angle of the lower jaw is almost always the primary seat of infection. From here either the chain of glands behind the sterno- cleido-mastoid muscle or the deep glands wliich follow the sheath of the large vessels of the neck are affected, or the superficial and deep lym- phatics are affected simultaneously. It has been my custom to expose the glands occupying the upper region of the neck by a transverse in- cision, extending from the tip of the mastoid process of the temporal bone to the lower angle of the jaw, and from there along the lower border of the bone, as far as the disease extends in the submaxillary region. This incision is joined by another, extending from the angle of the lower jaw either along the anterior border of the sterno-cleido-mastoid muscle as far as its sternal insertion, if the deep glands are to be removed, or, if the posterior superficial set of glands are affected, it is carried in a down- ward and backward direction, following the chain of enlarged glands. If the latter incision is selected, the external jugular vein is divided between two ligatures. The ])latysma niyoides muscle is divided throughout the whole length of the incision before an attempt is made to remove any of the glands. The siu-geon should aim to remove^ as nearly as he can, all of the infected glands in one disconnected string. In many cases one or two tubercular glands will be found imbedded in the lower portion of the parotid gland, and very frequently also in the submaxillar^' salivary gland. If the tubercular glands, with their capsules, can be enucleated, this should be done ; but if this is impossible, it is better to remove the lower portion of the parotid with them in preference to leaving any infected tissue behind. Under the same circumstances I prefer to ex- tirpate the submaxillary gland in foto. If the deep glands of the neck must be removed, it is absolutely necessary to divide the sterno-cleido- mastoid muscle near its centre, and then reflect both ends nearlj^ as far as the origin and insertion of the muscle, which freely exposes not only the affected glands, but also the important structures of the neck, which it is important to avoid in the dissection. The dissection must always be made with the greatest care, and in the vicinity of the large vessels every structure must be identified before it is separated. The finger and blunt-pointed, curved scissors are the most important instruments in making the deep dissection. The internal jugular vein should be seen before any of the deep glands are removed, for if this structure is seen it can be carefully followed the whole length of the neck without wounding it nnintentionally. If the internal jugular vein is imbedded TUBERCULOSIS OF LYMPH ATrr GLAXDS. 479 among the enlarged glands, and cannot he isolated without great danger of injuring it, it is better to resect it between two ligatures than to run the risk of wounding it accidentally. The chain of enlarged glands is followed as far as possible, as it is much better to remove a few healthy lymphatic glands than to leave minute, almost invisible foci of the dis- ease. After all of the infected glands have been removed the continuity of the divided muscle is restored by suturing. At least six catgut sutures are necessary to join the thick ends accurately. I have usually succeeded in removing all the glands after division of this muscle with- out dividing the spinal accessory nerve, but, should this l)e necessary, the divided ends are joined by suturing before the muscle is united. Drainage in tlie submaxillary region and at the most dependent point of the wound in the neck must always be established. The platysma muscle should be united with Ijuried sutures before the skin is sutured. Wounds of the neck, on account of the irregular outlines of the neck, shoulder, and chest, require a very copious antiseptic dressing to effect- ually exclude the entrance of pathogenic micro-organisms after the operation. The dressing should be kept in place by a few turns of the plaster-of-Paris bandage, which also keeps the head in proper position during the time required in the healing of the large wound. The sutured muscle must be kept in a relaxed position until firm union has taken place between the sutured ends, which usually requires from two to three ■weeks. On the second or third day the dressing is changed, the drains are removed, and, if the wound has remained aseptic, the second dressing can be allowed to remain for ten days or two weeks, when it is changed, and the superficial stitches are removed. If all of the diseased tissues have been removed, and the wound has remained aseptic, the healing process will be found nearl}' completed at this time. Local recurrence of the disease should only stimulate the surgeon to continue the actiA'e warfare, and glands are removed as soon as they can be felt. I have repeatedly performed, on the same patients, three and four oi)erati()ns in as many years, and had the satisfaction of finally eradicating the disease completel}'. Parenchymatous injections of car- bolic acid, so strongly recommended b}- Hueter in the treatment of tubercular glands, have little or no effect in either arresting further development of the disease in the affected glands or in preventing further regional infection. I have seen, in cases treated by this method, glands finally destroyed b}'^ suppuration caused by the punctures ; but the bacilli remained in the cicatricial tissue, as was evident b}' the oedematous, congested scar, and from here additional glands became infected. Genzmer advised ignipuncture in the treatment of tubercular 4R0 PRINCIPLES OF SURGERY. glands, and claims for this method excellent results. This treatment is applicable onl}'' in cases where a few of the more superficial glands are alfected, and where patients positively refuse to su])mit to a more radi- cal procedure. It is absolutely' contra-indicated when many glands are affected, as in cases where the glands are affected they have undergone extensive secondary pathological changes. The general treatment of tuberculosis of the lymphatic glands is the same as in the other forms of local tuberculosis. I have seen the best effects from the administration of arsenic and iron, followed or alternated by codliver-oil. All external applications to bring about resolution are worse than useless. TUBERCULOSIS OF PERITONEUM. Tubercular peritonitis occurs as one of the lesions of acute general tuberculosis, with chronic pulmonar}' phthisis, with tubercular inflamma- tion of the genito-urinary tract, and as a local inflammation. As a sur- gical lesion only the local form will be considered here. Bacteriological Remarks. — The susceptibility of the peritoneum to tubercular infection has been well established by numerous inoculation experiments. The peritoneum can, under favorable conditions, dispose of a large dose of a pure culture of pus-microbes, but the implantation of a minute fragment of tubercular tissue in animals susceptible to tuberculosis is almost certain to be followed by genuine local and general tuberculosis. For the surgeon, only those forms of peritoneal tubercu- losis have interest which are either caused by an extension of an adja- cent tubercular process to the peritoneum or from primary localization of the bacillus within or upon this membrane. The prevalence of the affection in the female sex among the cases which have been reported })oints to the Fallopian tubes as a frequent primary seat of infection, with secondarj' invasion of the peritoneum from this source. Although the genital organs in the male are more frequently the seat of tubercu- losis than in the female, so far only 2 cases of peritoneal tuberculosis in males have been reported, — 1 by Kiimmel and the other by Lindfors. Tuberculosis of the peritoneum, by extension from a tuberculous focus in the genital organ, can only mean an infection b}' contact, the bacillus of tuberculosis transferred from the primary seat of infection, and localization by implantation upon the peritoneal surface. Implantation experiments in animals furnish a good illustration of the manner in which the process becomes diffuse. At the point of implantation a granulation mass forms around the graft, and from here innumerable tubercle-nodules take their starting-point, forming everywhere new centres of infection. The movements of the abdominal walls during respiration and the peristaltic action of the intestines are potent factors TUBERCULOSIS OF PERITONEUM. 481 concerned in the local dissemination of the tubercular infection. Ana- tomicall}', the peritoneum is so closel}' allied to the 13'mphatie glands that we have every reason to believe that primary tuberculosis can occur in this structure as well as in the Ij-mphatic glands. In primary tuber- culosis of the peritoneum infection takes place in the same manner as iu intact joints, by floating bacilli becoming arrested in the capillary ves- sels of the membrane, where the primar}' nodule forms, from which, again, as from a graft, local dissemination takes place. These cases are, in the true sense of the woi'd, not cases of primary tuberculosis, as the peritoneal affection is only a local expression of an antecedent infection. As the peritoneum is endowed with absorptive capacities of a high degree, and is in direct communication with the l3'mphatic system, we would naturally expect that tuberculosis of this structure would lead to early general dissemination. But in peritoneal tuberculosis we observe the same tendency to limitation of the infective process as in joints, by the formation of an impenetrable wall of connective tissue, whicli imparts so often to this form of peritonitis its circumscribed character. Clinical Studies. — Kiimmel looks upon peritoneal tuberculosis as a pureh' local affection, amenable to surgical treatment in the same sense and to the same extent as a tuberculosis of joints. That some of these cases can be permanently cured by local treatment is well shown by a case treated by Sir Spencer Wells twentj^-six years ago by abdominal section, the patient having remained up to this time in perfect heiilth. In a recent paper on this subject Fehling reports 4 cases of his own, and gives an account of all the operations which had been done up to that time, — 21 in number. Of this number 15 recovered, and the patients are known to have been well from one year to twenty-three years, and in a number of cases their condition was learned four to five years after the operation. Six of the patients died, — 2 of sepsis, 1 of p3'temia several months after the operation, and 3 from the continuance of the disease for which the operation was performed. In 5 of the cases ascites attended the tuberculosis ; in 3 the swelling was not due to effusion, but to adhesions between intestinal loops that were covered with miliary tubercles. Of 54 cases of laparotomy for pei-itoneal tuberculosis, collected by Trzebicky, 4 died from the immediate consequences of the operation, while in a fifth death occurred after the operation from acute miliary tuberculosis, though the fluid had not re-accumulated. One case died in four months from general tuberculosis without the peritonitis disappear- ing; cures resulted in 40 cases, though here and there evidence of pul- monary tuberculosis was reported. The majority of cases were females, which may find its explanati(jn in the fact that most were operated upon 482 PRINCIPLES OF SURGERY. under error in the diagnosis of ovarian cyst. The most recent and com- preliensive work on tuberculosis of the peritoneum, which has recentl}^ appeared from the pen of Vierordt (" Ueber die Tuberculose der serosen Haute," in Zeitachrift f. klin, Medicin.^ Bd. xiii, Heft 2), should be con- sulted by those who wish to secure for reference an exhaustive treatise on this subject. Tlie statistics are 3^et too meagre, the correctness of diagnosis not entirely above doubt, and the period of observation after operation not long enough ; but, in view of the results, there is no longer any justification for expectant treatment. Even though in some cases recovery was not permanent, the fluid did not re-accumulate, and the patients were relieved of their disticss. Spontaneous recovery from tubercular peritonitis is exceptional, iuid operative interference is indi- cated the more, as it would seem that, in many cases, tuberculosis of the peritoneum is a primar}- aftection and the source of general infection. As all other therapeutic measures are of no permanent value in such cases, and laparotomy done under antiseptic precautions may be con- sidered almost free from danger, the operation is certainly stronglj^ indicated. Pathology and Morbid Anatomy. — The effect of the bacillus of tuber- culosis on the peritoneum is not uniform, and the conditions found in peritoneal tuberculosis are variable. Lindfors, in a clinical and patho- logical study, based on 109 recorded cases of peritoneal tuberculosis, divides the cases into seven classes. He states that the acute variety may assume the form of circumscribed, general, or suppurative perito- nitis ; in the chronic form there may be a free or encysted effusion, there may be simple adhesions, or the intestines may be so adherent as to cause intestinal obstruction. Lindfors thinks that the presence of acute or chronic pleurisv has an important bearing on the diagnosis of tuber- cular peritonitis. He is strongly in favor of laparotomy and the free use of iodoform within the peritoneal cavity. The conditions found in local tubercular peritonitis, in cases sul)jected to operative treatment and in examinations made in the post-mortem rooms, are such that all cases of this kind can be conveniently classified in three principal groups upon a pathological basis. I. Tubercular Ascites. — The peritoneum is thickened, hypersemic, and studded with masses of tubercle-tissue in the form of miliar}^ nodules. The omentum is usuall}- similarly affected. If the effusion is general, occupying the Avhole peritoneal cavitj^, the adhesions are few and slight. If the fluid is encapsulated the walls of the cavity are formed by intestinal loops, which are adherent among themselves and to the surrounding structures. The circuniscribed form usually takes its origin from the floor of the pelvis, and often gives rise to a swelling TUBERCULOSIS OF PERITONEUM. -183 which simulates an ovarian cj^st to perfection. The fluid contained in the peritoneal cavitj' in the diffuse form, and in the confined space in tlie circumscribed variet}^, is either a clear, transparent serum, or serum in ■which small flocculi are suspended, or the fluid has become slightl_y turbid from the admixture of tlie products of retrograde tissue metamor- phosis. The visceral peritoneum of the organs exposed to infection is in the same condition as the parietal peritoneum. Coagulation necrosis and caseation of the nodules appear to be retarded for a much longer time than in cases of glandular tuberculosis. The amount of fluid may vary from a teacupful in the circumscribed to 4 or 6 gallons in diffuse tubercular ascites. Secondary infection is found most frequentl}' in the spleen, pleune, and 13'mphatic glands. 2. Fibrino-plastic Peritonitis. — In this form of tubercular peritonitis no fluid is found in tlie peritoneal cavit}'. The bacillus of tuberculosis produces a copious inflammatory pi'oduct, and the peritoneal surfiices, which are studded with miliary tubercles, are covered b}' a thick layer of gelatinous fibrin, which cements together all the adjacent serous surfaces, so that tlie whole abdominal cavity appears to be filled with a large, boggy mass, composed of all the viscera adherent to each other, and with the inter-spaces between them filled with fil)rin. The inflam- matorj' product in these cases is rich in fibrin-producing substances, while the liquid transudation is either scant}" or is absorbed as soon as it is poured out. 3. Adhesive Peritonitis. — In this variety of tubercular peritonitis the bacillus of tuberculosis exerts its pathogenic properties more on the fixed tissue-cells than the blood-vessels. The primary inflammatorj- exudation is slight, but the endothelial cells proliferate new tissue, which undergoes cicatrization, giving rise to firm and extensive adhesions. The plastic peritonitis may be so extensive as to cause intestinal obstruction from perfect immobilization of a large portion of the intestinal tract. In this, as well as in the foregoing form of tubercular peritonitis, ulcera- tion of the intestine rna^- take place, resulting in the formation of a bi- mucous, internal fistula, if the opening in two adjacent loops correspond, or the formation of a faecal abscess with a subsequent fjecal fistula. Symptoms and Diagnosis. — As tubercular peritonitis without effusion is not amenable to successful surgical treatment b}^ laparotom}', nothing will be mentioned in reference to the diagnosis and treatment of the fibrino-plastic and adhesive varieties. Tubercular ascites is a chronic alTection, especially when it occurs in the circumscribed form. Pain and tenderness are not prominent or even constant S3'mptoras. The general health is at first but little impaired. Fever is slight or entirely- absent. If the effusion is general, it comes on slowlj', almost insidiousl}', as in 484 PRINCIPLES OF SURGERY. ascites iVoiu olher causes. From the aljsence of udliesions the fluid changes its location according to the position of the patient. If the patient is placed in the dorsal, recumbent position, the lumbar regions are dull on percussion ; if placed on the side, the upper lumbar region is t3'mpanitic, while the area of dullness on the opposite side is increased. In circumscribed tubercular peritonitis with encapsulation of the fluid, the swelling appears first either in the h^^pogastric or one of the iliac regions. The area of dullness does not change by placing the patient in different positions. In free ascites tuberculosis of the peritoneum should be suspected, if the ordinary causes of ascites, cirrhosis of the liver, valvular disease of the heart, and the presence of an intra-abdominal malignant tumor can be excluded. Circumscribed tubercular ascites might be mistaken for ovarian c,yst, pregnancy, pyo- or hydro- salpinx, and pelvic abscess. Fluctuation is a symi)tom common to all of these conditions, and a differential diagnosis can onh' be made b}' a careful stud}' of the clinical history and b}' a thorough examination. Pregnane}" can usuall}' be excluded by ascertaining the size of the uterus and by the presence or absence of the usual signs of gestation. A P3'0- or hj^dro- salpinx can generally be recognized by bimanual exploration, especially if the examination is made, as it should be, under the influence of an anaesthetic. A pelvic abscess is always preceded by an acute suppura- tive para- or peri- metritis, attended by severe s}'mptoms which are absent in tubercular peritonitis. The greatest difficult}' presents itself in differentiating between a circumscribed tubercular ascites and an ovarian cyst. So close is the clinical resemblance of these two affections that a positive diagnosis is almost impossible without the aid of an exploratory laparotomy, and, as both affections can only be treated successfully by abdominal section, it is sufficient for all practical purposes to narrow the diagnosis down to one of these, and reserve a positive diagnosis until the abdomen is opened. Treatment. — The surgical treatment of tubercular peritonitis with effusion by laparotomy has yielded sufficiently satisfactory results to make it an established procedure in such cases in the future. A spon- taneous cure is the exception ; death from local extension of the disease and from general infection the rule. A case came under my observation during the last two years where I have every reason to believe that tubercular ascites disappeared spontaneously. The patient was a woman, 40 years of age, with a marked hereditary tendency to tuberculosis, sev- eral sisters having died of pulmonary tuberculosis. She is the mother of several children, the youngest being 6 years old. Two years ago she was brought to me by her family physician with the diagnosis of ovarian cyst. At that time the swelling was as large as a child's head, occupying TUBERCULOSIS OF PERITONEUM. 485 the lij'pogastric and left iliac region. Fluctuation distinct ; no pain and but little tenderness on pressure ; menstruation regular. General health only slightlj' impaired. After a careful examination I coincided with the diagnosis, and advised an earl}- operation. Soon after this time the swelling began to diminish in size and disappeared completely in the course of a 3'ear, but the general health, instead of improving, began to fail. After the disappearance of the swelling she began to suffer from a deep- seated pain at a point corresponding to the cartilage of the eighth rib on the left side, and in the course of a few months a fluctuating swelling appeared under the costal arch at that point. Tuberculosis of the ribs was suspected, but at the time of operation an encapsulated tubercular abscess was found in the abdominal cavit3',to the left of the great curva- ture of the stomach arid above the splenic flexure of the colon. A large quantity of liquefied, caseous material was evacuated. The wall of the abscess was lined with a thick layer of granulation tissue, which was thoroughl}' removed with a sharp spoon, and after irrigation the cavity was carefully dried and packed with iodoform gauze. The wound healed b}- primar}- intention, and the entire cavity closed in the course of four weeks witiiout a drop of pus. The woman has since greatl}- im- proved in health, and is completely relieved of her pain. There can hardly be a question that the accumulation of fluid which was mistaken for an ovarian cyst was a limited ascites, caused hy a circumscribed tubercular peritonitis, and that the infection in the upper portion of the abdominal cavit}' resulted from this, tlie primary depot. It is not at all improbable that, had an operation been performed at the time it was ad- A'ised, this extension of the infection might have been prevented. The results obtainable b}^ laparotoni}' in the two different forms of tubercular ascites are well shown b3' 2 cases which occurred in my practice during the last year. The first patient v/as a girl, 1*7 years old, without a tubercular his- tory. She had alwa^'s been in good health until about a j'ear ago, when she commenced to suffer from pain in the left iliac region, and soon after a perceptible swelling appeared in that localit}', which graduall}' in- creased in size until the time I saw her, when it reached above the um- bilicus and beyond the median line. Has never menstruated. Patient is anfsemic and somewhat emaciated, but was never confined to bed. Ex- amination reveals no disease in any of the important organs. Diagnosis of ovarian cyst had been made by several ph3sicians. The abdomen was opened b}' a median incision, and a large quantity of clear, straw- culored serum escaped as soon as the peritoneum was incised. The parietal peritoneum, as well as the intestines, which formed a part of the wall of the cavity, were studded with innumerable nodules the size of millet-seed. 486 PRINCIPLES OF SURGERY. These nodules were largest and most numerous in the region of the left Fallopian tube, which, however, was normal in size. The cavity was dried and freel}^ dusted with iodoform, and a Keith glass drain inserted as far as the floor of the space of Douglas. A large quantity of serum was removed from the tube for the first few da^'s, when it became more and more scant}', so that the glass tube could be removed at the end of the second week. Through a small fistulous tract serum continued to escape for six weeks, when the fistula closed. The patient has gained 15 pounds in weight, and at this time, a ^'ear after the opera- tion, is in perfect health, with no signs of a local return. That the peri- tonitis in tliis case was tubercular was demonstrated by an inoculation experiment. A nodule was removed from the peritoneum and implanted into the peritoneal cavity of a guinea-pig with a positive result. The second case was a woman, 42 3-ears of age, without any history of tuber- culosis in her family. She is the mother of a large familj-, the youngest child being 5 years of age. Her abdomen began to enlarge four months before she came under m}' care. Pain not severe, but gradual loss of flesh and strength. As no local cause for the ascites could be found, the abdomen was opened in the median line, and at least two pail- fulls of clear serum escaped. The intestines and parietal peritoneum presented an exceedingly vascular appearance, and were studded with minute miliar}' nodules. These nodules, again, were largest in the pelvis, but both tubes were found in a normal condition. The same course was pursued as in the first case, and drainage was kept up for two weeks, when the flow of serum was so scant}' that it was deemed advisable to remove the tube. The wound healed completel}' in a few days, and the patient left the hospital greath' relieved. The fluid, however, accumu- lated so rapidly that in two weeks she had to be tapped, and from this time on the patient could not leave her bed. The tapping had to be re- peated ever}' two weeks. Symptoms of pulmonary phthisis developed soon after she left the hospital, and death from general miliary tubercu- losis occurred in less than three months after the operation. The danger of re-accumulation of fluid and general infection is much greater in diffuse tubercular peritonitis than in the circumscribed form, as in the latter the are;i, of infection is more limited, and general infection is less likely to occur on account of the presence of a wall of plastic material which surrounds the tubercular field. In operating for circumscribed tubercular ascites it is very important to exercise great care in opening the abdominal cavity, as a loop of adherent intestine may be found at the point where the incision is made. The peritoneum must be recognized and carefully divided in order to prevent wounding of the bowel, should such a condition be met with. lodoformization of the cavity is one of the TUBERCULOSIS OF PERITONEUM. 487 important indications of treatment. Drainage must be maintained until accumulation of serum in the tube has ceased. Uniform equable com- pression of the abdomen with strips of adhesive plaster or a well-fitting bandage should be kept up throughout the entire after-treatment. In cases where a well-defined local tubercular focus is found, which we have reason to regard as the cause of the peritonitis, this should be removed or rendered harmless by appropriate treatment. A tubercular Fallopian tube should be removed if this can be done. Other caseous foci are re- moved with a sharp spoon, or the}' can be destroyed or rendered harmless by igniquncture and thorough iodoformization. CHAPTER XX. Tuberculosis of Bones and Joints, tuberculosis of bone. Next to tlie lungs and Ij'nipbatic glands the bones are most fre- quentl}' the seat of tubercular infection. Tuberculosis of the bones is an exceedingly frequent affection in children and 3'oung adults. Its favorite location is in the epiphyseal extremities of the long bones, although it is also quite frequently met with in the short bones of the carpus and tarsus and some of the flat and irregular bones, as the ribs, scapula, ileum, and vertebrae. Embolic Infection the Cause of Osseous Tuberculosis. — Practically, direct tubercular infection does not occur, and when the disease has made its appearance it is onl}' an evidence of the existence of a tuber- cular focus in some other organ. We observe clinically, what Mueller has demonstrated experimentally', that, when the bacilli of tuberculosis are present in the blood-current, verj' often localization t.akes place near the epiphyseal cartilage in young persons Iw the microbes becoming arrested in one of the terminal branches of an artery, the lumen of which becomes obliterated by tlie presence of a minute embolus of granulation tissue containing bacilli; or the lumen of the vessel is gradualh' diminished by the formation of a mural thrombus, which forms around bacilli implanted upon the vessel-wall, and the lumen of the vessel is finally completel}'^ obstructed by the growth of the thrombus. The new vessels in the vicinity of the centres of growth in the bones of voung persons, on account of their imperfect structure and irregular contour, furnish the most fiiA'orable conditions for the arrest of floating granular matter and the localization of pathogenic microbes. The pre- disposing anatomical element goes far to explain the frequency with which we meet with tubercular foci in the epiphyseal extremities of the long bones. The following table, prepared by Schmallfuss, gives a good idea of the relative frequency with which different bones are affected with tubercular lesions : — (489) 490 PRINCIPLES OF SUKGERY. Billroth. Jaffe. Feb Cent. SCHMALLFUSS. Per Cent. Vertebra. Vertebra. 26 Knee. 23 Knee. Foot. 21 Foot. 19 Cranium and Face. Hip. 13 Hip. 16 Hip. Knee. 10 Elbow. 9 Sternum and ribs. Hand. 9 Hand. 8 Foot. Elbow. 4 Vertebra. 7.5 Elbow. Pelvis. 3 Tibia. 4 Pelvis. Cranium. 3 Cranium. 4 Tibia, Fibula, and Sternum, Clavicle, Pelvis. 3.6 Femur. and Ribs. 3 Sternum, etc. 3.6 Shoulder. Shoulder. 2 Femur. 1.9 Femur. 1 Shoulder. 1.5 Humerus. Tibia. 1 Ulna. 1.4 Ulna. Fibula. 1 Humerus. 1 Radius. Humerus. 1 Radius. 0.7 Scapula. Scapula. 0.6 Fibula. 0.5 Ulna. 0.6 Patella. 0.1 It is safe to state that before puberty the primary lesion in tuber- cular affections of joints is located in one or both of the epiphyses of the bones which enter into the formation of the joint, while in the adult primary tuberculosis of the synovial membrane is of more frequent occurrence. As age advances and the process of ossification is com- pleted, the predisposing localizing causes in bone apparently disappear, while the s^-novial membrane becomes more susceptible to primary localization. Of 204 specimens of tubercular joints obtained from patients of all ages, examined by Mueller, 158 were primary osteal, and 46 primary sj-novial, tuberculosis. Artificial Tuberculosis of Bone Produced by Direct Intra-vascular Infection. — Wm. Mueller, formerly one of Konig's assistants, produced the characteristic clinical form of tuberculosis in bone experimentally b}' injecting tuberculous material into the nutrient arter}' of long bones. Konig for a long time had claimed that the wedge-shaped sequestrum, so constantly found in tubercular foci in the articular extremities of the long bones was due to occlusion of a small artery by a tubercular embolus. Mueller's experiments were undertaken to produce this con- dition artificially. He made 16 experiments on rabbits, injecting tuber- culous pus into the femoral arter}^, some in a peripheral, some in a central direction, without any positive results following. In a second series the same material w^as thrown directly into the nutrient arteries of the femur and tibia. Of 10 of these cases 2 showed a tuberculous focus in the medulla of the diaphysis of the tibia ; in another case miliary tuberculosis in the femur and tibia, and in the latter bone a small caseous nodule in the spongy part which contained numerous bacilli. The animals were killed eight weeks after injection, and showed TUBERCULOSIS OF BONE. 491 no evidences of organic disease except a few tubercles in the lungs. Twent}' experiments were made on young goats, 5 on sheep, and 2 on dogs. The tuberculous material was injected directly into the nutrient arter}' of the tibia, the tibial artery being tied above and below the junction with this vessel. Primary union of the wound was obtained in all cases except in one dog. In the dogs and sheep all experiments resulted negativel}'. In the goats bone affections were produced that were identical with tubercular bone-lesions found in man. Most fre- quently the disease was established in the diaphysis, cheesy masses and granulation tissue showing themselves in the medulla and cortical portion of the bone, or tuberculous osteomyelitis with or without sequestration. T3q)ical lesions were also found in the ends of the bones, with and without implication of the adjacent joints. In 2 of these cases the epiphysis was affected, while in 3 the shaft was involved. The following experiment made by him furnishes a good illustration of the identity' of the bone disease produced experimentally with the disease as it occurs in man. Tuberculous material was injected into the tibial artery of a goat 3 months old. Wound healed in eight days. Some lameness four months later, gradually increasing during the next nine months. At the same time a swelling appeared at the knee-joint. Tibia painful on outer side. Animal killed thirteen months after the injection. At the necropsy there was found a t^'pical fungous disease in the knee-joint, most ad- vanced at the lateral aspects of the joint ; a wedge-sha[>ed sequestrum in one of the tuberosities of the tibia, a small granulation mass in the centre of the head of the tibia, and two similar granulation masses in the lower ei)iphysis of the femur. Excepting the 13'mphatic glands of the knee-joint, no other organs were aft'ected. In some of the cases, pulmonary tuberculosis, twice general miliary tuberculosis. The re- mainder of the animals were killed when the^- began to show lameness — fourteen days to thirteen months after infection. The tubercular lesions thus produced were examined for bacilli, and these were never found absent. The starting-point, in every instance, must have been a tuber- cular embolus in one of the ultimate minute branches of the nutrient arter}- near the ei)iphyseal extremity of the bone. Clinical and Bacteriological Researches. — Schuchardt and Krause examined a great variety of tubercular lesions, and came to the conclu- sion that tubercle Inicilli can be found in them without exception, but, as a rule, few in iium])er, and often only to be detected after long and patient search. 'iMiey found them invariably present in cases of second- ary and priniaiy tuberculosis of sj'novial membranes, tuberculosis of bone, in tubercular abscesses, and in the latter cases not in the fluid 492 PRINCIPLES OF SURGERY. contents, but in the granulations lining the abscess-wall. Renken found the bacillus of tuberculosis in all cases of spina ventosa ■which lie exam- ined. Mueller carefull}- studied numerous specimens of synovial and bone tuberculosis, with special reference to the existence of the bacillus of tuberculosis, and, although the results in a number of cases were negative, he believes that the most intimate and direct etiological relations exist between the bacillus and all tubercular lesions in bones and joints. Among others who have shown the never-failing presence of the bacillus in dilferent forms of surgical tuberculosis, including bones and joints, may be mentioned Kanzler, Mogling, Bouilly, and Letulle. Tub(!rculosis of bone and fungous disease of joints, like lym- phatic tuberculosis, have been, and by some are still, regarded as scrofu- lous affections. Kanzler wished to make a distinction between scrofula and tuberculosis, as he found the bacilli not as constant in the former, and observed that, after implantation of tissue of wdiat he regarded as scrofulous affections in animals, the process was slower than after inocu- lation with the products of recognized forms of tuberculosis. Letulle considers scrofula and tuberculosis as belonging to one and the same disease, of which the former constitutes the milder form, and appearing externall}'', while the latter represents the graver form, attacking by preference the internal organs. The points made by the last two authors are too unimportant for further consideration as a scientific, or even practical, distinction between scrofula and tuberculosis as applied to affections of tlife bones or any other organs. The surgeon must recognize every lesion as tubercular in its origin, nature, and course in which the bacillus of tuberculosis can be found, from which successful cultivations can be made , and with ivhich the disease can be artificially i^t'oduced in animals by inoculation. The presence of the bacillus of tuberculosis in the bod}' and its localization in the medullary tissue of bone is the con- ditio sine qua non in the causation of osseous tuberculosis. The influence of traumatism in the etiology of tuberculosis of the bones and joints has been greatly overestimated. Traumatism as an etiological factor occupies a subordinate role, inasmuch as it only proves, at least, as an exciting cause in persons already infected with the essential cause. Max Schiiller proved experimentally in animals infected with tuberculosis (for instance, through the respiratory^ tract) that a slight traumatism to a joint wOuld determine localization of the microbes floating in the blood-current in the part injured, and that a tubercular synovitis or pararthritis would follow. Clinically, tuberculosis of the bones can be traced only in a small per cent, of the cases to a traumatic origin. It is, as Volkmann asserted long ago, characteristic that the traumatism is always slight, often quite TUBERCULOSIS OF BONE. 493 insignificant ; tuberculosis of bone, even in tubercular subjects, seldom, if ever, follows a fracture, as the injur}^ in such cases is productive of such active cell proliferation that will neutralize the pathogenic action of the bacilli, which might reach the seat of injury with the extra vasated l)lood. It is also possible that in many eases, at least, the attention of the patient or his friends is first accidentallj' called to an existing tuber- cular focus b}' the immediate effects of the injury, the latter having had no influence in the causation of the disease. Ever}' child Inrge enough to run around injures himself more or less (almost) dail}', and yet tuber- culosis of the bones and joints follows as a consequence onh' in compar- atively few, and in such cases the essential cause must be present in the blood or tissues at the time the injury is received. As has been previ- ously stated, what is generally regarded as local bone tuberculosis (by which we mean the absence of recognizable tubercular lesions in other organs) is in renlity a secondary disease, resulting from the introduction of bacilli through the respiratory or alimentarj^ tract into the circulat- ing blood, with localization in the bone, or the entrance of bacilli into the circulation from a pre-existing but undetectable tubercular product with secondary'' localization in bone. In this sense a primary, or, to use a more correct expression, a localized osseous or articular tuberculosis is, according to Kummer, found in about 40 per cent, of the cases ; in the remaining 60 per cent, depots are found at the same time in other organs of the bod}^ ; the lung comes first, with 25 per cent. ; other joints, 10 per cent. ; other bones, 10 per cent. ; 13'mphatic glands, 10 per cent.; peritoneum. .3 per cent. : pleura, 2 i)er cent. Pathology and Morbid Anatomy. — The tubercle bacillus has a distinct predisposition for the medullar}^ tissue of the bones, and especially for the red medullary tissue in the cancellated tissue in the region of the epiphyseal cartilage of the long bones. As an inflammatory affection it is more correct to speak of tuberculous osteomyelitis than tuberculosis of bone, since the medullary tissue and the blood-vessels which it con- tains are the parts that take an active part in the inflammatorj- process. The anatomical conditions of the vessels in the epiphj^seal pegion of the long bones in 3'oung persons, and in the vessels of the medullar}^ tissue, favor implantation of the microbes upon the vessel-wall, and the}' also explain the frequenc}' with which localization of the tubercular process takes place in this locality. The shaft of the long bones is generally exempt from tubercular disease, with the exception of the phalanges of the fingers and toes, and the metacarpal and metatarsal bones in chil- dren, where the tuberculous osteomyelitis gives rise to the well-known spina ventosa of the old authors. As soon as embolic infection in bone has taken place, a process of osteoporosis and decalcification occurs 494 PRINCIPLES OF SURGERY. around the tubercular embolus or thrombus, and the preexisting medul- lar\' and connective tissues are transformed into embryonal or granula- tion cells, which imparts to the product of the specific inflammation its characteristic fungous appearance. It is not often that onl}- a single focus of tubercular infection in bone is present; more frequently two or three foci appear in the same region simultaneously or in slow or rapid succession, and it is not unusual to find that two neighboring epiphyses are infected at the same time or during the course of the dis- ease. In bone the granulation tis-ue undergoes the same series of sec- ondary degenerative tissue changes as in the lymphatic glands ; hence, in advanced cases we expect to meet with caseation, liquefaction of the cheesy material, and suppuration in cases of secondary infection with P3'0genic microbes. The obstruction of a small arter\- b}- an embolus or thrombus which contains tubercle bacilli usually leads to necrosis and sequestration of a triangular piece of bone, which, in its outlines, marks the area of tissue which received its blood-suppl}- from the obstructed vessel ; thus the triangular sequestra are formed that are so frequently met with in osteal tuberculosis of the epiphyseal extremities. If the embolus is located on the side of the epiphyseal cartilage toward the joint, the base of the triangular sequestrum is directed toward tlie joint, and not infrequenth' projects slight!}' into the joint. It is seldom that tuberculosis of bone develops in the course of pulmonary tuberculosis, but pulmonary and diffuse miliary tuberculosis can be traced frequently to a tuberculous osseous focus. The intimate relations which exist between the tubercular nodule in bone and the blood-vessels furnish a satisfactorj* explanation of the frequency with which s^'stemic infection takes place. A person once infected with the bacillus tuberculosis is liable to suffer from the different forms of localized tuberculosis, and finalh' dies of pulmonary or general miliar}' tuberculosis. Yolkmann has well said that a child suffering from glandular tuberculosis has a good chance to become the subject of osseous tuberculosis during adolescence, and to die of pulmonar}- tuberculosis before reaching the age of 30. As soon as the granulation process in bone reaches an adjacent vein, the tissues constituting the vein-wall undergo the same process, the bacilli reach the lumen of the vessel and re-enter the S3'3temic circulation, and give rise to miliary tuberculosis in organs which are anatomically pre- disposed to secondary infection. As long as decalcification of the sur- rounding bone goes on the infection is progressive, but as soon as osteosclerosis takes its place the process becomes limited ; the micro- organisms are shut in, as it were, by an impermeable wall of sclerosed bone. Tlie most unfavorable conditions are created in cases in which the tubercular focus becomes the seat of a secondarj* infection with TUBERCULOSIS OF BONE. 495 pyogenic microbes, as tlie suppurative process opens up to the bacillus of tuberculosis new areas for invasion, in which the resistance of the tissues to tubercular infection has already been greatly diminished. It is also during the suppurative stage that joint complications are most likel}' to arise. The clinical history of cases of tuberculosis of bone, as well as the macroscopical and microscopical appearances of the lesion, are typical of tuberculosis as found in other organs. The crucial test which proves the tubercular character of most of the chronic inflamma- tory aftections of bone in children has been furnished by bacteriological investigations and experimental research. Most of the investigators who have studied this subject agree that in tubercular bone affections it is sometimes very difficult to find the bacillus, that it is not found in great abundance, and that sometimes it has evaded even the most careful search. According to Konig, who is authorit}' on everything that per- tains to tuberculosis of bones and joints, all cases of osteo-tuberculosis can be arranged under four principal groups, according to the predomi- nating pathological conditions of the lesions : 1. The granulating focus. 2. The tubercular necrosis. 3. The tuberculous infarct. 4. Diffuse tuberculous osteomyelitis. 1. The granulating focus is found as single or multiple, round or oval cavities, from the size of a millet-seed to that of a pea or hazel-nut, containing living embryonal tissue, or, if this has been destro^yed by coagulation necrosis and caseation, a yellowish-gra}', cheesy material, or liquid tuberculous pus. Minute spiculse of bone are imbedded among the granulations or suspended in the liquefied caseous material. Histo- logically, the granulation material is composed of the same cell-elements as recent tubercle in other organs, only that, as a rule, the giant cells are more numerous and of larger size. If caseation has taken place, the chees}' material is surrounded b}' a zone of granulation tissue. As long as the process has not come to a stand-still, the surrounding bone is osteoporotic, and can be easilj' scraped out with a sharp spoon. As soon as the inflammator}^ process has subsided the osteoporotic bone becomes sclerosed, and the tubercular focus is walled in and, for the time being, is rendered harmless. Cheesy tubercular cavities in bone resemble the same condition in the lungs, onl}^ that secondary' infection with pus- microbes is of less frequent occurrence, and on this account the cavity never attains such large size as in the latter organ. 2. Tubercular necrosis necessaril}^ follows if the infected area exceed the size of a hazel-nut. The non-vascular structure of the tubercular product and the blocking and destruction of blood-vessels during the earl}' stages of the tubercular inflammation produce early death of the bone, corresponding to the limits of the inflammation, and if this exceed 496 PRINCIPLES OF SURGERY. the resorption capacity of tlie granulation tissue the dead tissue is not removed by absorption, and is found as a sequestrum as soon as it has become detached from the surrounding healthy bone. If the tubercular process has been rapid and the granulation tissue is scant3',tlie necrosed bone is not osteoporotic; but if the disease has pursued a more clironic course, and has resulted in the production of an abundance of granula- tion tissue, it presents a honey -combed appearance, is irregular in shape and in size, does not correspond with the area of the infected district, as part of it has been absorbed by the granulations. Its color depends on the condition of the granulations which surround it; if these have not undergone secondary degenerative changes it may resem])le health}' bone, but if caseation has taken place it is infiltrated witli the cliees}^ material, and then presents a grayish-yellow or yellow appearance. If tlie necrosed bone has undergone no reduction in size, and the granula- tions surrounding it are few, it remains firmly wedged in position, and under such circumstances it is often difficult to locate the exact boundary-line between it and the surrounding healthy bone or to dis- lodge it from its position. 3. The tuberculous infarct is only another form of tubercular necrosis, and is separately classified because llie necrosed bone is always wedge-shaped, and the necrosis has been caused b^^ the impaction of an embolus containing tubercle bacilli in a distal branch of a nutrient artery. The size of the vessel obstructed by an infected embolus will determine the extent of the necrosis. If the embolus is small, the area of necrosis may be increased by the blocked vessel becoming the seat of secondary thrombosis, obliteration of the vessel taking place in a proxi- mal direction bj' growth of the thrombus toward the heart. As the cortical portion of the bone is seldom involved by a tubercular infarct, the necrosed area is often overlooked in operations on tubercular joints unless the bone is sawn through. If tlie base of the wedge-shaped piece project into a joint that has been used, its surface will be found suioothl}'" polished by the movements in the joint. Separation of the sequestrum takes place more slowly than after suppurative osteom^'elitis, the process requiring often, according to the size of the sequestrum and the activity of the inflammatory process, months and years for its completion. If the granulations which surround the sequestrum do not undergo cheesy degeneration, the bone becomes imbedded, and fits accurately into the cavity, and if the surrounding zone of granulation is converted into connective tissue it ma}' become per man en tl}' encapsulated ; but even from such an apparently healed depot local and general infection can occur at an}' time. 4. The diffuse form of tuberculous osteomyelitis is quite rare. The TUBERCULOSIS OF BONE. 497 pathological and clinical characteristics of this form of local tuberculosis consist in the rapid local extension of the affection and the danger to life from general infection. On making a longitudinal section through a long bone aflected by diffuse tuberculous osteomj-elitis, we observe conditions -which closely resemble acute suppurative osteomyelitis. We find large, irregular, often multiple areas of a j-ellowish-white infiltration with multiple foci of liquefied chees}' material. The infection extends, as in cases of suppurative osteomyelitis, along the blood-vessels and Haversian canals to the periosteum, resulting in diffuse plastic osteo- m3'elitis with the formation of irregular, diffuse masses of bone. In these cases there is no tendenc}^ to limitation in the formation of sequestra, but rather a tendenc}' to spread indefiniteh', and to invade even the medullary tissue of the shaft. Patients suffering from this form of tubercular osteomyelitis are exposed to the dangers of a fatal general tuberculosis if the infected tissues are not removed Iw a timel}' and thorough operation. In operating it is important to recognize this form, since it requires more radical measures, — either amputation or verj'^ extensive excisions of the entire thickness of the affected bone. Local operations such as will meet the indications in the other varieties of osteo-tuberculosis are of no avail. With the exception of this form of tuberculosis of bone the periosteum seldom participates in the tubercular Inflammation. When the dry granulation form reaches the periosteum, a small, soft, elastic, limited granulation swelling forms, — first under the periosteum, later outside of it. It is characterized by slow growth, comparativel}' little pain, slight tenderness, and a tendenc}^ to remain stationary for a long time. If, however, the central focus has become chees}', and the liquefied cheesy material comes in contact with the peri- osteum and the paraperiosteal tissues, a large tubercular abscess forms in a short time. As soon as the periosteum has been perforated the cheesy material infects the connective tissue, which then takes an active part in the formation of the tuberculnr abscess. Before such an abscess spontaneously ruptures, the skin overlying it becomes tuberculous and presents, at the point of perforation, the appearance of lupus. Symptoms and Diagnosis. — The general symptoms are often no indi- cation of tlie existence or extent of the local disease, as patients with quite extensive osteo-tuberculosis may present ever}- appearance of per- fect health. More than ten years ago Konig called our attention to the fact that a slight rise in the temperature is frequently present even in cases of limited local tuberculosis. If the thermometer show a normal morning temperature, but a slight rise toward evening, if not more than half a degree Fahrenheit, but continued for weeks, it indicates a careful search for a local tubercular focus. Progressive anaemia is always an 32 498 PRINCIPLES OF SURGERY. unfavorable symptom, as it indicates either the presence of additional foci in important organs or accompanies the exhaustive purulent dis- charges after secondary infection with pus-microbes. Tiie occurrence of mixed infection, with or without a direct infection-atrium, is usually announced by a high temperature and other symptoms of septic infection. The local symptoms vary according to the location, condition, and size of the tubercular focus and the presence or absence of complications. I. Pain. — Pain is an almost constant symptom, but its intensity is subject to great variation. Unlike in acute suppurative osteomyelitis, tlie inflammatorv product does not give rise to the same degree of tension ; hence pain is not so severe. The primary exudation in tuber- cular inflammation is always scanty, and the inflammatory product is composed mostly of granulation tissue derived from pre-existing cells; at the same time the surrounding bone-tissue becomes osteoporotic, consequently tension is to a great extent avoided and pain is either slight or entirely absent. Children suffering from spina ventosa com- plain of little pain, although a phalanx of a finger ma}' be almost completely destro3'ed by a tubercular osteomyelitis. In such cases the granulation tissue is formed slowly, the compact layer of the bone is rendered osteoporotic, and generally yields to the intra-osseous pressure and expands perhaps to twice its normal thickness ; pain is slight or entirely absent, because no great intra-osseous tension has occurred. That tension or pressure greatl}' aggravates pain in osseous tuberculosis is one of the most familiar fixcts in surgery. Pain is promptly relieved in a case of tubercular spondylitis by suspension and rest in the recum- bent position, and greatly aggravated by flexion of the spinal column, which necessarily produces pressure upon the bodies of the inflamed vertebrae. In osteo-arthritis of the large joints pain is relieved by rest and extension, and is always increased by use of the limb or by pressing the inflamed articular surfaces against each other. It maj' be stated, as a rule, that the intensity of the pain bears a direct relationship to the acuteness of the inflammatory process. The pain is intermittent and more severe during the night. The nocturnal exacerbation of the pain, as evidenced in children by restlessness during sleep, moaning, grinding of teeth, and horrible dreams, is often one of the first symptoms which excites suspicion of the existence of osteo-tuberculosis. The pain is not always referred to the seat of lesion. Tubercular osteomyelitis of the head and neck of the femur gives rise to pain in the region of the knee- joint, and children suffering from tuberculosis of the spine usuall}' refer all the suffering to the pit of the stomach or to some other part of the abdomen supplied with nerves that take their exit from the spinal canal at a point corresponding to the inflamed vertebra. TUBERCULOSIS OF BONE. 499 2. Tenderness. — The existence of tenderness over a point corre- sponding to the tubercular focus in the interior of a bone is one of the surest indications of the existence of osteo-tuberculosis. In many cases of epiphj-seal tuberculosis patients have been treated for some supposed lesion in the adjacent joint, simply because this sj^raptom was not care- full}- searched for, or, if discovered, its significance was misinterpreted, lu such cases the existence of a circumscribed point of tenderness in the epiphyseal line and the absence of lesions in the joint will enable the surgeon to locate accurately a focus in the interior of a bone. If more than one focus is present in the epiphj-seal extremity of a long bone the number of tender points will correspond with the number of foci in the bone. Whether a central focus in a bone could be always recognized by relying upon this sj-mptom is somewhat doubtful, but usually the foci are located sufficiently near the surface of the bone to give rise to tender points, which can be readily located by finger pressure. 3. Swelling. — External swelling is absent until the atrophic layer of compact bone yields to the intra-osseous pressure, as maj^ be seen in advanced cases of spina ventosa, or until b}' pressure atrophy over the centre of the focus the compact layer is perforated, and a soft, circum- scribed, bogg}- swelling forms underneath the periosteum. If the granu- lation tissue has retained its vitality the extra-osseous swelling increases very slowlj- in size, and there is no tendenc}' to diffuse infection of the connective tissue after the granulations have reached the paraperiosteal tissues. Pseudo-fluctuation is generally present, and many such granu- lating foci at this stage have been carclessl}- incised under the mistaken diagnosis of abscess. If the central focus has undergone caseation before the periosteum is perforated, then the paraperiosteal tissues become rapidly infected, and a tubercular abscess, such as has been described before, develops in a short time. The abscess wanders away fiom the place where it originated in directions offering the least resist- ance, along preformed anatomical spaces and in obedience to the law of gravitation. The size of such an abscess is, absolutely, no indication of the extent of the primar}'^ lesion in the bone, as a minute focus Yna.y be the cause of a large abscess, and a small abscess maj- mark the location of an extensive primary lesion. (Edema is usually not well marked, even if the abscess is large, unless secondar}^ infection with p3'ogenic microbes has occurred. The diffuse form of tuberculous osteomj-elitis is alwa3'S attended by a plastic osteomyelitis, and, consequently, the early appearance of external swelling is one of the points to be taken into consideration in differentiating between the different forms of osteo- tuberculosis. The swelling that attends tuberculosis in bones deeply seated, as the vertebrse, hip-joint, and pelvic bones, docs not become 500 PRINCIPLES OF SURGERY. apparent until the existence of a tubercular abscess indicates the probable seat of the primar}' lesion, 4. Redness. — The skin over a tubercular focus in the interior of a bone or over a tubercular abscess presents a normal appearance until it has become infected and shows other unmistakable signs of tubercu- losis. This does not occur until the granulations have permeated the deeper portions of the skin, or until tlie caseous material has only the skin for its covering. Under such circumstances the skin presents a dusk3'-red hue, owing to impaired capillar}' circulation, and becomes more and more attenuated by pressure atrophy and destructive changes until it finally yields to the pressure atrophy from beneath, and spon- taneous evacuation of the contents of the abscess takes place. If the subcutaneous product is composed of granulation tissue the undermined skin, after putrefaction has taken place, is destroyed by degrees and the part presents the appearances of lupus. 5. Atrophy of Limb. — Muscular atrophy is almost a constant symp- tom in osteo-tuberculosis as well as in tubercular synovitis. This atrophy is not caused altogether by inactivity of the limb, and it appears to be due to tropho-neurotic lesions. Besides a careful study of the clinical histor}^ several diagnostic measures may be resorted to in doubtful cases to enable the surgeon to make a positive diagnosis. Means of DifFerentlal Diagnosis — (a) Akido Peurastik. — Exploration of a doubtful swelling with a strong steel needle was introduced by Mid- deldorpf, for the purpose of ascertaining the consistence and probable structure of the tissues composing the swelling. He called this simple procedure akido peurastik. The presence of a tubercular focus in the interior of a bone can often be demonstrated by this aid to diagnosis before an}' external swelling has appeared. A strong needle of a hypo- dermic syringe can be used for exploring a bone the density of* which has been diminished by chronic inflammation, if this latter has not been followed by osteosclerosis. During the active stage of osteo- tuberculosis the bone for a considerable distance around the focus is osteoporotic, and can be readily penetrated by a strong, sharp needle. The exploration should be made under strict antiseptic precautions. The puncture is made in the centre of the tender area, and in a direction corresponding to the probable location of the central focus. If tlie needle meet with any considerable resistance in the bone, it is advanced by rotatory movements; the arrival of the point in the granulating centre or caseous focus is announced by a sudden loss of resistance. By advancing the needle sufficiently to touch the opposite side of the cavity its probable size can be ascertained. TUBERCULOSIS OF BONE. 501 (b) Explopatopy Puncture, with Aspiration.— If the needle of an ex- ploratoiy or hypodermic springe is used to make the akido peurastik, exploration of the bone ma^' be followed by removing some of the eon- tents of the cavity for examination by aspiration. If the tubercular product has undergone caseation and liquefaction some of the cheesy material can be removed by aspiration, and the nature of the lesion may then' be revealed by positive demonstration. If still further evidence is required, a guinea-pig may be inoculated with the same needle, which still contains enough of the material to produce a positive result in the animal. If the cavity contain granulation tissue little fragments of this can be drawn into the needle, and with these inoculation experiments for diagnostic purposes can be made. In tubercular necrosis it may be pos- sible to detect the presence of the sequestrum and ascertain its mobility by exploratory puncture. If a tubercular abscess has formed, the char- acter of the contents of the swelling may be ascertained by using the exploratory- s^^ringe, and the nature of the primary cause demonstrated, if need be, by injecting the material aspirated into the subcutaneous tissue or peritoneal cavit}- of a guinea-pig. In the differential diagnosis of tuberculosis of ])one, it is necessary to exclude synovial tuberculosis, sarcoma, echinococcus-C3'st, rachitis, suppurative osteomyelitis, and syphilis. Many cases of primary tuberculosis of bone have been mistaken for synovial tuberculosis, and vice versa. Primary tuberculosis of bone frequently results in contractures of joints without direct implication of the joint, and this has often led to a wrong diagnosis. In primary syno- vial tuberculosis the first pathological changes occur in the joint, and no tender points will be found in the epiph^'seal regions. In osteo-tubercu- losisnot complicated b}^ an extension of the disease to the adjacent joint, the first S3-mptoms are referred to the lesion existing in the interior of the bone, and it is usually not difficult to ascertain the existence of cir- cumscribed points of tenderness which correspond to the location of the foci. Periosteal sarcoma is from the beginning an extra-osseous product. Central sarcoma, as a rule, increases more rapidly in size than a tuliercular swelling, and is often the seat of pulsations and a blowing sound which can be heard by auscultation. Central sarcoma is often the cause of a pathological fracture, while this accident is exceedingl}' rare in osteo-tuberculosis. Echinococcus of bone is an exceedingly rare aflfection, but, as it ni;.}' simulate osteo-tuberculosis, differential diagnosis must be based on an exploratory puncture, which will yield a clear serum containing the characteristic booklets in the former instance, and granu- lation tissue or the products of caseous degeneration in the latter. Rachitis gives rise to swelling and pain in the epiphyseal regions; but this affection is not limited to one or two bones, and affects almost ever}' 502 PRINCIPLES OF SURGERY. boue in the body alike. Epiphyseal multiple osteomyelitis is an acute or, at least, subacute affection, and results early in the formation of puru- lent foci, and is often attended by epiphyseolysis. The virus of syphilis has a special predilection for the periosteum, while this structure is almost immune to primary tubercular atlections. In 95 out of every 100 cases chronic inflammation in bone means tuberculosis, and, unless there are special reasons which should render the diagnosis doubtful, it is safe to adopt a treatment adapted for tubercular osteomj'elitis in almost every case where the symptoms point to a chronic inflammation and the existence of a tumor or parasitic growth can be excluded. Prognosis. — On tlie whole, the prognosis is more favorable in cases of osteo-tuberculosis than if the tubercular infection is located in the skin, a joint, lymphatic gland, or an}- of the internal organs. Spontaneous healing of a tubercular focus in bone is possible under favorable con- ditions. Everything that adds to the patient's strength and power of resistance to the microbic infection adds to the possibilit}' of such a favorable termination. If the patient is well nourished, and, above all, if the blood is in a normal condition, limitation of the disease may occur before caseation has taken place ; and if cheesy material has formed, and it can be removed b}^ operative interference, the prospects of a perma- nent recover}' are good. It must be, however, admitted that every person who has sufl^'ered from an attack of osteo-tuberculosis during childhood or youth, even if an apparent perfect cure has been effected spontaneously' or by operative measures, is always in danger of becoming the subject of re-infection at any subsequent time. The spores of the bacillus of tuberculosis may remain in a latent condition for an indefinite period of time in the cicatrized primary' lesion, to become a cause of subsequent danger as soon as the local or general conditions enable them to exercise their patliogenic properties. Healing by cicatrization is possible in the small granulating foci so long as the coagulation necrosis is limited and no caseation has occurred. In such cases the embryonal cells are con- verted into permanent connective tissue and the small fragments of bone are removed b}- absorption, while the bone around the cicatrix becomes sclerosed. If caseation has occurred, but the chees}' material has not undergone liquefaction, encapsulation of the tubercular product can take place b}' the wall of granulation tissue lining the cavit}' becoming con- verted into cicatricial tissue, forming a capsule, which, for the time being at least, mechanically prevents the local extension of the disease. Small sequestra may become imbedded in a connective-tissue capsule in u similar manner. If the sequestrum is large, it will act like every other foreign infected bodj', and sooner or later require an operation for its extraction. If the tubercular process has extended to a joint, the prog- TUBERCULOSIS OF BONE. 503 nosis is more grave, and the chances for a spontaneous recovery are much diminished. The prognosis is always more grave, other things being equal, if the bone affected is so located that removal of the pri- mary focus by operative treatment is anatomically impossible. The danger to life and the probabilitj- of local extension are always greater if the granulation tissue has been destroyed by coagulation necrosis and caseation, as the granulation tissue is one of the means by which regional and general infection are prevented. The danger to life is imminent if a large tubercular abscess has become infected with pus-microbes, as the secondary infection results in destruction of the granulation tissue lining the cavity, which favors the local and general extension of the tuber- cular infection and at the same time brings sepsis, exhaustion from pro- fuse suppuration, and am3loid degeneration of important internal organs as additional elements of danger. The prognosis is always more grave in persons advanced in years than in children, as limitation of the dis- ease occurs more frequently' in the latter. Treatment. — The medical treatment in patients suffering from osteo- tuberculosis must be tonic and supporting. Dietetic and hygienic treat- ment is of more value than the administration of drugs. Sea-bathing and change of climate will often accomplish more than bitter tonics, iron, quinine, arsenic, and codliver-oil. The local treatment, sliort of a radical operation, must consist in the use of such means as will aid the natural resources in effecting limitation of the tubercular process, of which the most important is I. Physiological Rest. — The importance of securing for the inflamed part, as near as can be done by mechanical support, absolute physio- logical rest cannot be overestimated. The process of repair in a tuber- cular focus often meets with great and insurmountable difficulties. The embryonal cells, of low vitality almost from the beginning, are poisoned as soon as born with the ptomaines of the bacillus of tuberculosis, and consequently are converted into tissue of a higher type only under the most favorable conditions. The non-vascularity of the tubercle is an- other cause why the inflammatory product so seldom takes an active part in the process of repair. The first indication in the treatment of a tuber- cular osteomyelitis is to secure for the part a favorable condition of the circulation, which can only be done by securing rest. The most efficient way to procure rest, not only for the diseased part, but for the entire body, is to confine the patient to bed ; but, as these affections are noted for their chronicity for months and years, enforced rest b}- this method would seriously impair the general health, and on this account it is ad- visable, in the majority' of cases, to resort to one of the numerous mechanical appliances which will immobilize the part ; while, at the same 504 PRINCIPLES OF SUKGERY. time, the patient can avail himself of tlie benefits to be derived from out-door air and change of scenerj- and surroundings. In tuberculosis of the spine Sa3're's plaster-ot'-Paris jacket, applied while the patient is partly suspended, answers a more useful purpose than any of the numerous complicated apparatuses which have been as j'et devised. To appl3- the jaclvet properlj^ requires a great deal of ex- perience and the exercise of considerable skill. In man}- communities this method of treatment has become unpopular, both among physicians and the laity, from the bad results caused by impro[)er application of the jacket. H^-perextension must be avoided, and the patient must be instructed to extend himself only until pain is relieved, and not beyond this point. The bou}' ])ronunence at the seat of curvature must be carefiill}' protected against pressure b}' applying on each side a pad sufficiently^ thick to prevent contact of the projecting spinous processes with the plaster cast. The plaster bandages themselves must be applied smoothly, so that after extension is removed the jacket will closel}'^ fit the unequal surface of the bod}'. Another matter of great importance is to see the patient from time to time, in order to determine whether the jacket causes injurious pressure at an}- point, which, if this should be the case, is remedied at once, either b^^ cutting out that portion of the jacket which has caused the decubitus or by applying a new one. In tuberculosis of any of the bones of the extremities rest can be secured most efficientl}' by immobilizing the limb in a plaster-of-Paris dressing. The splint must always include one or more of the adjacent joints. Undue constriction of the limb is prevented b}- interposing between it and the splint a thin layer of salicylized cotton. If the disease aflTect any of the bones of tlie lower extremities the patient must not be allowed to walk without crutches. 2. Ignipuncture. — During the early stages of osteo-tuberculosis excel- lent results have l)een obtained b}- ignipuncture, — a method of treatment devised a few years ago by Richet. If a tubercular focus can be accu- ratel}' located, this method of treatment should receive a trial, as it is not attended by any risks and frequently effects a permanent cure. The field of opei'ation is thoroughly disinfected, and, with the needle-point of a Paquelin cautery heated to a dull or red heat, the soft tissues and bone are perforated. In making the perforation it is necessary to advance the point slowly, and to remove it from time to time, and revive the heat in order to prevent impaction of the point. The entrance of the instrument in the cavity can be readily- felt, as resistance at that moment is suddenly diminislied. The therapeutic effect of ignipuncture is threefold : 1. The tunnel made establishes free drainage, and relieves prompth' the intra-osseous tension. 2. At least a portion of the in- TUBERCULOSIS OF BONE. 505 fected tissue is destroj-ed I)}- the heat. 3. A plastic osteoni3'elitis is excited in the vicinity of the track and in the cauterized portion of the cavit3', which exerts a favoral)le influence in bringing about limitation of the disease, or even in effecting a final cure. Through the opening made iodoform can be introduced into the cavity, which ort'ers additional ad- vantage in treating osseous foci successful!}' b}' this pressure. To insure a successful issue, it is ahsolutehj necessary to prevent infection with pus- microhes through the opening by making the operation under strict anti- septic precautions, and protecting the puncture with an efficient antiseptic absorbent dressing until it is completely closed by cicatrization and epi- dermization. Ignipunctnro is most useful in the treatment of accessible foci in the ei)iphyseal extremities of the long bones and during the early stages of tuberculosis of the wrist and tarsus. In incipient tuberculosis of the tarsus I have repeated}}' obtained a satisfactory and permanent result by making an opening through the entire tarsus from side to side, in a line of the disease, by inserting the point from each side, the two tunnels meeting in the centre. Ignipuncture always relieves the pain promptl}', and the track made is completel}' closed by permanent tissue in the course of a few weeks. 3. Radical Operation — (a) Removal of Limited Foci. — The radical treatment of tuberculosis of bone consists in the complete removal of the infected tissues b}' operative interference. The success which follows this treatment is most marked in cases where caseation has not taken place, — that is, in the granulating form, — and in other forms where the operation is performed before extensive secondar}- pathological con- ditions have occurred. The operation is indicated as soon as a positive diagnosis can be made, and after the milder measures have proved use- less in arresting the progress of the disease. Timely surgical inter- ference in osteo-tuberculosis is not onl}- calculated to become the surest means of preventing general infection, but it also has for its object the limitation of the disease by the removal of tlie primary cause, and by accomplishing these objects it becomes at once a prophylactic as well as a curative measure. If a tubercular focus or foci can be removed by a radical operation before the adjacent joint has become infected, then the operation has not onl}- been successful in effecting a permanent cure, but it has also been instrumental in preventing the extension of the disease to the joint. If the operation is undertaken at a time, as it should be, before an}- external swelling has appeared, the surgeon must be guided in finding the focus by searching for tender points, aided, if necessary, by exploratory punctures. As in epiphyseal tuberculosis the foci are always near n joint, the incision for exposing the bone should be made in such a manner as to avoid opening tlie joint. If the focus is so close to 506 PRINCIPLES OF SURGERY. the joint as to make it necessary to remove bone underneath the inser- tion of tlie capsule or ligaments of the joint, it is advisable to lift the periosteum with the joint structures from tlie bone to some distance from the incision, and in this manner to avoid injury to the joint. The bone overlying a tubercular abscess is usually softened and easily removed with a small, round chisel. The limb should always be rendered blood- less by using Esmarch's constrictor, so that the opei'ator can identify the tissues as they are being removed during the operation. If, after tunnel- ing the bone for a considerable distance, the focus is not found, it is advisable to make from this track exploratory punctures in different directions with a small perforator until the cavity is found, which is then freely exposed with the chisel. As soon as this has been done the sharp spoon is used, with which the necrosed bone, granulation tissue, or cheesy material is removed. The osteoporotic bone in the immediate vicinity of the cavity is removed in a similar manner, and the surgeon must assure himself, by repeated examinations of the tissue removed, that healthy tissue has been reached before the sharp spoon is laid aside. If any doubt remain whether all of the infected tissue has been removed, it is better to resort to ignipuncture, perforating the bone at different points to the depth of a few lines with the sharp point of a Paquelin cauterj^ in addition to the curetting. This procedure will destroy at least some of the bacilli which might have remained, and will incite a plastic osteomyelitis that will effectually resist the pathogenic action of such microbes that still remain. After the cavity has been thoroughl}- irrigated with an antiseptic solution it is dried, iodoformized, and packed witli antiseptic decalcified bone-chips. The periosteum is separately sutured over bone-packing, sufficient space being left to insert, at the low angle of the wound, a few threads of catgut to serA^e as a capillary drain. The remaining tissues are included in the superficial sutures and an antiseptic dressing applied. The limb must be immo- bilized by applying a well-padded posterior si)lint. If all the infected tissues have been removed, and no infection with pus-microbes has taken place during or after the operation, the wound unites under one dressing in from one to two weeks, and the definitive healing of the cavity is completed in the course of three to six weeks, according to the con- dition and age of the patient and the size of the cavity. The packing of such cavities with iodoformized decalcified bone-chips is an important element in the prevention of a local recurrence and general infection. Should suppuration follow the operation, secondar}' implantation with decalcified bone-chips can be done successfully as soon as suppuration has ceased, and the cavit}^ can be made thoroughly aseptic. (b) Excision of Portion of Shart. — This operation is only indicated TUBERCULOSIS OF JOINTS. 507 in some cases of diffuse tubercular osteomyelitis where amputation is considered unneeessar3\ Extirpation of the entire bone affected is fre- quently necessary in tuberculosis of the wrist and ankle-joint. (c) Amputation. — Amputation is often the only choice in the treat- ment of diffuse tuberculous osteomyelitis, as it offers the only chance to effect complete eradication of the disease, and to protect the patient against general infection. It is contra-indicated in the other forms of osteo-tuberculosis, unless complicated by tuberculosis of an adjacent joint, and even in such instances it is limited to cases that have passed bej'ond the reach of a tj'pical or atypical resection. TUBERCULOSIS OF JOINTS. Tuberculosis of joints, chronic fungous arthritis, strumous arthritis, and tumor albus are terms that even now are being used S3'nonymoiisly to indicate a form of inflammation of joints which clinicallj' is char- acterized by its chronic course and the absence of acute signs of inflam- mation. This affection is b}- far the most common joint disease, so much so that Konig states that in surgical clinics the surgeon will have 100 cases of tuberculosis of the joints to deal with to one of the other classes of inflammation, such as gonorrhoeal, S3'pliilitic, suppurative, osteomj^e- litic, rheumatic, or the metastatic inflammations subsequent to acute infectious diseases. Etiology. — We distinguish, as to origin, between primary synovial and primary osteal tuberculosis of the joints. If the primary focus is in the bone the disease usually extends to the joint b}' direct extension of the process to the structures of the joint. In primary synovial tuberculosis the bacillus is conveyed through the circulation, and locali- zation takes place in the synovial membrane. Max Schiiller proved experimentall}', in animals infected with tubercle bacilli, — for instance, through the respiratory tract, — that a slight trau- matism to a joint would determine localization, b}' way of the circula- tion, to the injured part, and that a tubercular synovitis or panarthritis would follow. The same author makes the statement, based on the results of his experiments, that a slight injury to a joint in a person who has bacilli floating in his blood would determine localization, commonly in the form of a S3'novial tuberculosis. Clinically, tuberculosis of joints has been ti'i^ced in 56 per cent, of the cases to traumatism hy a direct blow to a joint, or distortion, or overexertion. It is characteristic that the traumatism is always slight; a severe injury, causing intra-articular fracture, is very rarel}' followed by tuberculosis, for the same reasons that severe injuries do not produce the disease in bone and other organs. It may be stated that, as to the relative frequency of the two forms of 508 PRINCIPLES OF SUKGEKV. infection, it has been sliown that primary osteal tuberculosis occurs two or tliree times as often as tlie prinuuy synovial. Tuberculosis of joints is always closely related to the same disease in bone, because, when it does not follow the latter as a secondary lesion, the primary synovial not seldom implicates the adjacent bone from the direct extension of the infection from the fungous synovial membrane to tlie subjacent bone structure. Synovial tuberculosis is more frequent in the adult than in children. Primary infection of a joint is possible only through a wound, as in the case referred to under the head of Inoculation-Tuberculosis. Tubercular infection of an intact joint presupposes the entrance of the bacillus of tuberculosis through tlie respiratory- tract or alimentar}^ canal, or througli some external infection-atrium into the systemic circu- lation, or the dilfusion of bacilli through the same channel from some pre-existing tubercular focus, and the localization of floating bacilli in the synovial meml)rane by capillary embolism or by mural implantation. A simple tubercular nodule over the surface of the synovial membrane may lead, in a com[)arativel3^ short time, to diffuse tuberculosis over the entire surface of the joint b}- local dissemination of the microbes, in which the synovial fluid and the movements of the joint play an impor- tant part. In the osteal form of tuberculosis of joints the infection extends from the bone to the joint at once, in cases where the primary disease is the result of infarction, as the base of the wedge-shaped piece of the necrosed bone communicates direetl}' with the joint; while infec- tion of the joint occurs secondarily, in cases of granulating foci and tubercular necrosis, by perforation of the tubercular product into the joint. When the foci are located close to the articular cartilage, this must be destroyed before the joint is invaded, the cartilage forming a barrier that may sometimes prove sufficient to resist invasion. In case a focus is located at the surface of a joint, Avhere the bone is not covered with articular cartilage, the thin periosteum and the synovial membrane covering it are more easily perforated, and consequently secondary syno- vial tuberculosis is more liable to follow. The most complicating condi- tion ma^' arise if a tubercular focus is located at the insertion of the capsule of a joint. It may then open into and outside of the joint simultaneously, or the one or the other, the integrity of the joint de- pending on the few lines of space occupied b}' the cnpsule. Pathology and Morbid Anatomy. — In synovial tul)erculosis a series of pathological changes are initiated in which all the structures of the joint are (inally concerned, namel}', the sjaiovial membrane, para-S3-novial tissues, articular cartilage, and lastly the bone. The tubercle-nodule in the S3'novial membrane presents, under the microscope, the same histo- logical structure as in other tissues. When the synovial surface has TUBERCULOSIS OF JOINTS. -"iOD become the seat of diffuse tuberculosis, the tissues undergo tho same pathological changes as during the first stage of tuberculosis in other organs, and it is the charncteristic granulation tissue that has given to this form of arthritis the names of fungous synovitis and synovitis hyper- plastica granulosa. During the early stages of the disease the surgeon meets with two distinct varieties; in one the tubercular infection pro- duces a pulpy condition of the entire S5niovial sac, with little or no effu- sion into the joint, the swelling being due entirely to the presence of a thick layer of granulation tissue, — the true tumor alhus of the old writers. This form of tuberculosis gives rise, at an early stage, to exten- sive deformity of the joint, flexion, rotation, and, in the case of the knee-joint, partial dislocation of the tibia backward. In the other variet}' the fungous granulations are less marked, but a copious effusion takes place into the joint, which simulates a catarrhal synovitis, until time and tlie effect of treatment enable the surgeon to make a correct differ- ential diagnosis. In tliis form Konig assures us tliat he has never observed a tendency to flexion or any other form of displacement of the joint surfaces. If suppuration take place, which is not very often the case, it begins in the granulations which cover the synovial membrane, and the pus accnmuiates in the cavity of the joint until perforation of the capsule takes place. During the suppurative process the granu- lations are destroyed and the tubercular infection penetrates deeper, and, as during the destructive process blood-vessels are destroyed, the patient is exposed to the additional risks of general infection. If a tubercular joint open spontaneously', or is not incised under the strictest antiseptic precautions, the additional infection from without leads to the most serious consequences, as under these circumstances the pus-microbes are brought in contact with a surface that has been admirabl}- prepared by the bacillus of tuberculosis for suppurative and septic processes. Pathological Varieties of Joint Tuberculosis.— TnV>ercuhir inflamma- tion of the synovial membrane of joints results in different gross pathological conditions that serve as a basis for classification into : 1. Pannous hyperplastic synovitis. 2. Tuberous hyperplastic synovitis or papillomatous plastic synovitis. 3. Granular or fungous hyperplastic synovitis. 4. Tuberculnr articuhir emiiyema. I. Pannous Hyperplastic Synovitis. — The tubercle-nodules are ex- ti'emely small, rarely visible to the naked e3-e, and wideh' disseminated over the entire or greater portion of the S3'novial sac. The synovial membrane is only moderatelj' thickened, but quite vascular. From the border of the cartilage a thin, vascular layer of granulations approaches the centre of the surfice of the joint somewhat in the manner a pannus invades the cornea. Tiiis form of synovitis was first described b}' Hueter. 510 PRINCIPLES OF SURGlJiY. 2. Tubercular Plastic Synovitis or Papillomatous Plastic Synovitis. — The tubeiLMihir iiilluniination results in the foniuitioii of sub-syuovinl fibrous masses, which may attain the size of a walnut, protruding into the joint and filling, for example, the supra-patellar recess of the knee- joint, with simple irritative synovitis or pannous synovitis in the rest of the cavity. The tubercular infection in such cases is limited, and the removal of the fibrous swelling results in a permanent cure. In other oases of the same U'pe of inflammation the foci are numerous, resulting in papillomatous plastic synovitis where the whole inner surface of the synovial membrane is covered with sessile or pedunculated papillomatous growths, small and rather uniform in size, some of which may become detached, w^hen they constitute the so-called rice-bodies. 3. Granular Fungous Hyperplastic Synovitis. — In this variety of joint tuberculosis the synovial membrane is atiected throughout, being con- siderabl}' thickened and hypersemic, and covered b}^ a more or less thick layer of velvety granulations. The ligaments and para-articular struct- ures are affected at a comparatively early stage, and thus is formed the thick, oedematous mass of tissue, usuall}^ of a gelatinous appearance, in which here and there cheesy foci are found. Anj^ of the above-named forms of tubercular synovitis may give rise to the transudation of serum or a sero-fibrinous fluid into the joint, — the tubercular hydrops of Konig. As a rule, the serous effusion is most copious in cases where the synovial membrane has undergone the least change ; that is, in pannous hj'perplastie s^-novitis. In tuberous and papillomatous sjuiovitis the eflfusion is usually scant}', and in fungous synovitis attended by the formation of massive granulations it is absent, as a rule. The effusion into the joint, in tubercular hydrops, is either a thin, clear synovia, or it is rendered slightl}- turbid from the admixture of leucocytes and the products of coagulation necrosis, or, if the effu- sion is of a sero-flbrinous character, it contains shreds of fibrin. The rice-bodies {corpora amylacese)^ so frequently found in tubercular joints, are composed of dense masses of fibrin or they are detached papillo- mata. That these bodies are a tubercular product I have repeatedly satisfied myself by inoculation experiments. 4. Tubercular Articular Empyema {Konig). — The tubercular abscess of joints is an advanced stage of the other varieties of tubercular synovitis. The inside of the capsule is covered with loosely-adherent tuberculous membrane, similar to that in tubercular abscesses. The superficial granulations which compose this membrane have undergone degenerative changes. Outside of this membrane the tissues are diff'usel}' infiltrated Avith miliary tubercles, but the infection does not extend bej'ond the S3-novial membrane. The fluid in the joint, like in TUBERCrLOSIS OF JOINTS. 51 1 all tubercular abscesses, is not pus, but serum, in which we find suspended the products of coagulation necrosis. With the extension of the tuber- cular process be3'ond the limits of the synovial sac, the articular cartilage, and, finall}^ the bone, are successiA^ely attacked. The articular cartilage takes no active part in the inflammatory process; it is detached and removed b}' the granulations. An osseous focus in contact with the cartilage usuall}' makes a circular defect througli which the granu- lations or cheesy material can be seen. The cartilage covering a tuber- cular infarct is rapidl}^ destroyed, and is mechanically detached in smaller or larger fragments. In primary tuberculosis of tlie synovial membrane the process usualh' commences at the periphery' of the articular cartilage, and from here the granulations dip down into the vascular bone, and often undermine the cartilage extensively before any destructive changes are witnessed on the side directed toward tlie joint. In such cases the cartilage is not only often extensively detached, but perforated at numerous points bj' the granulations underneath it. The action of the granulations on the articular extremities of the bone produces a condition which has been described for centuries as caries. Caries is not a disease, but the result of a disease. The bone becomes softened, and by molecular disintegration, caused by action of the granulations, it becomes porous and honey-combed. Numerous miliary nodules can be seen in the affected area, which, in the course of time, imdergo coagulation necrosis and caseation. In long-standing cases the destruction of bone is so extensive that in the hip-joint, for instance, it may result in the loss of the entire head of the femur and perforation of the acetabulum. Symptoms and Diagnosis. — The s5'mptoms var^- according to the type of the disease and manner of infection. With the exception of circumscribed points of tenderness outside of the region of the joint that indicate the existence of primar}" osteo-tuberculosis, we haA^e no s^-mptoms which enable us to make a positive diagnosis between a primary- osteal and a primary synovial tuberculosis of a joint. The primary osteal form is the most common. In the knee the proportion of the primary osteal to the primar}' sj-novial form is in the proportion of 3 to 1 ; in the hip, 4 to 1 ; in the elbow, 4 to 1. As to age, the propor- tion is, in children below 15 years of age, 2 to 1 ; above 15, 3 to 1. In refer- ence to the location of the joints affected, it can be said that joint tuber- culosis is much more frequent in the lower than in the upper extremities. According to Albrecht, out of 325 cases, in 91 the disease affected the joints of the upper, and in 234 those of the lower, extremities. I. Swelling. — In the atrophic form of plastic s^'novitis, the caries sicca of Yolkmann, so common in the shoulder-joint, there is not only 512 PRINCIPLES OF SURGERY. no swelling, but the region of the joint may even be found atrophied from muscular atroph3^ The absence of swelling and the presence of considerable mobilit}' in the joint ma}' lead to a wrong diagnosis under the impression that the affection is a neurosis. A careful examination under the influence of an anjBsthetic will, however, reveal restriction of mobility from cicatricial contraction of the tubercular capsule, which will enable the surgeon to make an early and correct diagnosis. The swelling resulting from tubercular hydrops and abscess is caused exclu- sively by distention of the capsule with fluid, as the capsule in either case is but little thickened and the granulations are scanty. In both of these conditions the capsule of the joint is often enormously' distended. In the knee-joint the patella is raised from the condyles of the femur, and the depression on each side of it, present in a normal condition in the extended position of the liml), is not only effaced, but replaced b^^ a well-marked prominence. Fluctuation is distinct. In the dry, fungous variety of sj-novitis the swelling is due to the masses of granulation tissue Avithin, and, after perforation of the capsule lias occurred, within and outside of the joint. This is the most common of all the forms of articular tuberculosis. The old authors were of the opinion that the oedema in the neighborhood of a white swelling was due to expansion or enlargement of the articular extremities of the bones, until Samuel Cooper pointed out that it was caused by thickening of the capsule. The granulation tissue is often present in such abundance as to give rise to considerable distention of the joint, and, in the knee-joint, elevating the patella from the condyles of the femur to such an extent that the contour of the joint simulates an effusion into that articulation. The granulations are so soft that on palpation in these cases fluctuation can be distinctl}^ felt, especiall}' if the capsule of the joint is very thin from overdistention or destructive changes. To ascertain the character of the contents of such a joint, it is usually necessary to resort to an ex- ploratory pinictnre. The invasion of the para-articular tissues causes considerable swelling in the region of the joint, imparting to the latter the characteristic spindle shape so frequently found in the knee-, elbow-, and ankle-joint, the swelling being so much the more conspicuous when atrophy of the muscles above and below has taken place. Extension of the infiltration from the para-articular tissues in the direction of the subcutaneous tissues finall}^ causes the swollen joint to be covered with a whitish, immovable, dense skin, giving the joint the appearance from which the time-honored name of white sivelling was derived. If a peri- articular abscess appear tlie swelling of the joint is generally diminished, while a new swelling forms in the vicinity or some distance from the joint. TUBERCULOSIS OF JOINTS. 513 2. Pain. — Pain, as a s3'raptom accompan^-ing tuberculosis of joints, altliougli always present, is of extremely variable intensity'. In some cases it is so sliglit that patients will continue to use joints distended with masses of fungous granulations without much suffering, while in other instances a limited disease in the joint will cause complete dis- ability^ and a great deal of suffering. According to ni}^ observation, the pain is usually more severe in cases where the granulations are scanty than when the synovial membrane is the seat of extensive fungosities. As a point in ditlerential diagnosis, it may be said that in osteal tuber- culosis pain is present from the beginning in the bone, and is not much aggravated In' the joint disease ; while an almost painless primar}' syno- vial tuberculosis is attended b}' severe pain, with nocturnal exacerbations as soon as the S3'novial membrane and articular cartilages have been de- stroj'ed and the bone has been secondarily implicated in the inflamma- tory process. Absence of tenderness awa}' from the joint and its pres- ence in the line of the joint would indicate rather a primary tuberculosis than the osteal variet}'. In primary synovial tuberculosis in the hip- joint the pain is located in the joint and the groin ; while in the osteal form, during the early stage at least, it is usuall}^ referred to the inner aspect of the knee. 3. Deformity. — Contraction, lateral deviations, subluxations, and other abnormal positions usuall}' indicate more or less destruction of the articular surfaces of the bones and lateral ligaments. These malposi- tions are not seen in articular tubercular hj'drops or the milder forms of synovial tuberculosis, while we find different degrees of one or more of them nearl}' in every case of advanced fungous synovitis. In advanced cases of synovial tuberculosis of the knee-joint the joint is flexed, the leg rotated outward, and the head of the tibia displaced backward. In the hip-joint the disease gives rise to flexion of the thigh upon the pelvis, and first eversion, but later inversion, of the limb. After separation of the head of the femur, or extensive destruction of the articular end of this bone and the acetabulum, the contour of the region of the hip-joint and the position of the limb simulate dislocation of the head of the femur upon the dorsum of the ileum. Tubercular disease of the elbow-joint gives rise to flexion and pronation of the forearm. The clinical impor- tance of au}' of these displacements lies in the fact that the}' signifv a certain amount of destruction of the joint structures, thus often indi- cating surgical interference for the correction of the deformity, as well as the removal of the diseased tissue. Remembering the frequency' of tubercular affections of joints, as a rule, there is little difficulty in their recognition, if the historj-, course, and S3'mptoms are carefull}' studied and analyzed. Konig justly remarks that it is well to remember that 514 PRINCIPLES OF SURGERY. articular tuberculosis, even if the disease affect a large joint, is practi- cally a local disease, and has for a long time little or no influence on the general health of the patient. Thus, we may find patients presenting all the appearances of robust health suffering from articular tuberculosis. The tubercular articular hydrops is distinguished from a catarrhal or rheumatic synovitis with copious effusion b^- its persistency and tendency to return after aspiration or after active use of the joint. The presence of flocculi or rice-bodies in a joint confirm the tubercular nature of the affection. A tuberous S3'novitis, witli the formation of a single mass of fibrous tissue, sessile or pedunculated, might l)e mistaken for lipoma arborescens or gummata. The diagnosis of the latter will be cleared up b}' a course of antisyphilitic treatment, which should alwaj's be insti- tuted in cases of doubt. Tubei'cular joint abscess is distinguished from suppurative, gonorrlioeal, or rheumatic synovitis b}' the pain being less and the absence of all signs of acute inflammation. The local condi- tions in fungous synovitis are so characteristic that they can hardly be misinterpreted by a careful observer. The presence or absence of fluid in the joint has often to be determined by an exploratory puncture. The caries sicca of Yolkmann, or dry, pannous, h3'perplastic sjniovitis of Hueter, especially as found in the shoulder-joint, might be mistaken for a neurosis, with atrophy of the muscles covering the joint. The differ- ential diagnosis can be made b}' making the examination while the patient is fully imder the influence of an anaesthetic. If the affection is a neurosis, motion will be found unimpaired ; if it is tubercular, the mobilit}' of the joint will be found lessened by intra-articular adhesions and cicatricial contraction of the capsule of the joint. Prognosis. — Tuberculosis of a joint may terminate in a spontaneous cure in cases in which the intensity of the infection is slight, or the resistance on the part of the patient is so great that the fungous granula- tions do not undergo degenerative changes, but are converted into connective tissue. A partial or complete S3mechia of the cavity of a joint is often one of the unavoidable results in such cases, leaving the joint in a permanently stiff condition. This endeavor on the part of the organism to limit tlie extension of the disease is often observed in cases in which the joint affection occurs in connection with osteal tubercu- losis. As soon as perforation of a focus into a joint iias occurred a wall of granulation tissue is tlirown out around the circumscribed area of infection, and, under favorable circumstances, a partition of cicatricial tissue is formed which isolates the infected from the intact portion of the joint. In such instances we haA^e an illustration hoAv the tubercular process is retarded, and sometimes permanently' arrested, by the trans- formation of granulation into connective tissue. For such a favorable TUBERCULOSIS OF JOINTS. 515 termination to take place it is necessary that the tubercular virus should be attenuated by age or want of a proper nutrient medium, or that the pathogenic effect of the bacilli should be neutralized b_y an adequate resistance on the part of the tissues before degenerative changes have occurred in the granulation tissue. The course of articular tuberculosis is so variable in difterent cases that it is impossible, during the earlj' stages of an attack, to predict anythiug certain iu reference to the probable outcome. A spoutaneous cure is more likely to take place if the patient is joung, not aujemic, and, at the same time, well nourished. The hj^gienic surroundings must also be taken into consideration in rendering a prognosis. The disease shows greater tendencies to limita- tion in children than in persons past the age of puberty. Amoug the differeut forms of joint tuberculosis the tubercular hj'drops and caries sicca are the most benign, and in these cases a spon- taneous cure is most frequentl}' renlized and the same conditions are effected, and which are also amenable to successful surgical treatment. The caries sicca ma}', according to Kdnig, terminate in a spontaneous cure in two or three j-ears, with some loss of motion in the joint. It is sometimes difficult to ascertain in a given case when the lesion can be considered as cured. As the most reliable evideuces that such favorable termination has taken place must be considered disappearance of swell- ing, pain, tenderness, and restoration of function as far ns this can be expected. The patient should not be permitted to use the limb until the active symptoms of inflammation have disappeared. The danger to life arises from the existence of complications, foremost among them being septic infection, pulmonary or general tuberculosis, and amyloid degen- eration of im})ortant internal organs. Septic infection is caused either hy localization of pus-microbes brought to the tubercular focus through the circulating blood, or, what is more frequently the case, through an infection-atrium, created by a spontaneous opening through an operation wound, or, finall}', through a fistulous communication with the joint. Many neglected cases of joint tuberculosis die annuiilly of pulmonary or general tuberculosis. Billroth states that in sixteen j-ears 27 per cent, of bone and joint tuberculosis were lost in this ^vay. Konig, from a table of in operations for tuberculosis, found that after four years 16 per cent, had died from general tuberculosis. If a patient escape death from septic infection, after secondary infection with pus-microbes, he is liable to succumb several years later to amyloid degeneration of the spleen, the liver, and especially' the kidneys, with its accompanying anasarca. Treatment. — As spontaneous cure in cases of joint tuberculosis is more frequently the exception than the rule, and if finally' it does take 516 PRINCIPLES OF SURGERY. place it does so generally after the limb has become so much deformed that it has become useless and will require a formidable operation to restore partial function, it is evident that timelj- surgical treatment should be adopted to eradicate the disease, preserve function, and, at the same time, protect the patient as far as can be done against general infection. I. Rest. — As in cases of osteo-tuberculosis, rest is an important ele- ment in the treatment of tubercular joints. It is even more important to secure rest for an inflamed joint than for an inflamed bone, as the inflam- mation is alwa3's greati}' aggravated b}' the movements in the joint that necessaril}' take place as long as the joint is used, which does not appl}' with equal force to cases of osteo-tuberculosis. The best method to fulfill this indication is to immobilize the limb in a plaster-of-Paris splint, "which does not necessarily confine the patient to his room or bed. If one of the lower extremities is to be encased in a plaster splint, I am in the habit of applying the plaster-of-Paris roller over tight-fitting knit drawers, which protect the skin much better than an ordinary roller bandage. All bony prominences should be protected against pressure b}' careful padding with absorbent cotton. If the hip-joint is the seat of inflammation the splint is applied with the limb in the extended posi- tion, while the patient stands on the sound limb upon a low stool, as in this position autoextension is made by the weight of the suspended limb. In such cases the splint must extend from the toes and embrace the entire limb, the whole pelvis, and abdomen as far as the umbilicus, and the opposite limb as far as the knee-joint. In tuberculosis of the knee- joint the s[)lint should extend from the toes to the groin, and, in ankle- joint affections, from the toes to the knee-joint. Immobilization is to be made with the limb in such a position that in case the joint should be- come permanently stiff the limb can l)e used to greatest advantage. A slight degree of flexion in the hip- and knee- joint is to be preferred to a perfectly straight position. In inflammation of the shoulder-joint the limb makes the necessary counter extension and fixation of the joint by confining the limb, with the forearm flexed, at right angles to the side of the chest, bj' strips of adhesive plaster or a plaster-of-Paris bandage. The hand should be slightl}^ extended in immobilizing the forearm in the treatment of tuberculosis of the Avrist, Avhile the forearm is flexed at a right angle to the arm in tubercular synovitis of the elbow-joint, with the band in position half-waj' between pronation and supination. Early im- mobilization of a tubercular joint not only secures absobite rest for the joint, but, at the same time, this treatment i)revents to a great extent subsequent deformities. Treatment by immobilization should be con- tinued until all symptoms of inflammation have subsided, or until more TUBERCULOSIS OF JOINTS. 517 radical measures become necessary. If the arthritis has already' resulted in contractures the treatment by extension with weight and pulley is in place, and should be continued until the limb has been brought in proper position for treatment b^' immobilization. 2. Aspiration. — In tubercular hydrops the intra-articular effusion is often ver}- copious, resulting in enormous distention of the capsule of the joint, which, if continued for an3' length of time, must necessaril}' result in great weakening of the joint. Aspiration under these circum- stances relieves the distention and places the vessels in the s^'novial membrane in a better condition to perform their function in the subse- quent removal of the inflammatory product b}' absorption. After evacua- tion of the contents of the joint the limb should be immobilized and rapid re-accumulation of the fluid prevented by uniform, equable com- pression of the joint by strijis of adhesive plaster or rubber bandnge. 3. Subcutaneous Evacuation of Contents of Joint, followed by lodoformization. — In tubercular hydrops and abscess of a joint, subcu- taneous evacuation of the fluid contents, followed by iodoformization practiced in the same manner as has been described in the treatment ol' tubercular abscess, yields much more satisfactory results than simple aspiration. In tubercular hj'drops irrigation of the joint with a 3-per- cent, solution of boric acid is onl}- necessary for the removal of rice- bodies ; if such are not present, the iodoform mixture maj- be injected at once. Tubercular abscess always requires a preliminary irrigation with some mild antiseptic solution, for the purpose of removing detached and disintegrated tubercular products before the iodoform mixture is injected. Krause, in the last eighteen months, treated 43 tuljercular joints by means of iodoform injections; cases were treated by other means, and where cure without operation seemed imi)ossible, but in wiiich fistulse were not yet formed. The injections were repeated at intervals of two or three weeks. Pain was greatly relieved by this treatment ; the swelling j'ielded much more slowly, though in six weeks some cases showed a reduction in size and a hardness of the affected parts. The abscess-cavities frequentl}' filled again, rapidl3' at first, but ultimately re-accumulation ceased. In some cases fistulse formed at the seat of puncture, which first discharged pus, then serum, but ultimately healed entireh". In a fair percentage treated in this way definitive healing was obtained. This treatment promises the best results in cases where granulation tissue is scant}', and where the inflammatorj' product has not undergone extensive caseation. Its utilit}' is much impaired if suppu- ration has taken place in the joint. Billroth opens the joint, evacuates its contents through the incision, removes (if present) tubercular sequestra, rice-bodies, and tubercular meml)ranes, and then treats the 518 PRINCIPLES OF SURGERY. joint by iodoforniization. In general practice, however, it is much safer to follow tlie subcutaneous method by puncturing the joint with a medium-sized trocar, using the canula for evacuation, irrigation, and iodoformization. 4. Arthrectomy. — Excision of the infected tissues in primary tuber- culosis of the synovial membrane has been practiced for a number of 3'ears, and the results of this treatment have been quite encouraging. Primary synovial tuberculosis, without any foci in the articular ends of the bones, should be treated by arthrectomy and not by resection, as by the former operation the diseased tissues can be removed effectually without unnecessary loss of healthy tissues that are sacrificed b}' the latter operation. The success of an operation for tubercular affections depends largely upon the thoroughness with which the operation is done and the absence of suppuration. Arthrectomy should be performed before fistulous openings have formed, and the joint must be opened by an incision that will expose every nook and corner of the capsule. Of the many incisions that have been devised for opening the knee-joint, the one I shall describe here offers the greatest advantages and is open to the least objections. The old-fashioned horseshoe incision, with the convexity directed downward, makes it very difficult to suture the wound, and leaves a scar where it is most exposed to injur3% The incision carried directly across the knee-joint, if the patella is divided at the same time, leaves, subsequentl}', the superficial and deep parts of the wound directly opposite; if the patella is preserved, the scar of the external incision falls upon the most prominent part of the patella, which is again a great disadvantage. The incision, which for several 3'ears I have alwa3's selected in opening the knee-joint in performing arthrectomy or resection, is slightl3' curved, but with the convexity directed upward. It is carried from the most dependent portion of the knee-joint, at a point corresponding to the most prominent part of the internal condyle of the femur, in a gentle curve to the upper border of the patella, and from here downward and outward to a point opposite Avliere it was com- menced. The short, semilunar, cutaneous flap is now detached and turned downward. After this an incision is carried directh' 'across the joint, dividing the lateral ligaments and crossing the patella transversely at its centre. The patella, at this step of tlie operation, is divided with a saw. The upper recesses of the synovial sac are freely opened b3' making an incision on each side of the upper half of the patella, which is carried as far as the upper recess of the S3'novial sac. The rectangular flap, composed of the upper end of the patella with its muscular attach- ments, is reflected, which exposes ever3' portion of the upper part of the sj'novial recess. A somewhat similar flap is made of the lower half of TUBEKCUL06IS OF JOINTS. 519 the patella and its tendon, reflected in a downward direction, b}- which the tissues underneath that portion of tlie patella and its ligament are fully exposed. Witli the knee-joint thus exposed it is not diflicult to extirpate, with the help of a catch-forceps, a siiai-p scalpel, and a pair of curved scissors, the entire capsule. The part of the capsule that will be found most difficult to remove is that portion which covers the popliteal vessels, and dips down behind the condyles of the femur and behind the tuberosities of the tibia. During this part of the operation the leg must be forcibly flexed over a small cushion, or the fist of an assistant, in the popliteal space. Arthrectomy is always a tedious operation, as it is absolutely necessary- to remove all of the infected tissues in order to secure permanent success. If the patella is not diseased it should never be removed. After the capsule has been extirpated the patella is united by two chromicized catgut sutures, I have never failed in obtaining bony union in four to six weeks after this method of coaptation. After extirpation of the capsule, and before the elastic constrictor is removed, the whole surface should be once more irrigated with a hot solution of corrosive sublimate (1 to 1000), after which it is rubbed off" with dry iodoform gauze, in order to remove any detached fragments that have not been washed away. The whole surfece is now freely sprinkled with impalpable iodoform, which is rubbed into the surface. Before the con- strictor is removed the wound is packed witli aseptic gauze, the flaps are hiid over it, and manual compression made for five to ten minutes after the removal of the constrictor, with the limb in an elevated position. This simple procedure serves an admirable purpose in controlling capil- lary haemorrhage, and reduces the necessit}' of recourse to ligature to a minimum. After all the bleeding has been arrested, the patella is sutured, and the deep parts of the wound are united b}' buried sutures. Tubuhir ilrain- age can usually be dispensed with, as a capillary drain composed of a few threads of catgut will answer an excellent purpose, and will not, like the tubular drain, necessitate an early change of dressing. The external in- cision is closed with silk sutures, the line of suturing being out of the way of the patella, the parts united with the buried sutures being covered throughout by the external flap. A careful hoemostasis and rigid anti- septic precautions will make it unnecessary to change the dressing earlier than the end of the second week, and on this account I prefer to immo- bilize the limb in a plaster-of-Paris splint applied over a copious antiseptic dressing. The limb must be kept in an elevated position for at least six hours after the operation, so as to diminish the amount of parenchj^ma- tous haemorrhage. If all the infected tissues have been removed and the wound remains in an aseptic condition, the external wound will be found 520 PRINCIPLES OF SURGERY. closed in the course of two or three weeks. A fair restoration of func- tion with partial mobility of the joint can be expected in favorable cases. Passive motion must be delayed until the patella has firmly united, which will require from three to four weeks in children and nearly twice this length of time in adults. After the patella has united and the external wound is completely healed, recovery is hastened by passive motion, massage, and use of the faradic current. Arthrectoni}' has a future in the treatment of primary synovial tuberculosis of the knee-joint, but for well- known anatomical reasons it is not equally applicable in the treatment of synovial tuberculosis of any otlier of the larger joints. It is possible that the operation will be modified and sufficiently perfected in the future so as to be applicable in the treatment of synovial tuberculosis of the hip- and shoulder- joint. In 2 cases of tuberculosis of the elbow-joint I obtained an excellent result from arthrectomy combined with temp()rar3^ resection of the olecranon process. This process was divided obliquely with a saw at its junction with the shaft of the ulna, and, after the extirpation of all of the infected soft tissues of tlie joint, the process was fastened in its proper place witli an aseptic ivory nail. The functional result was satisfactor3^ 5. Atypical Resection. — The incision in atypical and typical resec- tion of the knee-joint should be the same as has been described above. The patella is divided transversel_y, and, if it does not contain a tuber- cular focus, it is not necessary or advisa])le to remove it, as its conti- nuity, after resection, can be restored by suturing with a durable form of catgut. An at^-pical resection consists in the removal of tubercular foci in the epiphyseal extremities of the bones that enter into the forma- tion of the joint, without removing the entire articular extremities by a transverse section with the saw. The unnecessarj- removal of the epiphyseal extremities should especially be avoided in the case of chil- dren, as the removal of one or both centres of growth of bone will result in so much shortening of the limb subsequenth^ as often to render it not onl}^ perfectly useless, but it becomes a burdensome appendage. In children atypical resection should be practiced in all cases where all the foci in the articular extremities can be reached and removed b}^ this method. The proper instruments to be used in this operation are the chisel, bone-forceps, and sharp spoon. After the joint has been freely opened, the articular surfaces are carefully inspected for evidences of deeply-seated foci. If perforation into the joint has taken place, the cavit}- is free)}' exposed from the articular surface, and all of the infected tissues are removed with chisel and sharp spoon. It is important not onlj'^ to remove necrosed bone, granulation tissue, and caseous material, but also the surrounding osteoporotic zone of bone that possibly might TUBERCULOSIS OF JOINTS. 521 contain tubercle bacilli. A deep-seated focus may be suspected and searched for if the articular cartilage has become detached over a gretiter or less extent. Explorations with a small perforator can be made in different directions from the articular surface in searching for deeply- seated foci. If the articular cartilage has become detached over a con- siderable area by granulations underneath it, it should be removed, and the exposed bone must be subjected to another careful examination for the purpose of locating and treating deepl}' seated foci. A circumscribed area of great vascularit}' is a suspicious indication, and calls for a lim- ited excavation with a small, sharp spoon for diagnostic purposes. It is well for the surgeon to remember that primary osteo-tuberculosis with secondary involvement of a joint usually consists of more than one focus in one or both epiphyseal extremities. A tubercular infarct is generally recognized b3' examining the articular surface, as the cartilage or the exposed portion of the wedge-shaped sequestrum presents ap- pearances of necrosis that cannot be mistaken. After the extraction of the sequestrum the tubercular cavity- is submitted to the same treatment as when dealing with a granulating or caseous focus. In primary' syno- vial tuberculosis, with extension of the disease to the subjacent bone, it becomes necessar}- to remove the honey -combed, softened bone over tlie entire surface with the sharp spoon and chisel. Before the operation is extended to the bone in osteo-tuberculosis, it is always necessary first to extirpate with knife and scissors the infected soft structures of the joint, the synovial membrane and ligaments, as otherwise the healthy vascular bone may become an infection-atrium for traumatic infection, — a not ver}- infrequent and serious complication after oi)erations on bones and joints for tuberculous affections. Wartmann, after giving a careful account of the results following- excision of tubercular joints in the hospital practice of Feurer, gives the statistics of 837 cases of excision of joints for tuberculosis from the practice of difTerent operators. Of this number 225 died. Of the fatal cases, in 26 death followed the operations closelj', and resulted from acute tuberculosis, probably induced 1)\- the operation. Konig observed 16 cases in his own practice in which miliary tuberculosis followed almost immediately after operations on bones and joints for tubercular affections. Konig states that the secondary infection sets in seven to ten days after operation, which may have lieen perfectly aseptic, with healing of the wound by primary union. The secondarv tubercular infection appears either as an acute pulmonar}- tuberculosis or tuber- cular meningitis, terminating in death three or four weeks after the operation. It is not difficult to conceive the modus operandi of such an occurrence. The resection wound opens numerous veins in the bone, 522 PRINCIPLES OF SURGERY. the lumina of which remain patent, ready for the introduction of minute fragments of granulation tissue or bacilli, which, on entering the venous circulation, are the direct cause of metastatic tuberculosis in distant organs. We must take it for granted in such cases that a tubercular focus, during the operation, furnished the essential infected fragments of granulation tissue, or free, bacilli are aspirated or forced into the openings of wounded vessels, and through them gain entrance into the general circulation. To guard against such an accident, it is necessary to remove from the joint all possible source of infection before operat- ing on the articular extremities^ Cartilage that remains firmly attached to the bone may be left. After all foci have been radically eliminated, the field of operation is flushed with an antiseptic solution, and, after drying and iodoformization, the bone-cavities are packed with decalcified antiseptic bone-chips, and the operation is completed in the same manner as in arthrectoni}'. The treatment of bone-cavities with decalcified bone-packing is of the greatest utilit}- in atypical resection. An at3'pical resection with subsequent implantation of decalcified bone has for its objects complete removal of the infected tissues in the joint and the surrounding bone, and the partial restoration of the parts destro^'ed by disease or removed during the operation. In at^-pical resection of the knee-joint it is not uncommon that nearly an entire condyle of the femur or tuberosity of the tibia must be removed. In such cases the surgeon aims at bony union between the articular ends of the bones, which is accomplished in the most satisfactory manner by placing the parts in a condition to repair the lost bone-tissue, which ma3' be done by filling the defect with decalcified bone-chips. I have repeatedly made excavations in one of the condyles of the femur and in the head of the tibia from the joint surface, the size of a small orange, and obtained bony ankylosis, with the limb in a good position, b3' filling the cavities with bone-chips. As the bone-chips are always iodoformized before implantation, they serve a useful purpose not only b}' furnishing a temporary scaff"olding for the reparative material, but they constitute a valuable therapeutic measure in the prevention of a local recurrence of the disease in case tubercle bacilli should remain in the cavity or its immediate vicinity. Immobili- zation of the limb after resection should be continued until the process of repair has been completed, which, under tlie most favorable condi- tions, requires from six weeks to two months. Atypical resections are applicable onl}' to certain joints, as the knee-, elbow-, ankle-, and tarsal joint. The elbow-joint is most accessible throngh a long, straight in- cision, and after temporary resection of the olecranon process. At3'pical resection of the ankle-joint can be done tlirough two lateral incisions, TUBERCULOSIS OF JOINTS. 523 with chisel and sharp spoon. In all resections, atypical and typical, ignipuncture is indicated after the excision has been completed, if any portion of the bone is abnormally osteoporotic, as this procedure will stimulate the process of repair, and may prove useful in destroying in- fected tissues, which, from their macroscopical appearance, indicate a heialthj' condition. 6. Typical Resection. — In typical resection one or both articular extremities are sawn across and removed. In the hip-joint it implies the excision of the head, neck, and part or the whole of the greater trochanter of the femur. A typical resection of the wrist-joint means the removal of the entire carpus, with or without the articular surfaces of the radius, ulna, and metacarpal bones. In a typical resection of the shoulder-joint the head of the humerus is removed. In the knee-joint the operation means excision of the articular surfaces of the femur and tibia ; in the elbow-joint, of the humerus, radius, and ulna ; in the ankle, of the tibia, fibula, and astragalus. Typical resections are alwaj-s made for tubercular aftections of the shoulder-, hip-, and wrist- joint. In the re- maining larger joints it is more frequentl}' resorted to in adults than children. In children the operation is limited, with tlie exception of the shoulder-, hip-, and wrist- joint, to cases where the articular extremities are so extensively' diseased that an atypical resection would fail in re- moving all of the infected tissues. Removal of the diseased synovial membrane and ligaments should precede section of the bones with the saw wherever, from the anatomical construction of the joint, tliis can be done. In the hip- and shoulder- joint the liead of the bone must be re- moved first before the soft structures of the joint can be removed. The operation best adapted for resection of the hip-joint is the one devised by Koiiig, b3" w^iich the borders of the trochanter major are preserved. In this operation the section of the bone must be made "with a chisel. Tlie entire neck and head of the femur are removed b}' dividing the bone transversely with a chisel just below the neck, with the exception of the borders of the greater trochanter, which are split off with the same instrument. The capsular ligament is removed as thoroughly as possible, and tlie acetabulum is scraped out with a sharp spoon. Pro- A'ision for drainage must be made in all hip-joint resections. The after- treatment consists of rest in bed upon a smooth mattress, with the limb extended by weight and pulley in an abducted position. After six weeks the patient is allowed to walk on crutches, with a raised sole under the shoe, worn on the opposite side, so that the limb on the resected side makes the necessary autoextension. During the night extension is :ip[)lied for eight mouths or a year, in order to prevent unnecessary shortening. Eversion and inversion of the limb while the patient is in 524 PRINCIPLES OF SURGERY. bed are prevented either by a Volkmaim railway-splint or by support- ing the limb with sand-bags, applied to each side. Immobilization, after resection of the shoulder-, elbow-, wrist-, knee-, and ankle-joint, is best secured in a plaster-of-Paris dressing, which also serves an excellent purpose in keeping the antiseptic dressing in situ. Temporary resection of the olecranon process in resection of the elbow-joint h;ts yielded excellent results in my hands, as by it the inser- tion of tlie bieei)s muscle is not disturbed. The resected olecranon, after tlie removal of an}' foci it may contain, is riveted to a denuded surface of the shaft of the ulna with a sterilized ivory or bone nail after the resection has been completed. The forearm is immobilized in a semi- flexed position until bone union between the ulna and olecranon process has taken place, which usually requires about six weeks. After this time passive motion and massage should be made to increase the mobilit}' of the joint. A straight, single incision upon the dorsal side is best adapted for resection of the wrist-joint, as the extensor tendons of the hand and fingers can be drawn aside sufficiently to afford ample room for the removal of the entire carpus. In the after-treatment of excision of the wrist the forearm and hand as far as the metacarpo-phalangeal joints are encased in a plaster-of-Paris splint, with the hand in a slightly- extended position. Immediate fixation of the resected ends by means of bone or ivory nails, after excision of the knee, is superfluous, as the parts can be kept in accurate position by ordinar}' fixation dressing. In knee-joint resections the section through the bones must be made in such a manner that when the sawn surfaces are brought in apposition the leg will be slightly flexed, as this position enables the patient to walk more gracefuU}' than with a straight, stiff" limb. The artificial support must not be removed until firm bony union has taken place, which will require from two to three months, according to patient's general health and age. 7. Amputation. — -Amputation must be reserved for cases presenting special indications. It is the onl}' operation that promises any benefit if the patient suffer from tuberculosis of other organs, -provided the general conditions furnish no positive indications. It is also indicated if a tubercular abscess has perforated the capsule of a joint and has extensively infiltrated the surrounding tissues. This condition is to be expected if the limb has become oedematous some distance from the joint. Tlie flaps must be taken from the side of the limb where the skin is in the best condition, and the incision through the deeper tissues must be made through health}- tissue. It is astonishing how rapidly wounds heal, and how quickly patients will recover after amputations for exten- sive local tubercular processes, even in patients greatly emaciated by the disease. CHAPTER XXI. Tuberculosis of Tendon-Sheaths, etc. tubercular tendo-yaginitis. Tuberculosis of the tendon-sheaths, or, as Hiieter termed this affec- tion, tendo-vaginitis granulosa, has onlj- been recently' recognized and described as a primarj' local tuberculosis. Pathology. — Hueter -was of the opinion that this affection is seldom met with as a primary lesion, but that it appears usuall}' as a complica- tion of joint tuberculosis. As a secondary' lesion it is a frequent con- comitant of osteal and synovial tuberculosis b}^ direct extension of the inflammation from the primary focus to tendon-sheaths. Yolkmann gave an able and accurate description of tendon-sheath tuberculosis in 1875, but at that time he was not aware of its tubercular nature. The first scientific treatise on this affection came from the clinic at Gdttingen by Riedel, who showed that the rice-bodies so commonly found in the so- called fibrinous h3'drops of the tendon-sheaths, or h3'groma of the flexor tendons of the hand, always indicated a synovial tuberculosis. Another important paper on the same subject was published b}' Beger, who re- ports 4 cases that occurred in the clinic at Leipzig. The chronic tendo- vaginitis, or compound ganglia of the old authors, has been shown to be, on careful clinical observation, microscopic examination, and bacterio- logical research, cases of local tuberculosis. The extension of tubercular processes along tendon-sheaths from a tubercular joint after perforation of the capsule has, for a long time, been known to occur, but as > primary lesion it has onl^' recently been added to the long list of surgical lesions of a tubercular character. As compared with other tubercular affections, primar^^ tendon-sheath tuberculosis is quite rare, as it consti- tutes only 1 or 2 per cent, of the cases in the statistics of local tubercu- lar lesions. "When this affection occurs primarih' and independently of tuberculosis of an adjacent bone or joint, infection with the bacillus of tuberculosis takes place b}^ localization of floating microbes in some small vessel, and subsequently the pathological processes in the tendon- sheaths resemble those of tubercular joints. In some cases the products of the disease are massive granulations that occupy- the inner surface of the tendon-sheaths ; in others the irrnn illations are less .nbundnnf. but (5-25) 526 PRINCirLES OF SURGERY. u co[)ioiis synovuil exudntion is thrown out; while in a third class the i^ran Illations form hard, white masses, the so-called corpora orijzoidea, which either remain attached to the inner surface of the sheath, or, after their separation, are found as loose bodies. In the form of tendo- vaginitis which corresponds Avith the fungous variety of tul)ercular synovitis, the granulations form a layer of from 1 to 4 lineB in thickness upon the inner surface of the sheath. The tendon itself is covered with a, somewhat thinner layer of granulation tissue, the granulations pene- trating the substance of the tendon between the bundles of connective- tissue fibres, "where, b}- absorption and pressure atrophy, they cause extensive destruction of tissue. In this manner the tendon becomes so much weakened that it ruptures on the slightest traction, or, if the dis- ease has progressed still farther, the loss of continuity becomes complete without a trauma. The intrinsic tendency of the disease consists in progressive extension by continuity of structure along the course of the tendon primarily affected, and when this tendon is part of a compound tendon the disease gradually creeps from tendon to tendon until all the sheaths are involved. As this affection is met with most frequently in the tendon-sheaths surrounding the carpus, and as these sheaths are not infrequently in direct communication with the wrist-joint by means of small synovial sacs, it extends to tlie joint by continuity of surface. When no such direct connection exists between the tendon-sheath and the subjacent joint, tlie joint may become secondarily involved after the granulations have perforated the capsule. Next to the region of the wrist-joint the tendo Achillis, the patellar, and other tendons about the knee-joint are most frequently affected. In tuberculosis of the sheaths of the tendons of the deep flexors of the fingers the swelling is often large, extending from the lower portion of the palm of the hand under- neath the annular ligament to the middle of the forearm. Underneath the annular ligament the swelling is constricted by this structure, which gives rise to considerable bulging in the palm of the hand and over the lower anterior aspect of the forearm. The fluctuating wave can be dis- tinctly felt above and below the annular ligament, showing that the two swellings are in direct communication. The tubercular product under- goes the same pathological regressive changes as in synovial tuberculosis. If a sufficient number of tubercle bacilli is present in the granulation tissue the cells are destroj^ed by coagulation necrosis and caseation, tlie fungous masses breaking down into an amorphous, granular detritus. At this stage perforation of the tendon-sheath may take place in an out- ward direction, and a subcutaneous tubercular abscess develops. If such abscess open spontaneously, or is incised without regard to antiseptic precautions, infection with pus-microbes will lead to acute suppurative TUBERCULAR TENDO-VAGINITIS. 5^7 inflammation, ■which Avill often result disastrously from rapid extension of tiie phlegmonous inflammation and septic infection. The occurrence of rice-bodies in tendon-sheath and synovial tuberculosis can be traced to a specific action of the bacillus of tuberculosis on the tissues. Kdnig attributes to this bacillus i)roperties which place it among the agents that produce fibrinous infiammation. The rice-bodies in the tendon- sheaths, the seat of a chronic inflammation, he considers as the product of a fibrinous inflammation caused by the action of the bacillus of tuber- culosis. Nicaise, Poulet, and Villard examined 4 cases of hygroma con- taining rice-bodies, and found in all of them the bacillus of tuberculosis. Symptoms and Diagnosis. — Tuberculosis of the tendon-sheaths is an exceedingly chronic atlection. The disease is not painful, and patients often continue to follow their occupation after a number of tendons have become involved and the swelling has reached considerable dimensions. The swelling increases in length in the direction of the tendon first aflfected, and if the disease extend to neighboring sheaths it branches out in the direction of the tendons aflfected. In 9 out of 10 cases it attacks a flexor or extensor tendon in the region of the wrist-joint, and then extends upward and downward in the direction of the tendons. In tubercular hj-drops of the tendon-sheaths the swelling often attains great size. In one such case I found the palm of the hand the seat of a swelling, the size of a large orange, that communicated Avith a smaller swelling above the annular ligament of the wrist-joint. In the fungous variet}' the swelling imparts to the palpating finger a semi-elastic resist- ance, and fluctuation is either entirel}- absent or not well marked. The disease often extends to the middle of the forearm, and in this locality' attacks the muscular tissue in the same manner as the tendons farther below. Extension to a joint is attended by symptoms that point to synovial tuberculosis. Tlie symptoms are so characteristic that a correct diagnosis can often be made on first sight. The only aflTections that must be excluded are the ordinary ganglion of tendon-sheaths and acute plastic tendo-vaginitis. A ganglion alwa3'S remains as a circumscribed swelling without manifesting any tendencies to extend. The contents of a ganglion are a gelatinous mass, of the color and consistence of clarified hone}'. After evacuation of the sac no swelling remains, as the cyst-wall is not much thickened. A plastic tendo-vaginitis, resulting from injur}' or overexertion, is an acute aflfection not attended by much eff'usion or inflammatory exudation. The tendon-sheath is abnormally dry, giving rise to friction-sounds which can be plainly felt and often heard ns the tendon moves within the inflamed and roughened sheath. Prognosis. — Spontaneous cure is the exception, progressive exten- sion the rule. The danger from regional extension arises from the 528 PRINCIPLES OF SUKGERY. tendencies of tlie disease to invade adjacent joints, and to extend from tendon to tendon, and finally along these to the respective muscles. There is no reason why, occasionally at least, tendon-sheath tuberculosis should not be followed by pulmonary or general tuberculosis in conse- quence of secondary infection. Treatment. — The nse of external applications, compression and aspiration, are of doubtful utilit}' in the treatment of this aflection. Sub- cutaneous evacuation, followed by iodoformization, promises more, especiallj^ in cases of tubercular h3'drops Avith few or no rice-bodies. As the rice-bodies contain the essential cause of the disease, it will usually be found necessary to remove them in order to effect a permanent cure. Removal of tliese bodies, as well as extirpation of the gniiuihition tissue, can only be accomplished by a radical operation. A radical operation has for its object the removal of all of the infected tissues, which means extirpation of the tendon-sheath and erasion of the granulations that have invaded the tendon. No operation should be undertaken unless the surgeon can count with almost positive certainty upon aseptic healing of the wound. Infection with pus-microbes under such circumstances would not only prevent a satisfactory functional result, but would place the patient's life in great peril. Fortunately, this form of surgical tuber- culosis attacks localities where the surgeon has it in his power to obtain, almost with absolute certainty, an aseptic healing of the Avound. Extir- pation of a tubercular tendon-sheath is a tedious and difficult task. The operation must be made with the nicety of a dissection in the anatomical room. A large tenotomy knife and a small pair of curved scissors are the most useful cutting instruments in making the dissection. A number of small tenacula and toothed dissecting forceps are necessary to retract tendons and expose the parts fully to view. Esmarch's constrictor is an indispensable aid, as it renders the parts perfectly bloodless, which enables the operator to identify the parts concerned in the dissection. After the antiseptic precautions have been completed with the greatest care, the limb is rendered bloodless and the tendon-sheath is fully exposed by free external incision, which should reach on both sides a little be^'ond the visible limits of the disease. The tendon-sheatli is now slit open, and the fluid contents are washed awaj' by an antiseptic irrigation. In operating upon the flexor tendons of the hand and fingers, it often becomes necessary to divide the annular ligament, which can be done without fear of impairing the functional result, as, after the opera- tion on the tendon has been completed, its continuity can be restored by a number of separate buried sutures. The large arteries and nerves are, of course, carefull}' avoided. In order to remove the tendon-slieath TUBERCULAR TENDO-VAGINITIS. 529 completely, it becomes necessary to liberate the tendon and to have it drawn out of the way b3' an assistant. The removal of the deep portion of the sheath requires special care, as it often is in close proximity to the underlying joint, which should not he opened unless tlie disease has invaded the capsule deeply. Tlie extension of the disease to the mus- cular tissue can be readily ascertained from the naked-eye appearances of the muscle, which, if aftected, presents a grayish appearance, and is firmer than in a normal condition. If the tendon is extensively infil- trated its size is often much diminished by the removal of the infected portion, which must be done with a sharp tenotomy knife. If several tendons are affected, and access to the more remote ones is rendered im- possible without division of tlie more superficial tendons, these can be divided and again united after the dissection has been completed. I have repeatedh- spent two hours in an operation for tendon tuberculosis in the wu'ist-joint region, and have always felt that the time was well spent, as a hast}' operation is often attended by unnecessary injury to contiguous parts, and is frequently followed by local recurrence on account of incomplete removal of the infected tissue. Should it become uecessar}' to resect a portion of a tendon on account of extensive disease of this structure, restoration of continuit}- must be effected by an auto- plastic operation. The tendon-end most suitable for this purpose is selected. The tendon is cut through one-half at a distance from its cut end which corresponds with the length of the defect, when it is sijlit toward the cut end to within a few lines, and the piece is then laid over the defect and sutured at both ends. After the removal of the infected tissues the wound is irrigated once more with an antiseptic solution, dried, and iodoformized. The deep fascia is united separatel}' with buried sutures, and the skin is coaptated accurateh' with interrupted stitches and the continued suture. A catgut capillary drain is inserted and a copious antiseptic dressing applied. The limb is placed upon a well- padded splint, and, if no indications for a change of dressing arise, the first dressing is allowed to remain from two to tliree weeks, when the wound will be found healed throughout. The functional result is almost always satisfactory if the wound heals In" primary union. Massage and passive motion are instituted as soon as the wound is healed. If the operation is done early and with the necessary care, a local recurrence is not to be expected. For the purpose of illustrating the pathological conditions and the clinical tendencies of this disease, I will briefly' describe one of the man}' cases of tendon-sheath tuberculosis that have come under my observation. This case is remarkable on account of the rapid extension of the disease. The patient was a man 60 years of age, laborer, and addicted to intemperate habits. I examined him. in consul- 34 530 PRINCIPLES OF SURGERY. tation with his l\iniily physician, about four months before the operation was performed. At that time I found an oblong swelling on the dorsum of the right hand, corresponding to the location of the extensor tendon of the index finger. The swelling was not painful, and but little tender on pressure. Fluctuation was well marked ; on deep pressure movable bodies could be distinctly felt, which were recognized as corpora ory- zoidea. An operation was advised, but was declined, as the patient was still able to follow his occupation. The swelling was first noticed six weeks before the examination, but steadily increased in size. Four months later he was admitted into the Milwaukee Hospital, as the pain and the size of the swelling now disabled him from performing manual labor. At this time the dorsum of the hand corresponding to the index and middle fingers and the radial aspect of the forearm as far as the middle presented a continuous swelling, with well-marked fluctuation. The swelling had lately become painful, and was tender on pressure. Under strict antiseptic precautions the swelling was incised in its entire length, and a large quantity of synovia-like fluid and softened rice-bodies escaped. The sheaths of the extensor communis digitorum and exten- sors of the wrist were found lined with a thick la^^er of fungous granu- lations, and near the annular ligament numerous free and attached rice- bodies w^ere found. The tendon-sheaths were careful!}^ dissected out, and the whole wound, after thorough disinfection, was dusted with iodo- form, drained, and sutured. A copious dressing of iodoform gauze and sublimated moss was applied, and the forearm and hand fixed upon an anterior splint. Healing of the wound by primary intention. Almost complete restoration of function. No return after two years, and patient able to perform hard manual labor. Inoculations of the fluid upon potato remained sterile. Cultivation upon coagulated hj'drocele- serum showed, after a few weeks, a scantv culture of the bacillus of tubercu- losis. Implantation of one of the rice-bodies into the subcutaneous connective tissue of a guinea-pig resulted in a tj'pical tuberculosis, starting from the point of inoculation, spreading to adjacent lymphatic glands, and finally resulting, in six weeks, in death from difl"use miliary tuberculosis. FASCIA TUBERCULOSIS. The bacillus of tuberculosis has a special predilection for fascia, and primary localization in this tissue is a frequent occurrence. It is a well- known clinical fiict that, as soon as a deep tubercular focus in a lymphatic gland, bones, or joints has reached the connective tissue outside of the organ primarily affected, the infection travels along the connective tissue, often resulting in extensive destruction of this tissue before the process reaches the surface. The extension of tubercular abscesses along FASCIA TUBERCULOSIS. 531 preformed connective-tissue spaces has been previuusly described. If the tubercular product, when it reaches the loose connective tissue, is composed of living embryonal tissue, the pathological lesions which are later produced in the connective tissue correspond with those of the primarj"^ lesion. The connective! tissue is transformed into masses of granulation tissue, which remains in this state for a long time before it is destroyed by coagulation necrosis, with subsequent cell disintegration. In primary tuberculosis of the fascia the disease often spreads with great rapidity, dipping doAvn between the muscles along the intermuscular septa, and invading from here the muscles themselves. I have seen ;> number of cases during the last few years where the disease originated primarily in the deep fascia of the thigh, resulting in the most extensive regional dissemination in the course of two or three years. In one case, a veteran of the late war, 55 years of age, the disease commenced at a point between the greater trochanter and the crest of the ileum several years before he came under mj^ observation. I found the thigh moder- ately swollen with several prominences from the crest of the ileum to the knee-joint, where fluctuation was quite distinct, I mistrusted a primar}' osteo-tuberculosis, but, on making free incisions at different points, I found no evidences of [)rimary tuberculosis of an^- otlier tissue or organ. The deep fascia and intermuscular septa were found destroyed, and in their place masses of granulation tissue presenting foci of coagu- lation necrosis and caseation invading extensively the muscular tissue. Yolkmann's spoon was freel}' used, but I soon found that this treatment was utterly- inadequate to remove all of the infected tissue, as the deep muscles throughout were extensively- infiltrated. Amputation was out of the question, as the gluteal region as far as the crest of the ileum was so extensively affected that it would have been impossible to obtain a covering for a hip-joint amputation. lodoformization of the enormous spaces made by scraping out the fungous granulations had no effect in arresting further extension of the disease. The patient died, three months later, of general miliary tuberculosis. In a second somewhat parallel case the disease extended from near the knee-joint as far as the trochanter minor. This patient was onh' 25 years of age, and the disease had existed a year and a half. Several incisions had been made, and a number of fistulous openings were found in communication with large cavities between the deep muscles of the thigh. The sinuses were laid open and scraped, and the most careful examination failed in disclosing a primary osteal or tendon-sheath tuber- culosis. The muscles were again found extensively infiltrated and of a graj'ish-white color, and almost of gristl}' hardness on being incised. The operation rather hastened than retarded the progress of the disease, 532 PRINCIPLES OF SURGERY. and I was forced, a few weeks later, to amputate the thigh just below the trochanters. The patient made a slow recovery, but at the present time, two years after the operation, he is in fair health, and there is nothing to point to a local recnrrence. I have learned to regard fiiscia tuberculosis affecting the intermuscular septa of the thigh as an exceedingly grave form of local tuberculosis, and, if at all extensive, only amenable to successful treatment by amputation. TUBERCULOSIS OF MOUTH AND TONGUE. We have now every reason to believe that many cases of ulceration of the tongue, pharynx, and cavit}^ of the mouth, which have been here- tofore diagnosticated and treated as carcinoma, were not carcinoma, but S3'philis or tuberculosis. Professor von Esmarch, in a very able paper, has recentl}' again called attention to the difficulties in the wa}' in differ- entiating between these affections. Pathology. — There is no doubt that man}' reported cases of perma- nent recovery, after removal b^- operation of ulcerating swellings of the tongue, were not cases of carcinoma, l)ut tuberculosis. Lupus of the pharynx and tongue are cases of local tuberculosis. Onh- a few weeks ago I had an opportunity to examine a case of primary tuberculosis of the pharynx occurring in a man 30 years of age. The disease had ex- isted for four months, and involved the posterior wall of the phar3aix, and had extended to the left tonsil. Ragged, deep ulcers had formed, which were covered with flabb}^ yellowish-gray granulations. Numerous minute miliary nodules could be seen in the mucous membrane around the ulcers, and on scraping away the granulations they were also found present in the softened, inflamed tissues underneath the floor of the ulcers. A beginning hoarseness indicated that the disease was extend- ing b}' continuity of tissue to the larynx. Laryngoscopic examination revealed numerous minute nodules, which studded the mucous membrane of the posterior surface of the epiglottis. The recent advances made in the microscopical, bacteriological, and experimental methods of exami- nation have succeeded in separating from syphilitic affections and malignant disease of the mouth and tongue man}' cases that belong to the long list of affections now classified under the head of surgical tuberculosis. Tlie cavity of the mouth is often the seat of slight abra- sions and pathological conditions, which ma}' become an infection-atrium for the entrance of micro-organisms that might be contained in the air we breathe, the food we eat, and the water we drink. Remembering the frequency with which superficial abrasions and ulcerations occur in this locality', it is not strange that primary tuberculosis should occasionally develop here. The tubercle bacillus produces the same tissue changes TUBERCULOSIS OP MOUTH AND TONGUE. 533 here as on the surface of the skin, the primary pathological product con- sisting of granulation tissue undergoing molecular retrograde tissue metamorphosis, followed by ulceration. Ulceration is an earlier occur- rence, and a more conspicuous clinical feature in tuberculosis of the mouth than in sunie other localities, as the new tissue is constantl}^ macerated b^' the fluids with which it is moistened at all times. The tubercular ulcer is generall}^ covered b}' the products of interstitial necrobiosis and superficial coagulation necrosis, which result in the formation of what appears as a false membrane. If this membrane, when present, is removed, the characteristic granulation surface is exposed. The ulcer is surrounded hy a zone of inflammator}' infiltra- tion, which, however, does not present the same feeling of hardness as carcinoma. The most characteristic feature of a tubercular ulcer of the mouth or tongue consists in the presence of minute tubercle-nodules in the margins and underneath the layer of granulations, and, if the infec- tion has extended to some distance, in the surrounding mucous mem- brane. Schliferowitsch has published an exhaustive resume of the literature on this subject to date, and has collected all the recorded cases in which the diagnosis of tubercular disease of the cavity of the mouth could be made with some degree of certaintj-. The cases number 88, and included those of primary and secondary tuberculosis. From a care- ful study of this affection he has come to the conclusion that it occurs seldom in the very young, and that it attacks most frequentl}- persons between 40 and 50 years of age. Symptoms and Diagnosis. — Tuberculosis of the mucous membrane of the cavity of the mouth appears as a flattened, submucous infiltration composed of granulation tissue, which, at an earl3' date, becomes the seat of a superficial ulceration in the centre that rapidl}' extends toward the margins of the swelling. Caseation is seldom observed. The cells are destroA'ed by coagulation necrosis, and as the}^ become detached the defect increases in size. The appearance of the ulcer in this localitj^ is characteristic. If on the tongue, it is found on the borders near the tip of the organ. It appears as an oblong ulcer, with raised, ragged borders of firmer consistence, showing the color of fresh granulations. The ulcer often appears as if covered b}- a pseudo-membrane; if this cover- ing is removed, the surface left easily bleeds. The surface of the ulcer is uneven, as if covered with hypertrophic papillae. The discharge of pus is slight, and, in many cases, miliary nodules maj^ be found around the ulcer. Pain is not as severe as in carcinoma. Lymi^hatic glands ma^' become secondarily' infected, but this is not often the case. In the primary- form of the disease, when a positive diagnosis is most difl3cult, the presence of tubercle bacilli will demonstrate the nature of the ulcer. 53i PRINCIPLES OF SURGERY. A gumma of the tongue, as a rule, develops into a larger swelling than a tubercular affection before ulceration takes place, and the resulting ulcer is more deeply excavated ; at the same time, other evidences of syphilis can usually be detected. Miliary nodules in the immediate vicinit}^ of the ulcer are absent in a syphilitic ulcer, and frequently present in tuberculosis. If any doubt remain as to the differential diag- nosis between these two affections, this should be set aside b}- a course of antisyphilitic treatment before resorting to any serious operation. If the ulcer is s^'philitic it will heal kindly under such treatment, while no improvement will be noticeable if it is tubercular. Epithelioma com- mences as a sujierlieiul infiltration and penetrates the tissues from with- out inward. Induration around and underneath the ulcer is more marked in an ulcerating epithelioma than in a tubercular ulcer. Glandu- lar infection takes place earl}", and is almost a constant occurrence in epithelioma, but is seldom observed in the course of a tubercular ulcer, A simple ulcer of the tongue caused b}^ the mechanical irritation from a sharp projection of a carious or displaced tooth can be readily recog- nized by the location and character of the ulcer. Such an ulcer may become the seat of a tubercular ulcer or the starting-point of an epithelioma. Treatment. — The local treatment of a tubercular ulcer of the mouth or tongue is the same as when a similar ulcer is located upon the surface of the bod}'. If the lesion is circumscribed sufficiently that the wound, after complete excision, can be closed by suturing, this method of treat- ment should be adopted, as it is certainly the most radical, and results most speedily in complete recovery. If the extent of the disease render this treatment inapplicable, the diseased tissues should be removed as thoroughl}' as possible by a vigorous use of the sharp spoon, or by destroying it Avith the actual cautery, or both of these measures may be combined. The use of superficial caustics- has a tendenc}' rather to aggravate the disease than to cure it. With a sharp spoon all of the soft tissues are scraped awa}", the health}' tissue being recognized by its greater firmness and resistance to the spoon. After bleeding has ceased, the surface is cauterized with the flat point of a Paquelin cautery, and, if the disease has dipped in farther at certain points, these are attacked by making ignipuncture with the needle-point. The cavity of the mouth, during the after-treatment, must be kept as nearly as possible in an aseptic condition by dusting the surface daily with iodoform, and by the frequent use of a mild, antiseptic mouth-wash, such as a saturated solu- tion of acetate of aluminum or boric acid. If all the infected tissues have lieen destroyed, healing takes place rapidly by granulation, cicatrization, and epidermization after separation of the eschar. If nny of the infected TUBERCULOSIS OF MUCOUS MEMBRANE OF INTESTINES. oSo tissues have remained, the process of healing is rt4arcled or completely arrested ; in the latter event, a repetition of the same local treatment will become necessary. TUBERCULOSIS OF THE MUCOUS MEMBRANE OF THE INTESTINES. Primary tuberculosis of the intestinal mucous membrane is a com- paratively frequent affection, but becomes a surgical lesion only in case it leads to intestinal obstruction or perforation. If, as is sometimes the case, the infection is limited to a single focus, a timely operation not only relieves the symptoms which made surgical treatment a necessitj^, but it may result in a permanent cure. The tubercular lesions of the intestinal mucous membrane that occasionally indicate treatment b}' laparotomy are usuallj'^ found in the lower portion of the ileum, the ileo-caical region, caecum, or ascending colon. Tubercular inflammation of the large intestine may cause so much swelling as to give rise to intestinal obstruction. When the inflammator}' process is limited to a small portion of the bowel, operative removal of the affected segment is justifiable, and holds out a fair prospect of permanent relief. Seiner reports a successful case of this kind. At the close of October, 1887, he was consulted by a man who had a painful swelling in the right hypochondrium; the swelling was as large as a man's fist, with a nodular surface. Considerable pain, tenderness, emaciation, and evidences of intestinal obstruction, which were gradually increasing in integrity, A tumor of the caecum was diagnosticated, and laparotomy was performed November 1st of the same year. The abdomen was opened by a lateral incision. The omentum near the swelling was much inflamed and covered with whitish-j'ellow nodules, from the size of a pin to that of a pea. Twelve to sixteen enlarged glands, some as large as a walnut, situated along the vertebral column, were enucleated or removed with a sharp spoon. The caecum was so fragile that it ruptured during the manii)ulations and some faeces escaped. The bowel above and below the swelling, which involved the ctecum, was emptied by expression, tied with rubber bands, and the affected portion excised. The part of the caecum containing the valve and the vermiform appendix was left. Circular suturing by a double row of sutures. The subsequent history' of the case was favorable in ever}- respect. Pain was severe for two days, and yielded to large doses of opium. Eighteen months after the operation the patient remained in good health. Examination of the part removed showed that the swelling was of a tubercular nature, the sub- mucosa and external layers of the bowel being mainly involved. Durante reported a somewhat similar case. The patient was a woman, aged 56. who, for four or Ave ^ears, had suffered from obscure 536 PRINCIPLES OF SURGERY. pain in the right iliac fossa when at stool. The pain increased in inteiisitj' and became paroxysmal, and the patient almost starved her- self with the object of avoiding the torture of defecation. On examina- tion a tumor was found in the right iliac fossa, extending downward toward the upper outlet of the pelvis. Carcinoma of the caecum or neighboring parts was suspected. The abdomen was opened. The swelling, as large as a lemon, was found adherent to the iliac fossa, tiie parietal peritoneum and coils of the small intestine being matted to it so firmly that the lower end of the latter, measuring 25 centimetres in length, together with the caecum and a portion of the ascending colon, were removed with it. The two ends of the divided intestine were brought together by tliree rows of sutures. The abdominal wound was closed, and the patient made a rapid and permanent recovery. The swelling, which had almost completely blocked up tlie lumen of the intestine, was found to be of a tubercular nature. If, in cases of intes- tinal tuberculosis indicating laparotomy, it should be found, after opening the abdomen, that the foci in the ileo-caecal region are too numerous to warrant a radical operation by enterectomy, the symptoms can be relieved and the inflamed parts excluded from the faecal circulation by establishing an anastomosis between the inte?itine above and below the affected segment by means of decalcified, perforated bone-plates. TUBERCULOSIS OF THE MAMMARY GLAND. A number of well-authenticated cases of primarv tuberculosis of the mammarj' gland have recently been reported. So far as the infection is concerned, the breast must be considered as an appendage of the skin. The bacillus from without ma}- effect entrance into the gland through the milk-ducts, in which case the inflammatory process commences in the parenchyma of the gland ; or it may enter through a fissure of the nipple, in which case the process is primarily interstitial. "When direct infection from without can be excluded, the disease is tlie result of auto-infection, and on this account the prognosis is alwa^'s more unfavoi'able. Regional dissemination takes place along the chain of axillary Ij'mphatic glands. Orthmann examined the enlarged lymphatic glands in a case of primary tuberculosis of the mamma, and found numerous tubercle bacilli. The disease is differentiated from carcinoma by the absence of pain and hardness in the swelling, and from an ordinar}- suppurative mastitis by the absence of the prominent symptoms of acute inflammation. It might be mistaken for a lacteal C3'st or an echinococcus-c3-st, but all doubt as to the nature of the swelling can be set aside by an exploratory puncture. Treatment. — The more expectant i)lans of treatment recommended TUBERCULOSIS OF THE GENITO-URINARY ORGANS. 537 in the management of tubercular abscesses conimunicnting with the primary foci in tissues and organs deeph' situated should not be fol- lowed in the treatment of tubercular affections of the breast, as in these cases a radical operation is not attended by any danger to life, and usuall3' results in a permanent cure. The plan to be pursued depends on the extent and location of the disease. A superficial limited tubercular focus of the mamma can be successfull}- treated by excising the infected tissues. If the process is more deepl}' located, it may become necessar}' to remove a portion of the mammar^^ gland with it. Partial excision of the gland should be done in such a manner as to include tlie tubercular focus in a wedge-shaped section of the gland, the base of the wedge being directed toward the peripiiery of the gland. After excision the cut surfaces of the gland are united with buried catgut sutures. If the disease has infiltrated the gland extensivel}', or if a number of sinuses have formed, it becomes necessary to extirpate the entire gland. Enlarged glands are removed in the same thorough manner as in operating for carcinoma of the breast. TUBERCULOSIS OF THE GENITO-URINARY ORGANS. It is only within the last few years that a number of chronic inflam- matorj^ processes of the genito-urinary organs in both sexes have been shown to be tubercular in their origin, clinical tendencies, and final ter- mination. The susceptibilit}' of the mucous membrane of the genito- urinary tract to tubercular infection has been demonstrated experimentally by Cornet. In rubbing a pure culture of tubercle bacilli in superficial abrasions of the penis in dogs, he produced a tubercular lesion of that organ. In bitches, tuberculosis of the vagina and uterus could be pro- duced by injection of a pure culture into the vagina. The local lesions were followed by general tuberculosis. (a) Tuberculosis of Vulva, Vagina, and Uterus.— Direct tubercular infection of the genital tract in women has been observed, but tlie cases so far reported are few. Barbier believes that a woman can be infected by a tuberculous man during coitus, as bacilli have been demonstrated in the semen of tuberculous patients, as well as in the discharge attending tubercular cpidid3-mitis. The uterus maybe infected by extension from a tubercular lesion of the vulva without any intermediate trace of infection in the vagina. The author even admits the possibilitj- that tubercular infection maj' be transmitted b^- the finger of the attendant, by infected instruments, or even through the medium of tlie air. Zweig- baum reports a case of primary tuberculosis of the portio vaginalis uteri, which, at the time of examination, api)eared in the shape of an ulcer the size of a walnut, with thick, indurated margins and cheesy floor. 538 PRINCIPLES OF SURGERY. Numerous tubercle bacilli were ibuiul in the secretion taken from the surface of the ulcer. Evidences of tuberculosis were apparent at this time. After a few weeks the ulcer extended toward the left vaginal wall and left labia majora. A section of a fragment of tissue removed from these parts, on staining, showed numerous bacilli. This form of tuber- culosis is not frequent, as the author could lind only 2 cases of vulvo- tuberculosis in literature, although genital tuberculosis is quite a frequent atfection. Jonin believes that tubercular endometritis from local infec- tion is quite a common affection. Of 9 cases which were observed by him it was due to sexual contact with men suffering from genital tuber- culosis. In 2 others the husbands were tuberculous, but had no genital tuberculosis. He calls attention to the fact that Cornil and Chantemesse have produced this disease artificially in rabbits by injecting bacilli into the vagina. The cases of primary tuberculosis of the vulva, vagina, and uterus will undoubtedly become more numerous in the literature of the near future, when Improved methods of examination will enable the surgeon to make a positive diagnosis between these affections and carci- noma and syphilitic lesions. The same points in differential diagnosis are to be remembered in this connection as have been enumerated in the consideration of tubercular affections of the mouth. Treatment. — Primary tuberculosis of the utero-vaginal canal and vulva should be treated by curetting, and, if the extent of tlie lesions make it necessar}^ b}' cauterization with the actual cautery. Before either of these procedures are put into practice, the parts must be ren- dered aseptic b}' antiseptic irrigation. Sul)sequent infection can be guarded against b3' the free use of iodoform, and tamponade of the vagina with iodoform gauze. Under ordinary circumstances, it is not necessary to remove the tampon oftener than once a week, when the surface is again freely dusted with iodoform before a new tampon is inserted. (b) Tuberculosis of Fallopian Tubes. — In the absence of tubercular lesions of the vagina and uterus, it is doubtful if infection of the Fallopian tubes can take place b}- the entrance of the bacillus through the genital tract, and the relatively frequent occurrence of the disease in that part of the genital tract is only explainable by attril)uting it to auto-infection, in the same way as w^e have explained the occurrence, for instance, of primary tuberculosis of joints, bone, and peritoneum. We can safely assert that tubercular infection of the Fallopian tubes often, if not always, takes i)lace upon the basis of pre-existing pathological conditions, taking it for granted that the health}^ tubes do not present favorable conditions for the localization of the tubercle bacilli. A catarrhal con- dition of the mucous membrane lining the tubes, as in other organs, TUBERCULOSIS OF THE GENITO-URINARY OKGANS. 539 undoubtedly furnishes, in many instances, the locux minoris resistentiae for the localization of bacilli brought to the part through the circulating- blood. An interesting case of primary tuberculosis of the Fallopian tubes has been recorded by Kotschau. The patient was 45 j-ears old, having ;i good family history ; has surtered for a year with pains in the abdomen, l)rofuse metrorrhagia, and various nervous disturbances. Slie was treated for retroflexion, and subsequently had an attack of pelveo- peritonitis. Vaginal examination disclosed a firm, smooth, movable swelling, as large as an apple, to the right of the uterus ; tliis was taken for a malignant ovarian growth, and laparotomy' was done for its removal. On opening the abdominal cavity, a quantity of turbid, purulent fluid escaped. The swelling, of oblong shape, was found lying apparently in a bed of pus ; on account of its intimate adhesions it could not be removed. The patient died from shock. The autopsy showed the uterus enlarged aud retroverted. The right tube was tortuous and gen- erally thickened. Near its distal end it was dilated into a swelling the size of a hen's egg^ in the centre of which was a cavity containing cheesy material. Other smaller caseous foci were found in the tubal wall in close proximity to the large swelling. The ovary on the same side was enlarged aud transformed into a caseous mass. The left tube and ovary showed similar changes, though less extensive. The microscopic exami- nation of the pathological product confirmed the diagnosis of tubercu- losis. Although the disease appears to have been primary in the tubes, the affection occurs more frequently from the direct extension of a tuber- cular endometritis to the tubes. LebedeflT gives a full description of a case that came under his observation. The patient was the widow of a man who had died of pulmonary tul)erculosis. An examination before the operation revealed a firm, nodulated, intra-abdominal tumor in the space of Douglas. An attempt was made to remove the tumor b}' laparotom}', but had to be abandoned, as the disease had become too widely disseminated. Six weeks later the patient died with symptoms of general tuberculosis. At the post-mortem miliary tuberculosis was found in the peritoneum, lungs, colon, uterus, and Fallopian tubes. The most advanced stages of the disease were found in the uterus and Fallo- pian tubes, showing that the disease had commenced in these organs. Both of the Fallopian tubes were dilated and filled with pus, the epithe- lium in parts being absent. Stained sections from the uterus and tubes showed the presence of numerous bacilli. Symptoms and Diagnosis. — Tubercular salpingitis, occurring as a secondary lesion to a primary tuberculosis in the lower portion of the genital tract, can be suspected if, in connection with a cervical or 54:0 PKINCJPLES OF SUKGEKY. endometritic tuberculosis, examination revenl a swelling in the region of one or botli Fallopian tubes. Primary tubercular disease of the Fallo- pian tubes gives rise to local conditions and sj'mptoms tliat it would be impossible to differentiate from an ordinary p^-osalpinx. Tlie existence of a dilated, inflamed Fallopian tube can generally be made out with some degree of certainty by making the examination while the patient is under the influence of an anaesthetic. Werth has described an acute and chronic form of tubercular salpingitis. In the acute variety both the muscular and serous coats undergo caseous degeneration, numerous bacilli being found in tlie interior of the tube ; while in the chronic form the wall of the tube undergoes thickening and infiltration with new cells, and its contents contain only a few bacilli. Tlie increase in size of the tube is due to the collection of pus in its interior as well as to the thick- ening of the wall. When suppuration takes place in the interior of the tube the tubercular product has become the seat of a secondary infection with pus-microbes ; hence, indications for operative treatment have become more urgent. If the tubercular inflammation extend from the abdominal extremity of the Fallopian tube to the peritoneum, symptoms of tubercular salpingitis are obscured later on by those of tubercular peritonitis. Treatment. — As a tubercular salpingitis calls for the same treatment as a pyosalpinx, it is, for all practical purposes, only necessary to narrow the diagnosis down to either one of those two affections before resorting to treatment by lai);irotom3'. A median incision is preferable to a lateral, as frequentl}^ both tubes are affected simultaneously. Salpingectomy should be combined with oophorectomy, as the ovaries are frequently implicated in the tubercular process, and these organs would be of no further use after extirpation of the tubes. As tubercular tubes are usually found firmly adherent to the surrounding tissues, their removal is often attended with the greatest difficulties, and maj' become an impossible task. If the disease is limited to the tul^e-structures, and has not in- volved surrounding important organs, it would appear rational, under such circumstances, to la^- the tube open, remove its contents, scrape out the infected tissues as far as possible, arrest bleeding by applj'ing the actual cauter}', and, after thorough iodoformization, pack Avith iodo- form gauze. This treatment would certainly appear more rational than to be content with an exploratory incision, and allow the patient to re- main a sufferer until relieved bj' death from tuberculosis. In one case that came under in}' treatment, where both tubes were imbedded in a mass of granulation tissue, I was unable to remove the entire mass, was compelled to pursue this course, and the patient recovered quickly and permanently-, in spite of a faecal fistula that formed a few days after the operation. TUBERCULOSIS OF GLANS PENIS AND URETHRA. oJrl TUBERCULOSIS OF GLANS PENIS AND URETHRA. Kraske has observed a case of tubercular ulceration of the urethra, extending from the membranous portion to the neck of the bladder, in a patient, 33 ^ears of age, who was treated for chancre. The autopsy revealed advanced tuberculosis of the genito-urinary tract and pulmonary tuberculosis. In another case, a man 49 years old, a tubercular ulceni- tion existed on the dorsum of the glans the size of a cent piece. This sore was also mistaken for a primar3' lesion of syphilis. There were no signs of pulmonary tuberculosis. The glans was amputated, when it was observed that the tubercular infiltration extended deepl}' into the cavernous structure. The lesion could not be traced to genital contact, and under the microscope showed the typical structure of tubercular tissue. In the examination of doubtful lesions of the glans penis, it is well to remember the possibility of tubercular infection in this locality, and, in case the tubercular nature of a lesion can be established on suffi- cient grounds, to resort to cauterization with the actual cautery, excision, or amputation, according to the location and extent of the disease. TUBERCULOSIS OF EPIDIDYMIS AND TESTICLE. In the male genital apparatus tuberculosis attacks most frequently the epididymis, for the reason that the vessels in this structure are more tortuous and smaller than in the remaining portion of the testicle or the vas deferens, both of which are important elements in determining locali- zation in that part from floating bacilli that reach it through the circu- lating blood. Saltzmann states that these anatomical conditions are im- portant factors in the arrest and localization of floating bacilli. That in cases of tuberculosis of the testicle we are only dealing with an external manifestation of an antecedent infection becomes apparent by the clini- cal observation that not infrequently' both testicles are infected, either simultaneouslj' or some time apart, showing that the infection came from the same source. Tuberculosis of the genital organs in the male fur- nishes one of the best examples of the t^'pical clinical course of local tuberculosis. The disease extends by continuity of structure often to a great distance from its starting-point. Nothing is more familiar than the clinical course of a case of tuberculosis of the testicle. A sm.nll, hard nodule is first detected in the epidid^nnis, and from this point the whole structure of the epididymis is infected, when the infection slowly, but surel}', extends to the testicle ; then along the vas deferens to the vesiculje seminalis, the prostate gland, and bladder, and from this viscus along the ureters to the pelvis of the kidney. As a rule, the disease remains limited to the genito-urinary organs, but in some instances metastatic infection takes place, either from the genito-urinary organs or 5 + 2 rKINCIPLES OF SURGERY. from the prinuiry source of infection. A gentleman was recently unrler my care whose case illustrates a number of interesting poiwts descriptive of the clinical behavior of genital tuberculosis. He was 35 years of age ; married for ten years; the marriage had been childless. He claimed that he never had syphilis or gonorrliosa. Tuberculosis is hereditar}' in the familv. Nine years ago he noticed a small, hard swelling in the epididy- mis of both testicles. Two years ago symptoms of cystitis appeared, which were not much improved 1)3' internal medication and antiseptic irrigation of the bladder. Six months ago his left knee became swollen and painful. Four months later he commenced to suffer severe pain in the region of the left kidney. Temperature varied from 100^ to 103° F. A swelling soon formed in the left lumbar region, and four weeks later I evacuated a large quantity of pus through a lumbar incision. Through the incision the kidney could be seen and felt, and, by passing the index finger around it, it appeared to be extensively separated from the con- tiguous structures. The left knee presented all the appearances of ad- vanced synovial tuberculosis. No evidences of pulmonary tuberculosis. The disease in both testicles had made no progress for j^ears, and the infiltration appears to be limited to the epididj-mis. The epididymis on both sides is moderately swollen and indurated. The vas deferens on each side is somewhat larger and firmer than normal. The disease had extended from the epididymis to the pelvis of the kidne3' on both sides, all of the intervening organs being involved in the tubercular process. The only apparent manifestation of general tuberculosis was presented by the left knee. An interesting feature in this case was the formation of a paranephritic abscess around a pyelo-nephritic kidney, which must be regarded as the result of a secondary infection with pus-microbes. Symptoms and Diagnosis. — Tubercular epidid3'mitis alwa3S appears as a chronic affection, in this respect differing from gonorrhoeal epidid3'- mitis and the ordinar3' form of acute parenchymatous and suppurative orchitis. Pain and tenderness are either entirely absent or, at least, slight when present. Circumscribed hydrocele may develop as soon as the disease extends to the tunica vaginalis. The tubercular inflamma- tion is characterized by the same pathological conditions as in other organs, new nodules appearing in the neighborhood of the first one, which, b3^ confluence, form masses of considerable size. Caseation is an earl 3^ and almost constant condition. In many cases the process extends in the direction of the skin ; a tubercular abscess forms in the tunics of the scrotum ; the skin presents a bluish-red color, and spontaneous perfo- ration gives rise to evacnation of the abscess. Frequentl3'- multiple abscesses form in this manner, and the fistulous openings lead down to caseous masses. In some cases, as the one reported, the disease in the TUBERCULOSIS OF THE VESICUL.1-: SKMINALIS. 543 epididymis becomes latent, but the infection extends at an early date along the vas deferens, which becomes swollen and indurated, and from which, if a cross-section is made, the characteristic chees}^ material can be squeezed. From the vas deferens the disease extends to the vesiculae seminalis, prostate gland, bladder, and finally creeps along the ureters to the pelvis of the kidney, usually simultaneous!}' on both sides. The only disease with which tubercular epididymitis might be confounded is tertiary syphilis, affecting the same part of the testicle. In cases of doubt the patient should be placed on antisyphilitic treatment for a few weeks, which, if the affection is tubercular, will produce no impression on the swelling ; on the other hand, if it is syphilitic, it will rapidly diminish in size. Treatment. — The only radical treatment in tuberculosis of the epi- didymis and testicle is castration. This operation is indicated if the disease is limited to one testicle, and no evidences of tuberculosis can be found in anj- other organ beyond the reach of surgical treatment. I liave removed both testicles in two cases, but in both patients tubercular cystitis developed one and two years, respectivel}', after the operation, and in one of them the immediate cause of death was pulmonary tubercu- losis. Mv own cases and the experience of other surgeons would tend to dictate a conservative course of treatment if both testicles are affected. After the disease has extended to the organs at the base of the bladder or the bladder itself, castration is. of course, positively contra- indicated. The co-existence of pulmonar}' tuberculosis, or tuberculosis of any of the larger joints, would furnish a sufficient ground against the propriety of castration. Castration is a legitimate operation, and yields fair results if the patient is otherwise in good health and the disease is limited to one side, and has not extended along the cord be^'ond a point where all of the infected tissues can be removed. The tunica vaginalis should always be removed with the testicle, and, if the scrotum is adherent at anj'^ point, the adherent portions of the skin must be excised at the same time. In removing the testicle for tuberculosis, it is always necessary to carr}^ the incision as far as the internal ring, in order to remove as much as possible of the cord. The vessels of the cord should be tied separately, as tying the cord en masse gives rise to unnecessai-y pain, and the ligature is liable to slip, — an occurrence that might be followed b}' troublesome hfemorrhage. TUBERCULOSIS OF THE VESICUL^ SEMINALIS. In 1829 Dahmar described a chronic inflammation of the seminal vesicles, the description of which corresponds closely to that of tubercu- losis. Since then this affection has been described by Aibers, Jaye, 54:4 PRINCIPLES OF SURGERY. Naumunn, Humpliro}-, and Kocher, and latel3' it has been studied by Raver, Cruveilhier, and lleclus as secondary to pulmonary tuberculosis. As a secondary affection this ailment is not only seen in connection with tuberculosis of the lungs, but is n)ore common after primary tubercu- losis of the epidid3'mis, either as a continuation of the cheesy degenera- tion in the vas deferens or spreading by contiguity of tissue from the sides of the prostate. Primary tuberculosis of these organs is ex- tremely- rare, and still less often diagnosed, and up to quite recently no surgical interference has been attempted. Ullmann now reports a case of primary tuberculosis of the right testicle, with secondary affection of the seminal vesicles on both sides, in a lad It years of age, where, after removal of the right testicle, he extirpated these organs through a semi-lunnr incision in the perineum. The general health of the patient improved after the operation, but a small urinary fistula remained, which formed in consequence of injury to the base of the bladder during the operation. He is of the opinion tliat the seminal vesicles should be re- moved in primary- tuberculosis of the testicle or epididymis, when no suspicious symptoms have appeared on the sound side, and when on the affected side the vesiculae seminalis are already attacked ; also in cases of primary tuberculosis of the seminal vesicles. Tlie impotence following the operation should be no contra-indication, for in all reported cases of tuberculosis of the seminal vesicles impotence always occurs in a short time ; in fact, it is regarded as a cardinal sj^mptom of the disease. TUBERCULOSIS OF THE BLADDER. Tuberculosis occurs either as a primar}- or secondary affection. Several cases of well-marked primary tuberculosis of the bladder in the female have come under ni}' observation, where the disease evidently commenced at the neck of the bladder, and, after spreading over the whole internal surface of the viscus, extended along the ureters to the pelves of the kidneys, and, finally, in the course of a few years, proved fatal from tubercular pyelo-nephritis. Primary tubercular cystitis appears to be more frequent in females than in iiinles. undoubtedly because, on ac- count of shortness of the urethra, direct infection is more liable to occur. Striimpell, after a careful study of 4 cases of primary tuberculosis of the bladder in men, came to the conclusion that infection takes place through the urethra. The tubercle bacilli, finding no favorable place for localization and growth in the urethra and bladder, finally reach the prostate gland or the epididymis, the whole process resembling what occurs in inhalation tuberculosis, in which the disease manifests itself not in the mucous membrane of the bronchial tubes, but in the paren- chyma of the apices of the lungs. TUBERCULOSIS OF THE BLADDER. 545 Symptoms and Diagnosis. — Tuberculosis of the bladder is clinically characterized b}' symptoms of cystitis, the intensity of the S3^mptoms varying- according to the part of the bladder affected, the extent of the disease, and the presence or absence of complications. If the disease primaril}' involve the neck of the bladder, tenesmus and frequent desire to urinate are the most distressing symptoms. As long as no ulceration of the vesical mucous membrane has taken place, the urine ma}^ present a perfectly normal appearance, and, on examination, is found normal in other respects. Very frequently the symptoms become ver}- much aggravated shortly' after an examination of the bladder, made upon the supposition that the patient is suffering from stone in the bladder, as the introduction of a sound without the necessar}' antiseptic precautions is often followed by a secondary infection with pus-microbes, which gives rise to an acute suppurative cystitis. The general health of the patient now becomes rapidly undermined, and the extension of the local disease in the direction of the kidne^-s is hastened. The urine contains large quantities of pus and mucus, and becomes ammoniacal from the presence and action of putrefactive bacteria. The walls of the bladder become greatly thickened from inflammator}- exudation and tubercular infiltra- tion; the organ is unable to empty itself completely, and the decomposed residual urine becomes an additional source of irritation and progressive infection. Incontinence of urine is a frequent S3^mptom in advanced vesical tuberculosis, and is usuall}' an indication that the organ is ex- tensively diseased. In secondar}' tuberculosis of the bladder it is usually not difficult to locate the primary disease, and thus establish a positive diagnosis. The presence of tubercle bacilli in the urine in cases of primary tuberculosis of the organ furnishes a positive diagnostic crite- rion between ordinary cystitis and vesical tuberculosis. In the absence of ordinar}' causes of cystitis, such as gonorrhoea, stricture of the ure- thra, enlarged prostate, calculus, and tumors of the bladder, symptoms of cystitis point strongl}^ toward a tubercular origin of the inflammation, and should induce the surgeon to make a most careful examination in reference to the etiology and nature of the C3'stitis. It is only by ex- cluding the presence of the different lesions of the bladder b}- a careful and thorough examination of that viscus and its neighboring organs, as well as a chemical, microscopical, and bacteriological examination of the urine, that a positive diagnosis of vesical tuberculosis can be made during the early stages of the disease. Tuberculous urine injected into the peritoneal cavity of a guinea-pig will produce tuberculosis in this animal, and in doubtful cases this diagnostic measure may prove of great value. Prognosis and Treatment. — In secondary tuberculosis of the bladder the regional infection has extended so far that even the most heroic 546 PRINCIPLES OF SURGERY. surgical measures will necessarily fail in eliminating the disease, and death from extension of the disease to the kidneys, or from secondary pulmonary or general tuberculosis, will follow as an inevitable result. In primary vesical tuberculosis, the disease, at tlie time a positive diagnosis can be made, has usually invaded so much of the walls of the bladder that a radical operation would necessitate an extensive resection of its walls, after which it would be found impossible to utilize the remaining portion of the organ as a reservoir for the urine. Resection of the wall of the bladder has been done in several instances in the treatment of malignant tumors at its base, but have usually terminated in the formation of a permanent urinar}' fistula. Dr. R. Harvey Reed, of Mansfield, Oliio, has recentl}' made an in- teresting series of experiments on dogs, with a view to dispense with the bladder altogether in cases of extensive disease of this organ, neces- sitating partial or complete excision. He has shown that the ureters can be successfully implanted intc the rectum, thus excluding permanenth- the urinary tract below this point from the urinary passages, and utiliz- ing the rectum as a reservoir for the urine. If the operation of im- plantation of the ureters into the rectum can be perfected to such an extent as to become a feasible and practical procedure in surgery, it may be possible, in the future, that vesical tuberculosis can be successful!}'' dealt with by complete excision of the affected organ. The conservative treatment of vesical tuberculosis by injection of solutions of boric acid, benzoate of soda, the ordinar}^ antiseptic solu- tions, and iodoform has little or no effect, either in aflfording palliation or in retarding the regional extension of the disease. Internal medicines, such as boric acid, benzoate of soda, uva ursi, buchu, and triticum repens, are of utility in relieving vesical tenesmus, before secondary infection with pus-microbes and putrefactive l)acteria has occurred, by rendering the urine alkaline and more copious ; but during the later stages of the disease they are useless even as palliatives. If the tubercular process is limited to the urinar^^ passages below the ureters, incision and drainage of the bladder secure rest to this organ and open up a direct route for the more eftectual treatment of the tubercular lesions, and thus not onh' constitute the most efficient palliative measure, but also the most effective procedure in retarding tiie local extension of the disease b}^ direct vigorous antitubercular treatment. I had an opportunity to observe the palliative effect of an opening in the bladder, in a case of primary' vesical tuberculosis in a female aged 35 years, where the tuber- cular ulceration resulted in the formation of a vesico-vaginal fistula. The tenesmus was promptly relieved, as soon .is the l)ladder was placed in a condition of rest, by the escape of urine through the fistulous opening. TUBERCULOSIS OF THE BLADDER. 547 In the female the most direct route into the bladder, and aflurding the most efficient drainage and furnishing the most advantageous con- ditions for the local treatment of the tubercular lesions, is a vaginal cj'stotom}' made near the neck of the bladder. The opening should be at least 1^ inches in length, extending from near the neck of the bladder in an upward direction. Tubular drainage should be dispensed with, as all foreign substances in the bladder not only act as irritants, but interfere Mith complete drainage. As the opening is made in the most dependent portion of the bladder^ free drainage can be secured most efficientl}' bv means which prevent contraction or closure of the vesico-vaginal open- ing. This can be done by suturing the mucous membrane of the bladder to the vaginal mucous membrane, thus establishing a permanent bimu- cous fistula between the bladder and the vagina. Through this opening- accessible tubercular lesions can be treated b}- the use of the sharp spoon and the direct application of iodoform. The parts below this opening- should be protected against the irritating- effect of urine b}- applications of vaselin or lanolin containing one of the milder antiseptic remedies. After the fistulous opening has been established the bladder can be irrigated with antiseptic solutions, or a mixture containing iodoform, through the urethra. In the male the same objects are attained most efficientl}' b}' making a suprapubic cystotoni}', as through a perineal incision the direct treat- ment of tubercular lesions is impossible. The fistulous communication should be made complete by suturing the margins of the visceral wound to skin-flaps taken from each side of the external incision, — a method first suggested by Morris, of New York. B}' lining the margins of the incision with mucous membrane and skin, the loose connective tissue in the pre-vesical space is protected against infection, and the fistulous opening is rendered permanently patent. At the time of operation visible tubercular ulcers are curetted and iodoformized. The bladder can be irrigated subsequently through the urethra or through the fistulous opening. In a case of advanced primary tuberculosis of the bladder where I pursued this method of treatment the operation afforded marked relief, but appeared to have no influence in retarding a fatal termination, as the disease had already extended to the kidnej^s. The patient lived for nearly two months in comparative comfort, the principal complaint made being the moisture caused b}- the constant escape of urine through the artificial urethra. A case is described by Battle in which recover}' followed curetting through a suprapubic incision, after the failure of less formidable means. The patient was a girl aged 20 years. The operation was performed 548 PRINCIPLES OF SURGERY. July 29, 1889. The patient was discharged September 20th, and April 8, 1890, was in good health and working at her trade. In cases where the disease in the bladder is circumscribed, and the organ is opened early, the treatment might, occasionally at least, result in a permanent cure, if the infected tissues can be completely removed b}^ curetting or destroyed by the actual cautery through the incision at the time of operation. In such favorable cases the opening should not be allowed to close until the surgeon can satisfj^ himself that the ulcers have completely healed, and that no new centres of infection are present. CHAPTER XXII. Actinomycosis Hominis. Actinomycosis is a form of chronic inflammation caused by the presence of actinomyces or ray-fungus. Until quite recently this disease was included among the malignant tumors, and we have reason to believe that, in many of the reported cases after operations for sarcoma, the disease for wliich the operations were done was not sarcoma, but actino- m3'cosis. Before degeneration of the inflammatory product has taken place actinomycosis resembles a tumor more closely than any other inflammator}' swelling. The swelling is composed largely of granulation tissue, which, on examination under the microscope, presents a histo- logical structure that, in the absence of other evidences, it would be difficult or impossible to differentiate from a round-celled sarcoma. The presence of the specific fungus in the granulation tissue settles the diagnosis. history of the disease. The disease, as occurring in cattle, was first described by Bollinger, in 1877. as a condition in which sarcoma-like tumors were met with, associated with a peculiar growth which, from its structure, was named '■'■ Strahlen pilz^'' (ray -fungus), or actinomj'ces. James Israel was the first to recognize the disease in man, but it was not generally understood until the appearance of the classical work of Ponfick (" Die Aktino- mykose des Menschen,'' Berlin) in 1882. Numerous articles on this subject have since appeared in the current medical literature, so that Partsch, in 1888, mentioned in his monograph seventj'^-five references, with a supplemental list of thirty-three names furnished b}- Schuchardt. Since the publication of Israel's case numerous cases have been reported by different observers, representing Germany, England, Belgium, Switzer- land, Russia, Austria, France, and America ; so that Partsch in his paper estimates the Avhole number up to that time at not less than one hundred. While most of the articles in medical journals contain only a descrip- tion of isolated cases, it appears to have been the good fortune of some of the writers on this subject to meet with a number of cases in a com- parativel3' short time. Thus, Hochenegg reports 7 cases that came under his observation, and Moosbriigger has increased the list of published cases by 10 well-authenticated and carefully recorded cases. (549) 550 PRINCIPLES OF SURGERY. Rotter observed 13 cases in two years. Albert has seen not less than 38 cases of actinomycosis in man within the past few j^ears ; of these 8 have come under his observation during the last two years. These eases have come mostl}' from Vienna and its vicinitj'. DESCRIPTION OF FUNGUS. The ray-fungus, or actinomyces, is not, strictly speaking, a microbe, as it is large enough to be seen with the naked eye ; but its identity can only be ascertained from its characteristic structure, which I'equires the use of the microscope. Bollinger described as peculiar to this disease certain yellow bodies, visible to the naked eye, always found in the pus of actinomycotic abscesses and in the granulation tissue before suppu- ration had occurred. Microscopically, they were found to consist of threads similar to the ordinary m^'celium, which terminated in bulbous ends. The threads radiate from the centre, and their clubbed extremities impart to the fungus the character- istic ra3'-like appearance. Sometimes but one of these bulbs is connected with a thread ; at other times there may be several. In some specimens one of the rays projects far be3'ond the others and terminates b}- several bulbous ends, as is shown in Fig. 99. In man the actinomj-ces occurs as a small, globular mass, commonly about the size of a millet-seed, usu- alh' of a pale-yellow color, but at times white, brown, green, or speckled, the color being influenced by age and the consecutive pathological conditions by which it ma}- be surrounded. In man the clubbed bodies are often absent, and the growth then consists of the radiating filaments alone. The rays, when immersed in water or in a weak solution of chloride of sodium, become enormousl}- swollen and lose their shape ; while thej' effectuall}' resist the action of acids, ether, and chloroform. Staining. — For staining the actinomyces, Weigert uses Wedl's orseille ; Mnrehand,eosin ; Dunker and Magnussen, cochineal-red ; Moos- briigger, haematoxylon-alum ; and Partsch,in section-staining, has had the Fig. 99.— Ray-Fungus, with One of THE Rays More Projecting and Branching. (Ponfick.) DESCRIPTION OF FUNGUS. 551 best results with Gram's method. Recently, Babes has made beautiful diy preparations by using a 2-per-cent. solution of safranin in aniline-oil, followed b}' treatment with iodide of potassium. 0. Israel has found that a solution of orcein in acetic acid stains the rays a Bordeaux-red, while the filaments, if decolorization is not carried too far, present a blue tinge. Baranski uses picro-carmine for staining fresli preparations of actinomyces bovis. A small amount of the contents of a yellow nodule, or pus from the part, is spread in a thin layer on a cover-glass and dried in the air. The cover is then passed three times through the flame of an alcohol-lamp, care being taken not to overheat the preparation. It is then floated in the picro-carmine solution, or a few drops of the staining fluid are placed on the cover. The whole process of staining is completed in two or three minutes. The cover is then carefull}- washed by agitating it in distilled water and alcohol, and examined in water and glycerin. The fungus takes a 3'ellow color, while the remaining fitructure a[)pears red. Cultivation Experiments. — It has been found extremely difficult to cultivate the actinomyces outside of the bod}', probabl}- on account of the usual culture media not being well adapted for its growth. Tiie first successful experiments were made in 1886 by Bostrdm, of Giessen, upon plates of coagulated blood-serum and agar-agar, the fungus attaining its maturity in five or six days, when it presented the t3'pical structure of actinomycosis as found in man. 0. Israel cultivated the fungus success- fully upon coagulated blood-serum. Upon this medium the culture grows very slowly and the fungus often undergoes calcification. Israel made the observation that water, glycerin, blood-serum, and Aveak saline solutions seriousl}- impair the vitalit}- of the fungus, and he maintained that tiie eftect of these agents on the actinomyces explains the failure of previous culture and inoculation experiments. If evaporation is pre- vented, a thin, velvety la^-er forms on tlie surface of the blood-serum in about eight weeks, in the vicinit}' of which, not before the expiration of fourteen days, cell-nodules appear more in a downward direction than on the sides of the inoculation streak. From the tenth to the fourteenth day numerous spores are produced and a thick wall of club-shaped mycelia in typical centrifugal arrangement. At a meeting of the Medical Society of Berlin, March 5, 1890, M. Wolft'made a communication in which he described culture experiments with actinomyces which he made jointly with James Israel. He an- nounced that they had succeeded in cultivating the fungus in and upon coagulated albumen of egg and agar-agar. The material used was taken from a case of retromaxillary actinomycosis immediately after the abscess was incised. With the yellow granules stab and streak inocu- 552 PRINCIPLES OF SURGERY. lations were made, using agar-agar as a soil. It was found that the actinomyces is not a purely anaerobic fungus, as it grew upon the sur- face as well as in the depth of tiie culture soil. The agar culture appeared first as transparent little drops, which, by confluence, made an opaque, white mass. Under the microscope the culture was seen to be composed of short, tliick rods, with an admixture of other elements. The egg cultures, on the other hand, were made up of short, thick rods besides a mass of threads, some of them twisted in the shape of a cork- screw, presenting an intricate net-work of threads. With these cultures successful inoculation experiments were made. Inoculation Experiments. — In 1883, James Israel succeeded in pro- ducing the disease artificially in a rabbit by introducing a fragment of actinomycotic tissue into the peritoneal cavity. Somewhat later, Pon- fick made successful inoculation experiments in calves by implantation of infected granulation tissue under the skin into the abdominal cavity or directly into veins. Rotter experimented on calves, pigs, dogs, guinea-pigs, and rabbits, and in only one instance, a rabbit, did he succeed in reproducing the disease. In this case a piece of granulation tissue the size of a bean was inserted into the peritoneal cavity, and the animal, having manifested no symptoms of disease, was killed six months after the inoculation. On opening the abdominal cavity, about twenty nodules, varying in size from the head of a pin to a hazel-nut, were found distributed over a considerable surface around the graft, each of them showing the typical histological structure of actinomycosis. The transplanted piece of tissue was found perfectly encapsulated in one of the nodules the size of a bean. As the fungus was found in all the nodules, it is only reasonable to conclude that the disease spread from the original focus b}^ migration of some of the new fungi, which, at their respective points of localization, established independent centres of infection and tissue proliferation. While the actinom3rces in the new nodules presented a perfect structure, and could be readily stained, the transplanted fungus in the graft had lost its structure, and could no longer be stained. The first successful inoculation experiments with pure cultures were made by Wolff and James Israel. Three rabbits were inoculated by injecting a pure culture into the peritoneal cavity. The post-mortem showed numerous nodules upon the parietal perito- neum, the omentum, and between the intestinal coils. The nodules varied in size from the head of a pin to that of a hazel-nut, and each of them was surrounded by a fibrous capsule. The interior of each nodule was composed of a yellow mass the consistence of tallow. Typical actinomyces were found imbedded in masses of round cells in a state of fatty degeneration. SOURCES OF INFECTION, 553 SOURCES OF INFECTION. As regards the history of the parasite outside the body, as j^et only a few facts are known. It is fv/Und in pig-meat, and is peculiarly sus- ceptible to outside influences. Virchow found the fungus as a small, calcareous concretion in the muscle-fibres of the pig, and considered their flesh highly dangerous food unless well cooked. As the actino- myces found in man and beast resemble each other morphologically and iu their elfect on the tissues, as well as in their reaction to chemical sub- stances, it is evident that the etiology of the disease is similar in both. The fungus has never been found outside of the body. Israel is of the opinion that both man and animals are infected from the same source such as vegetables or water. Jensen traced an epidemic in Seeland to the eating of rye grown on land recently reclaimed from the sea ; and Johne discovered a fungus closely resembling actinomyces in grains of rye stuck in the tonsils of pigs. That the ears of barley or rye are sometimes the carriers of the fungus is well illustrated by the case reported by Soltmann. The patient was a boy who had swallowed an awn of barley. The foreign body lodged in the pharynx, where it gave rise to difficulty in deglutition ; afterward it perforated the pharyngeal wall, — an accident atteniled by haemorrhage, — and later an actinomycotic phlegmon developed ; it spread rapidly, and finally opened below tlie scapula. Through this opening the foreign body was extracted. Piana examined the tongue of a cow sutt'ering from a circumscribed actinomy- cosis of this organ, in which the disease could be traced to a similar origin, — perforation of the tissues and infection by a sharp beard of an ear of barley. Actinomycosis has as yet onlj'' been found amongst herbivorous and omnivorous animals, including man, and the frequent location of the primary swelling in the mouth seems to indicate that the fungus gains entrance with food. PATHOLOGY AND MORBID ANATOMY. As to the manner in which the fungus exerts its pathogenic action much yet remains to be ascertained. The most striking effect is the transformation of mature connective tissue into embryonal or graiiuln- tion tissue. The fungus possesses no pyogenic properties. It gives rise in the tissues to a low grade of chronic inflammation, and becomes imbedded in the specific product of tissue proliferation, — granulation tissue. The product of inflammation around each fungus consists of granu- lation tissue, which, under the microscope, might be easily mistaken for tubercle or sarcoma tissue. At first the cells are round ; at a later stage of the inflammation epithelioid and giant cells are formed immediatelj^ 00^ PRINCIPLES OF SURGERY. around the fungus. As the disease is almost always attended by sup- puration at some time during its course, it has been customary to ascribe to the actinomyces pyogenic properties. Israel has always held that the actinomyces is a pus-producing fungus, in opposition to Ponfick and other pathologists, who claim that when suppuration takes place it is the result of a secondary infection with pus-microbes. As cases of actino- mycosis have been recorded in which the disease remained stationary in the granulation stage, for an indefinite period of time, without suppura- tion taking place, and pus-microbes have been cultivated from the pus of actinomycotic abscesses, it appears more than probable that suppura- tion occurred independently of the presence of the fungus, and was pro- duced by the specific action of pus-microbes on the granulation tissue. Firket asserts that the actinomyces does not appear to produce coagula- tion necrosis, but, from a study of the earliest-formed colonies, he finds that the first effect of the fungus is to induce cellular hyper- plasia. It is as if the tissue ele- ments resented the intrusion of the parasite, which, however, mostly gains the upper hand ; so that the result is the formation of granula- tion tissue and, later, abscesses that characterize the disease. Suppura- tion takes place earliest when the disease occupies a location where secondary infection with pus-mi- crobes is most liable to occur. As a rule, it may be stated that, the earlier suppuration takes place, the more rapid is the spread of the disease and the graver the prognosis ; while the absence of suppuration indicates comparative benignity, and points in the direction of a more chronic form of the affection. The localized chronic form of actinomycosis resembles, in its clini- cal features and its anatomical locations, more closeh' sarcoma than an}^ other affection, and is most frequently mistaken for this form of malignant growth. In such cases it would be difficult, if not im- possible, in the absence of the specific fungus, to make a differential diagnosis between it and round-celled sarcoma, even by a most careful microscopical examination, as the histological structure of both is almost identical. Fig. 100.— Actinomyces. Section from Ac- tinomycotic Swelling. X300. (Fluegge.) CLINICAL VARIETIES. 000 CLINICAL VARIETIES. If infection take place by fully -developed actinomj'ces, it can only do so b3- the fungus gaining entrance into the tissues through some loss of continuity in the cutaneous or mucous surface ; any other method of ingress is impossible on account of the large size of the fungus. In the cases in which no such primar}' infection-atrium could be found, it must be taken for granted that the local lesion had healed between the time infection took place and the first manifestations of the disease, or that infection was caused by the entrance of spores, which, from their smaller size, could possibly find their way into the tissues through intact mucous surfaces. In reference to the primary- localization of the disease, Moosbrugger gives the following statistics : In 29 cases the lower jaw, mouth, and throat were afiected ; in 9, the upper jaw and cheek; in 1, the tongue; in 2, the region of the cesophagus ; in 11, the intestines ; in 14, the bronchial tract and the lungs ; in 1 the point of entrance could not be ascertained. Infection ma}' take place through any abraded surface brought in contact with the specific cause, and for clinical purposes the cases ma}" be divided into the following three groups : 1. Cutaneous surface. 2. Alimentary canal. 3. Respiratory tract. i. Cutaneous Surface. — A number of well-authenticated cases of primary actinomycosis of the skin have been placed on record. Partsch describes a case of actinomycosis developing in the scar left after extir- pation of the breast. The patient was a man aged 60 years. In June, 188-t, his left breast was removed for an ulcerating carcinoma. As the Wound did not heal by primary union, and the process of cicatrization was very slow, a number of small skin-grafts from a perfectly healthy young man were transplanted. The wound was practically healed in September. Two months later the cicatrix ulcerated and an abscess discharged itself. Actinomyces were found in the pus. The parts were excised, and the progress of the disease was apparently arrested. No explanation could be made as to how the infection occurred. Hochenegg reported a case of primary actinomycosis of the skin in the left submaxillary region. He attributed the disease to an invasion of the fungus through a small atheroma. In Kaposi's case, when the disease was first noticed, it appeared as a red spot, the size of a florin, on the left pectoral muscle, Avhich gradu- ally increased to the size of a walnut and then gradually flattened down and disappeared. Meanwhile, fresh spots and lumps appeared, some as large as a pigeon's egg. Eleven years after the beginning of the disease, :i swelling as hirge as an apple appeared over the spine of the sixth ver- tebra, which gradually extended forward and, a year later, formed a large 556 PRINCIPLES OF SURGERY. tumor behind the right axilla. A 3eai' later this swelling had diminished in size to that of a pigeon's egg, and then again inereased in size. Ulcera- tion set in, exposing a fungous, bleeding surface. At this time the entire trunk, but not the limbs, was covered with nodules, spots, and stripes. The infiltration was located in the corium. This case is remarkable for the chronicity of the disease, the multiple points of regional infection, and the limitation of secondary infection with pus-microbes to a few isolated nodules. At tlie meeting of the German Society of Surgeons, in 1889, Leser reported 3 cases of primarx^ actinom3'Cosis of the skin that had come under his own observation in the course of a single year. In his remarks on this subject he placed special stress on the manner in Avhich the disease extends. In the periphery of the primar^^ lesion he found numerous minute nodules, later becoming the seat of destructive changes, resembling in this respect the clinical features of tuberculosis of the skin. The extension of the disease in the direction of the deep tissues takes place by the formation of passages corresponding to the size of a lead-pencil ; these are filled with 3^ellowisli-gray or reddish-gray granulations, which attack and destroy tissues, irrespective of their anatomical structure. The l^-mphatic glands were always found intact. 2. Alimentary Canal. — Tiie frequenc}- with whicli the disease affects the mouth mid jaws of cattle is explained by the occurrence of numer- ous points of injury- caused by masticating rough food, that furnishes the necessary infection-atrium through which the fungus invades the tissues. Teeth. — In man infection takes place fre(piently through carious teeth, and through abrasions in the gums and mucous membrane of the mouth. Israel found the fungus in the cavities of carious teeth, and Partsch detected in the same localitx^ almost pure cultures without any manifestation of disease except chronic peri-odontitis. The fungus occurs here often side b}^ side with leptothrix. Tongue. — Hochenegg saw a case of actinom3'cosis of the tongue caused by an infected carious tooth. Tiie swelling was the size of a cherry, located near the apex of the organ. The affection had existed for two months. The growth was excised, and on examination was found to consist of granulation tissue, with a central yellow mass the size of a millet-seed. Besides this case only 3 cases of actinomycosis of the tongue are on record, — 1 primary, 1 secondary to disease of the jaw, and 1 metastatic. Jaws. — Tliat carious teeth furnish a frequent infection-atrium in maxillarj' actinomycosis is well known, and in many instances the disease in its early stages has been mistaken for an ordinary dental CLINICAL VARIETIES. 557 affection, and patients have often songht relief at the hands of a dentist. The lower jaw is most frequenth' affected, the growth being connected with the bone or situated close to it, or it has already- extended to the submental or submaxillary region. The disease often pursues a chronic course, closel}' simulating periosteal sarcoma, until it reaches the loose tissues of the neck, when rapid extension takes place, in a downward direction, along the subcutaneous connective tissue and the inter- muscular septa. Israel refers to a case in which the actinomycotic swelling in the submaxillar}' region extended, in five months (August to December), to the level of the thyroid cartilage. When the disease is primaril}^ located in the upper jaw, which, however, occurs onl^'in excep- tional cases, it tends to invade rapidly the adjacent soft parts, and even to implicate the base of the skull and the brain. The prognosis is always more serious when the disease affects the upper than the lower jaw, as the tendency here to invade the deep structure is much greater. Two cases of actinomycosis in man have come under mj^ observation, and as both of them originated in the mouth, and repre- sent, from a prognostic point of view, two distinct classes, I will describe them briefly. The first patient was a man 30 years of age, German bj' birth, and a soda-water manufacturer b}- occupation. His business required him to make frequent trips into the countr}- bj- team. He had no recollection of having come in contact with cattle suffering from " swelled head" or "lumpy jaw." During the winter of 1886 he suffered from what he supposed was an ordinarj^ cold ; the right side of the lower jaw was swollen and painful. As one of the molar teeth showed evidences of deca}' and had become loose, it was extracted. The pain and swelling, however, did not improve, and the attending physician extracted all of the molar teeth of the lower jaw on that side. At this time a fungous mass commenced to appear over the surface of the edentulous bone. The cheek on the affected side was also greatl}' swollen. The patient was admitted into the Milwaukee Hospital about six months after the first SA'mptoms had appeared. At this time the lower jaw, in the mouth, presented a fungous mass extending from the angle of the bone to the first bicuspid ; the swelling extended as far as the tonsil. The cheek was enormoush- swollen from the angle of the mouth to the lower margin of the parotid gland. The skin over the swollen part presented a pale, gloss}' appearance, and the superficial veins were considerably dilated. Around the margin of the swelling no distinct border-line could be felt, the infiltrated parts fading graduall}" into the health}' sur- rounding tissues. Free suppuration from the surface of the fungous granulations, and a number of small abscesses had dischnrged themselves 558 PRINCIPLES OF SURGERY. into the cavity of the month. As some donbt existed as to the char- acter of the inflammation, carefnl and repeated examinations were made of the pus removed from the small abscess-cavities, and on several occa- sions fragments of actinomyces were found. The discovery of the specific cause of the inflammation cleared up the diagnosis and furnished an urgent indication for operative treatment. An incision was made along the lower border of the jaw from just below the articulation to near the symph3-sis, and, after arresting .'ill ha?morrhage, it was carried into the cavit}' of the mouth. The alveolar processes of the jaw were affected, and were removed with chisel and cutting-foi'ceps. Wherever the periosteum showed signs of infiltration it was carefully scra[)ed awa}'-, and finally the whole bone surface was thoroughly cauterized. The infiltrated soft tissues were dissected out with knife and scissors ; the disease was found to hnve extended as far as tlie tonsil. The bottom of the wound was iodoformized and packed with iodoform gauze, while the external wound was sutured. The entire external wound healed In- primary union, and the cavity in tlie month closed slowly by granula- tion. The patient's general health continued to improve rapidly, until six weeks after the operation, when tlie neck below the scar became swollen, followed in a short time by the formation of abscesses reaching from the angle of the jaw to the clavicle, and posteriorly as far as the spine of the scapula. Numerous openings were made and efficient drainage established, but suppuration continued unabated, and the patient became extremely emaciated. The suppurative inflammation extended, and four months after the first operation the patient died ; the symptoms during the last days of life pointed to a hypostatic pneumo- nia. Actinomyces were continuous!}- found in the pus during the entire course of the disease. I believe that the recurrence of the disease was due to imperfect removal of infected tissues in the posterior and lower portion of the pharynx. The second case came under m}'^ care during the summer of 1887. The patient was a young man, employed on a farm. About five months before he was admitted into the Milwaukee Hospital he had a number of teeth extracted from the right upper jaw, under the belief that the teeth, some of which were decayed, were the cause of the pain and swelling in tliat region. The ph3-sician in attendance diagnosed sarcoma of the upper jaw, and sent the case to me for operation. On my first examina- tion, I found a swelling involving the right side of the face, extending from the zygomatic arch to near the lower border of the lower jar, in- volving the deep tissues, and connected with the alveolar processes of the posterior portion of the upper jaw. The swelling was firm and with- out well-defined margins. No evidences of suppuration. The historj- CLINICAL VARIETIES. 559 of the case, and particularly the location, extent, and physical properties of the swelling, led me to the opinion that it was the result of actinomj-- cotic infection. All infected tissue was thoroughly excised tlirough a large external incision, the jaw-bone scraped and cauterized. The entire thickness of the cheek, with the exception of the skin and superficial fascia, appeared to be transformed into granulation tissue. In the granu- lations numerous minute yellowish-gray bodies were found, which, under tlie microscope, showed the tjq^ical structure of the ray-fungus. The mj'^celia were not so bulbous as we find them pictured in the books, but the distal extremity appeared to be surrounded I)}- dust-like bodies, pre- senting the appearance of a small brush. These minute granules I re- garded as spores. In the first case, in which suppuration had taken place, I never succeeded in finding the actinom3-ces perfect and com- plete; in the second case the granulation tissue had not been destroyed by suppuration, and the fungus was found in a perfect condition and in a state of fructification. These cases present a striking contrast, both in regard to the local condition and the ultimate termination. In the first case secondary infection with pus-microbes had already taken place, and the phlegmonous inflammation that followed this occurrence prepared the tissues again for the diffusion of the actinom3-cotic process; while in the second case the inflammatory process had not passed beyond the granulating stage, and the boundar3'-line between health}^ and diseased tissue was also more distinctly marked, — a most important factor in the operative treatment. The first patient died from recurrence of the disease in the vicinit}' of the operation wound and its extension to the neck and chest; while in the second case the wound healed, and the patient has remained in i^erfect health since. 3. intestinal Canal. — In primary intestinal actinomycosis the disease is caused b}' ingress of the fungus with food or water, and its implanta- tion upon the mucous surface. At the point of implantation the fungus multiplies, and by its growth invades the submucous tissue, which becomes the seat of active tissue proliferation. Arrest and implantation of the actinomyces are determined by antecedent pathological changes. Chiari has given an excellent account of the pathological condition found in a case of intestinal actinomycosis that came under his observation. Tlie patient was a man 36 years of age, who during life presented, as the most prominent clinical feature, progressive marasmus. At the necropsy chronic tuberculosis in the apices of the lungs and a few tubercular ulcerations in the lower portion of the ileum were found. The large intestine presented a verj' remarkable appearance, the mucous mem- brane of which, except the caecum and ascending colon, was covered with whitish deposits, forming round and oblong patches, some of them 1 560 PRINCIPLES OF SURGERY. cubic cenliiuetre in diameter and 5 millimetres in thickness. In some of these patches could be seen minute yellowish-brown and yellowish-green granules. The patches were firmly adherent, and when removed left a loss of substance in the mucous membrane. The mucous membrane throughout was in a state of catarrhal inflammation. On microscopical examination the grannies proved to be actinomyces. The mycelium had penetrated into the tubular glands and showed calcified, club-shaped conidia. The calcification of the club-shaped extremities had undoubt- ed\y prevented deeper penetration of the fungus. Hochenegg presented a case of actinomj-cosis to the Medical Society' in Vienna in a man 43 years of age, who had sustained an injury of the abdomen nine months l)reviousl3', and had since that time noticed a painful swelling at the seat of injury. In the region of the umbilicus a fistulous opening formed, which continued to discharge a thin secretion, in which actinomj^ces were constantly found. The patient was very much emaciated and many of the teeth carious. There was no swelling about the jaws or neck. Ex- amination of the organs of the chest and the sputum revealed no addi- tional diagnostic information. The author expressed the opinion that the inflammatory swelling caused by the contusion furnished the necessary conditions for the localization of actinomyces from the intestinal canal. Zemann reports 5 cases of actinom^'cosis of the abdomen. In 4 of them the disease commenced with sharp, lancinating pains in the abdomen, and during their course presented the clinical picture of chronic peritonitis. Swellings could be found in one or more places in the anterior abdominal wall, and the abscesses were either incised or opened spontaneously, and in 3 cases thej- communicated with the in- testinal canal. The first case was a woman, 30 years of age, who had a fistulous opening in the anterior abdominal wall which communicated with a swelling in the left parametrium. The patient stated that this swelling appeared soon after her last childbed. A constant discharge of yellowish-red pus was maintained, in which, under the microscope, nu- merous actinom3'ces could be seen. The patient died of exhaustion, and at the post-mortem chronic para- and peri- metritis were found, with ex- tensive pus-cavities that communicated with the rectum and 1)ladder. The second case occurred in a person 18 years of age, who, during life, had suffered from a large abscess in the abdominal cavit3', under the right lobe of the liver, which communicated with the intestinal canal, and had led to numerous fistulous openings in the anterior abdominal wall. At the necropsy a loop of the ileum was found perforated and in communication with the abscess-cavit}-. The pus contained numerous actinomyces. In the third case the diagnosis was made post-mortem b\'' CLINICAL VARIETIES. 661 the discovery of actinomyces in the pus. The disease was located in the lower portion of the ileum and caecum, where it had caused suppura- tion and numerous adhesions. A most remarkable and interesting- histor}' is connected with tlie fourth case. A robust, well-nourished woman, 40 3'ears of age, was attacked quite suddenly with pain in the stomach, high temperature, diarrhoea, and vomiting, followed by cerebral symptoms and death. At the necropsy the riglit Fallopian tube was found transformed into a large abscess, both extremities of the tube closed, and walls of sac lined with granulations containing actinomj'ces. The fifth patient was 50 years of age, and had suttered for a long time from lancinating pain in the abdomen ; a fistulous opening formed in tlie umbilical region and discharged a thin, 3'ellowish-green pus. The post- mortem showed actinomj'cosis of the peritoneum, small intestine, left ovarj-, and liver ; large abscess among the intestinal coils ; perforation of small intestine and bladder. In the upper part of the small intestine small pigmented cicatrices were found. In all of the above cases the microscopical examination revealed the presence of actinomyces in the granulation tissue as well as in the pus of the abscess-caAities. In a case of intestinal actinom3'cosis reported by Langhans, the disease started evidently from the appendix vermiformis, 4 centimetres in length, the end of which appeared as if transversel}' cut in an abscess- cavity the size of a walnut. The abscess was on the right side of the bladder, and so deep in the pelvis that during life it could not be located. The abscess pursued a chronic course, and the walls were well defined ; no signs of chronic or acute peritonitis. Furthermoi'e, the mucous membrane of the appendix was studded with cicatrices, and presented a slate color. The principal seat of the actinomycotic process was in the liver. In a second case reported by the same author tlie clinical course of the disease resembled perityt)hlitic abscess. The necropsy showed perforation of the caecum and ascending colon. No cicatrices in the mucous membrane or surrounding tissues. In all probability^, the perforations occurred from without inward. Luening and Hamm have recently reported, with interesting details, a case of primary actinomycosis of the colon with metastatic deposits in the liver. The patient was a man 28 years of age, who, in 1880, suffered from an acute abdominal affection, which at the time was diagnosed as typhlitis. Four years later a second attack occurred, attended b}' symptoms of intestinal obstruction. Patient was very ill for eight days, when the symptoms of obstruction subsided, and he made a slow recovery. During the 3-ear 1887 he had a third attack, attended by high fever and absolute constipation for eight to ten daj'S. During the month of December of the same 3'ear he had another but less 562 PRINCIPLES OF SURGERY. severe attack, and at this time a hard swelling made its appearance in the right side of the abdomen. From this time until he was admitted into the liospital, April 5, 1888, he was confined to bed. The patient was at tliis time greatly emaciated, with a temperature of from 38.4° C. to 39.8° C. Swelling tlie size of a fist in the right side of the abdomen, half-way between umbilicus and anterior superior spine of the ileum. Externally this swelling presented redness and oidema. Fluctuation indistinct. Deep palpation showed tliat the swelling extended to right h3'pochondrium ; abdomen not tympanitic. Swelling painful and tender, pain extending to spermatic cord and testicle on same side. A few da3^s later abscess was incised, and nearly a quart of brownish pus, having a fsecal odor, escaped. Digital exploration revealed an irregular cavity, whose walls at some points were plainly- lined with intestinal coils. Disinfection and drainage. As the symptoms did not improve materiall}', the abscess-cavity was again scraped out and disinfected four weeks later. After the second operation it was noticed that the pus contained yellow granules, which, under the microscope, were shown to be actino- myces. The abscess was incised a third time, but the patient kept losing- ground, and died October 9th. The autopsy revealed primarj'^ actino- m^'cosis of the ascending colon, with multiple fistulous perforations. A metastatic actinom^'cotic abscess of the liver had perforated into the hepatic vein, resulting in multiple metastases in the lungs. The cases of intestinal actinomj-cosis reported above warrant the opinion that the mucous membrane of the intestinal canal is frequentl}^ the seat of primar}' localization of the actinomyces, thus corroborating the state- ments of Johne in reference to this disease in animals. BRONCHIAL TUBES AND LUNGS. If an actinoiuyces should be inlialed with the inspired air, and should become implanted upon the bronchial mucous membrane, and find favorable conditions for its growth, the granule will become sur- rounded by new cells derived from the pre-existing epithelial cells, and thus become the centre of a minute granuloma. By multi[)lieation of the actinomyces new nodules are produced, around each of which the pre-existing tissue is transformed into embr3'onal tissue, wiiicli in time is destroyed, resulting in suppuration and loss of tissue. Israel reported a case of actinom3'Cotic abscess of the lung caused bj?^ the entrance of an infected tooth into the air- passages. In this instance the fungus was conveyed into the bronchial tube with the carious tooth, and the infected foreign body became the centre of the specific inflammation. Cases of primary actinomj-cosis of the lungs, however, have been BRONCHIAL TUBES ANt> LUNGS. 563 observed where no such direct carrier of the contagiiim coukl be foiiiul, and in which infection must have occurred by the direct inhalation of the fungus or its spores with the inspired air. Szcnas}- found, in the case of the wife of a butcher, who had suffered for nine 3'ears from severe pain in the right side of the chest, latterly attended b}' a severe cough, in the right manunarv region, a fluctuating swelling, the size of a hen's egg, covered with normal skin. On the outer side of this swelling, in the intercostal space between the tliird and fourth ribs, another swell- ing existed, double in size and elongated in shape, and with indistinct margins. This latter swelling has been noticed for nine j'ears, and was tender to the touch. Auscultation OA'er the fourth and fifth intercostal spaces on the healthy side revealed bronchial breathing and diffuse bronchial rales. Temperature, 38.4° C. (101.1° F.). The urine contained a trace of albumen. By aspiration 150 cubic centimetres of thick, j-ellow Fig. 101 .—Actinomyces from Lttng of Cow. Fungits in the Centre of Inflammatory Product. X 350. (Marchand.) A, normal epithelial cells of bronchus attached to connective tissue ; B, large epithelioid cells ; C, leucocytes. pus were removed, and contained colonies of actinomyces. Actinom3'ces were also found in the sputum. The patient had carious teeth, but no signs of actinomycosis could be detected in the mouth. Canali relates the clinical history of a girl, 15 years of age, who had suffered for eight years from a cough, attended by a scant}', fetid expectoration. Inspection and percussion j-ielded only negative results. Auscultator}' symptoms pointed to a diffuse catarrh. Under the micro- scope the sputum was seen to contain pus-corpuscles, epithelial cells, and numerous actinomj'ces. No primary- source of infection could be found in the mouth, phar^mx, or nose. Moosbriigger interprets the mechanism of the ingress of actinom3'ces by assuming that the fungus enters the In'onchial tubes during inspira- tion, and becomes at first deposited upon the mucous membrane, where its pi'esence and growth cause a destruction of the epithelial cells, when it reaches the submucous and peri-bronchial tissues, in which a nodule 564 PRINCIPLES OF SURGERY. of granulation tissue is prodnc(Ml that by pressure induces degenerative changes and gradual destruction of the broncliitvl wall for further infec- tion. He believes that the pori-l)ronchial lyni[)hatic vessels and glands take an active part in tlie local diffusion of the process, as they furnish an avenue for the dissemination of the fungus or its spores. He claims the existence of an actinomycotic lymphangitis, but confesses that he has never seen the fungus inside of lymphatic vessels. As soon as the fungus reaches the pulmonary tissues, it gives rise to parenchymatous inflammation, whose first protluct is always granulation tissue, which, at a later stage, and under the influence of a secondary infection with pus- microbes, undergoes transformation into pus-corpuscles and the formation of abscesses. ACTINOMYCOSIS OF BRAIN. Quite recently, Bollinger placed on record the first case of primar3' actinomycosis of the brain. The patient was 26 years of age. The intra vitam diagnosis was tumor of the brain ; the most prominent symp- toms were severe headache, paral^'sis of left abducens, congestion of optic papilla, and momentary unconsciousness. The swelling in the brain, found on autopsy, presented the characteristic features of a cysto- myxoma in the third ventricle ; all of the ventricles were found consid- erably dilated. The swelling contained numerous colonies of actinomyces in all possible stages of development. The tendenc}- to suppuration of the tissues, usually found in all cases of actinomycosis in man, was entirely absent in this case. This case, if any, appears to be one of cr^'ptogenetic infection, as the fungus or spores must have entered somewhere through the cutaneous or mucous surface without producing the disease at the primary' portio invasionis^ and, localizing in the brain b}^ embolism, resulted in primary actinomycosis in this organ. Keller (Brit. Med. JouDial, March 29, 1890) reported, this year, a case of metastatic actinomycosis of the brain in which a correct diagnosis was made during life. The patient was a middle-aged woman, who suffered from pleurisy, and six months thereafter abscess developed over the cartilages of the sixth and eleventh ribs, in the pus of which actino- m^'ces were found. Two years later increasing paresis of left arm developed, followed b}' convulsions, confined at first to the arm, then becoming general, and at times identical with cortical epilepsy-. Diag- nosis of actinomycosis affecting the motor area was made ; operation was suggested and declined. The paresis extended to left lower extremity and left side of face ; later, convulsions, headache, vomiting, and loss of consciousness, soon deepening into coma. Burger then obtained consent to operate. The patient ■syas moribund, and required no anaesthetic. He exposed the right ascending parietal convolution, incised the dura mater SiMPTO^MS AND DIAGNOSIS. 565 and the discolored brain-surface, and removed 2 ounces of thin, greenish pus, in which were found actinoin^ces in great abundance. When the pus was evacuated, she recovered from the deep coma, and, while still on the operating-table, called for water. On the following day consciousness returned, and on the eighth the facial paralysis disappeared. In two months the wound had healed and the paralytic lesions improved, but there remained some paresis of left arm, with contraction of the fingers. In less than one year there was a recurrence of the symptoms, and Burger re-opened the brain-abscess, followed by the escape of a considerable quantitj' of pus. No material improvement followed, and the patient died a few days thereafter. At the post-mortem, the middle third of the right frontal and parietal convolutions was occupied by a large mass of newlj^-formed tissue, protruding over the surface and reaching into the substance of the brain for one inch. Underneath it, deeply- buried in the white sub- stance, an unopened, encapsulated abscess, the size of a nutmeg, was discovered. SYMPTOMS AND DIAGNOSIS. Actinomycosis is an inflammatory^ disease that clinically is noted for its chronicit}'. The specific product, composed of granulated tissue, is abundant, and the swelling, often of considerable size, resembles more a tumor than an inflammatory swelling. The extension of the morbid process takes place by eflfusion of the actinomyces in loco, in preference along the loose connective-tissue spaces, each fungus constituting a nucleus for a nodule of granulation tissue. By confluence of many such nodules the inflammatory swelling often attains a very large size, and when suppuration occurs in the interior the further history is that of chronic abscess. Regional dissemination of the infective process never takes place through the lymphatic glands. When the lymphatic struc- tures become implicated, it is an indication that secondary infection has taken place. In exceptional cases the disease pursues quite a rapid course, and may then be mistaken for an acute phlegmonous inflamma- tion, osteomyelitis, or, when diffused over a large surface of the bod^', for syphilis. A good illustration of the former class is furnished by the case reported by Kapper. A soldier, 22 ^-ears of age, became suddenly ill with febrile symptoms and a rapidl^'-increasing swelling of the lower jaw. An early incision was made and liberated a large quantity of pus, which, on microscopical examination, was found to contain actinomyces. It is interesting to note that in this case the various teeth from where the infection had evidently taken place contained threads of leptothrix and actinomyces. At a meeting of the Berlin Medical Society, about two years ago. 566 PRINCIPLES OF SURGERY. 0, Israel gave an accurate description of the post-mortem appearances of a case of diffuse actinomycosis. The patient, a woman 44 years of age, had been treated for syphilis in one of the surgical clinics. The heart contained a number of minute abscesses containing the fungus in large numbers. A large abscess between the diaphragm, stomach, and spleen contained tliick pus of a greenish color, — an unusual occurrence in cases of actinomycosis, — but no actinomyces. The spleen was tlie seat of large and numerous minute abscesses, and the liver and kidneys also contained small abscesses, and in all of them actinomyces were found. Israel claims that this case alfords a good illustration of his view that the actinomyces, as regards its effect on the tissues, occupies a position half-way between the bacillus of tuberculosis, which produces onl}' granu- lation tissue, and the pus-microbes, which produce pus. It was im- possible in this case, as in so many others in which multiple deposits have been found, to locate with accurac}' the primary seat of infection. The teeth were perfect and the whole digestive tract showed no evidence of disease. Metastasis in actinomycosis takes place in the same manner as in p3'8emia and malignant tumors. At the primary seat of infection the fungus or its spores gain entrance through a defective vein-wall into the general circulation, and, at tlie point of arrest in a distant capillar}- vessel, establish an independent centre of infection, with all the attri- butes of tlie primary infection. General infection is of rare occurrence in actinom3^cosis, as this disease is noted for its tendenc}'^ to extend locally, where it often results in external regional dissemination and destruction of tissue. Actinomycosis resembles, in its clinical behavior, very closely the malignant tumors, in that it will invade ever}^ tissue with w^iich it comes in contact, irrespective of its anatomical structure. Primary localization is very apt to occur in the connective tissue, and in preference it extends along this structure; but periosteum, bone, muscles, tendons, cartilage, — in fact, all of the tissues of the bod}*, — succumb to the fungus as quickly as the}' become infected. In actinomycosis of the jaws and the vertebra we often find exten- sive destruction of bone, with large abscesses communicating with the primary lesion. Before suppuration takes place the actinomycotic swell- ing is quite firm on pressure, and, if the disease extend rapidl}', it is surrounded by a diffuse oedema. Pain and tenderness are usually never severe, and often almost wanting. Redness appears as soon as the in- fection has extended to the skin. Suppuration usually develops in con- sequence of direct infection with pus-microbes through some minute surface defect in the swelling. As soon as suppuration sets in, the swell- ing not onl}' increases rapidly in size, but regional diffusion is hastened by the breaking down of the granulation tissue that before held the PROGNOSIS. 567 fungi fixed in their respective localities. The same tendenc}' to migra- tion of an actinomycotic abscess is observed as in tubercular abscess. The characteristic feature of actinomycotic pus is the presence of minute, macroscopical, yellowish granules ; the actinomyces,on careful inspection, can almost always be discovered. If these granules are placed under the microscope their characteristic structure will at once become apparent. In cases of actinomycosis of any of the internal organs, attended by suppuration and discharge of pus through some one of the outlets of the body, the diagnosis will usually depend almost exclusively upon the detection of the fungus in the discharges. Microscopical examina- tion of the sputum and faecal discharges, in cases of suspected actinomy- cosis of the lungs or the intestines, is the onl}- positive means of making a differential diagnosis between these affections and pulmonary and in- testinal tuberculosis. Actinomycosis of the skin, mouth, tongue, and jaws might be mistaken for sarcoma, carcinoma, tuberculosis, and sj-ph- ilis. As, with the exception of carcinoma, all of these affections present under the microscope a histological structure that it would be often dif- ficult to identify microscopically-, tlie differential diagnosis bj^ means of the microscope must rest on the detection of the raj'-fungus imbedded in the granulation tissue. Sarcoma does not suppurate or break down as early as the actinomycotic or tubercular swelling. Carcinoma primarily starts in the epiblast or h3-poblast, and, even during the earliest period of the growth, there is no difficult}' in demonstrating an intimate relation- ship between the skin or mucous membrane and the tumor encroaching upon the mesoblast. In actinom^'cosis, tissue proliferation takes place around each fungus in the mesoblast, and the skin or mucous membrane is infected and destrov^ed from within outward. In tuberculosis, regional infection almost always occurs through the medium of the lymphatic vessels and glands, while these structures are seldom or never invaded in actinomycosis. In the absence of microscopical proof of the nature of the lesion, it may become necessary to resort to a therapeutic test in differentiating between syphilis and actinomycosis. Large doses of po- tassic iodide, administered four times a da}*, will have a decided effect in reducing the size of a gumma in the course of two or three weeks, while no such result will be obtained if the lesion is of an actinomycotic nature. PROGNOSIS. Actinomycosis is a more dangerous affection than tuberculosis. While a spontaneous cure not infrequently' takes place in the latter, we have no proof that actinomycosis ever terminates in such a satisfactory manner without the surgeon's aid. Actinom3'cosis of the internal organs proves fatal almost without exception on account of the inaccessibility 568 PRINCIPLES OF SURGERY. of the disease to radical surgical treatment. In such cases numerous fistulous openings form, discharging profuse quantities of pus, and the patient dies in from one to two or three 3'ears from exhaustion or am}'- loid degeneration of the internal organs. If the disease is located in external parts, local extension often takes place very slowly until sup- puration sets in, when the actinomycotic abscess migrates from place to place, attacking all the tissues that come in its way, and life is finally destroyed I)}' pyaemia, sepsis, or exhaustion. The prognosis is always favorable when the disease is recognized early, and when it is located in parts accessible to a radical operation. As metastasis is of rare occur- rence in actinom^'cosis, complete removal of the primary focus is followed by a permanent cure. TREATMENT. General treatment in actinoraj^cosis is of no avail, and all local measures, short of complete removal of the infected tissues, result in more harm than good, as the)'' often give rise to secondary infection with pus-microbes, w^hich alw^ays aggravates the local conditions and hastens a fatal termination. In cases where a radical operation is out of question on account of the extent of the disease or the importance of organs involved in the process, parenchymatous injections of a 2-per- cent, solution of boric acid, a 1-to-lOOO solution of corrosive sublimate, or a l-to-1500 solution of nitrate of silver might be tried ; but, on the ■whole, such injections have little influence in arresting the local exten- sion of the disease. The surgical treatment of actinomycosis, before suppuration has occurred, consists in the excision of the infected tissues in all cases where such a procedure is practicable. The incision should be carried some distance, at least I- to I inch, from the visible granula- tions, with a view of removing not only the inflammator}- tissue, but also the minute invisible foci in its immediate vicinity. If, after the excision, suspicious tissue is found in the wound, this should be removed by a careful dissection with forceps, knife, and scissoi-s, or destroyed by using the actual cautery. Acids and other chemical caustics should not be relied upon in destro3-ingthe infected tissues. An actinomycotic abscess should be treated on the same principles as a tubercular abscess. The abscess-cavity is freely exposed by lading open the fistulous openings, and the granulation tissue is removed with a sharp spoon. Undermined skin is cut away with scissors. If the disease has extended to bone, this is also thoroughly scraped, and it is a good plan, after the cavity has been thoroughly irrigated and dried, to cauterize the whole surface with the actual cautery. Such wounds should not be sutured, but packed with iodoform gauze in order to keep the infected area readily accessible to inspection, so as to enable the surgeon at each dressing to recognize a TREATMENT. 569 local recurrence. Should this occur, the same means are to be repeated in eliminating the infected tissues. As soon as the wound is covered with health}' granulations it mu}- be closed b}^ secondary suturing, or, if this cannot be done on account of too great loss of skin-tissue, the defect is covered with large skin-grafts according to Thiersch's method. Repeated scraping operations will often succeed in finally eradicating the disease, provided the infected parts are accessible to vigorous curetting and the application of the actual cautery. CHAPTER XXIII. Anthrax. Synonyms: Contagions carbuncle ; cliarl)on ; Milzbrand ; malignant pustule; wool-sorters' disease. The ni3cology of anthrax is better under- stood than that of an} other niicrobic disease. The bacillus of anthrax is the largest of the known pathogenic microbes, and ever since it was discovered it has been a favorite subject of investigation in every labora- tory and by every bacteriologist. HISTORY. As a disease among animals, anthrax has been known since the earliest records of historv. The contagiousness of this disease has been recognized since the beginning of the eighteenth centur}'. During the first part of the present century it was described as a blood disease. Heusinger. in his classical work, " Die Milzbrand Krankheiten der Thiere nnd des Menschen " (Erlangen, 1850), declared anthrax to be a malarial neurosis. In the year 1855 Pollender published his discoveries, which inaugurated a new era in the study of anthrax. As early as 1849 he discovered, in the blood of cattle suffering from anthrax, a mass of innu- merable, fine, rod-like bodies, which appeared to be of a vegetable nature and resembled vibriones. Branell found the same rods in the blood of men, horses, and sheep which had died of anthrax. He also detected the same bodies during life in the blood of the diseased animals. Dela- fond regarded this parasite as a variet}' of leptothrix. In 1863 appeared the work of Davaine, wherein he pronounced these rods to be bacteria, .and later he called them bacteridia. He believed them to be the essential cause of anthrax, as the disease could not be found in blood that did not contain them. Through the labors of Pasteur, Koch, Nsegeli, Bollinger, and others, the bacterium found so constantly in the blood and tissues of anthracic animals finally found a permanent place as the bacillus anthracis among the schizomA'cetes. The first reliable and positive accounts of the disease in man we owe to Fournier, Montfils, Thomassin, and Chabert, who published their de- scription of the disease between the j-ears 1769 and 1780. Fournier first distinguished the spontaneous and the communicated carbuncle of man. The primary existence of anthrax in man was asserted by Bayle in 1800 and bv Bsivy la Chevrie in 1807. (571) 672 I'lUNCIFLES OF SURGERY. DESCRIPTION OF THE BACILLUS OF ANTHRAX. Non-motile rods, 5 to 10 micro-millimetres long and 1 to 1.25 micro- millimetres broad, and threads made up of rods and cocci. The rods, as a rule, are straight ; only when they grow to a con- siderable length and meet with resistance they become slightly curved. The rods and threads are round, and, with their threads truncated at right angles, appear as though they had been cut otf obliquely. The interior, as long as lission does not proceed, is perfectly homogeneous, and absorlts aniline dyes very readily and uniformly. The development of spores in long, undivided threads, as we find them in fluid culture media, takes place at regular intervals, where we find them as bright, oval spots that become more and more apparent, marking tlie direction of the rods. Upon solid culture media the development of spores is preceded <^ 6bi> «» Fig. 102.— Anthrax Bacilli. Spoke Formation anb Spore Germination. (Koch.) a. From the spleen of a mouse after twenty-four hours' cultivation in aijuenus humor. Spores arranged in rods like a string of pearls. X650. B. Germination of spores. X^50. C. The same greatly magnified. X ItioU. by transverse segmentation of the rods. The cell-membrane of each section finally becomes the membrane of the spore, each pole of the spore presenting a small mass of protoplasm that can be stained. (a) Staining. — Cover-glass preparations of fluid specimens can be stained with a waterj' solution of any of the aniline dyes. They can be rapidl}- stained with a drop of fuchsin or gentian-violet, but more satis- factorily' b}' floating tlie cover-glass for twent3'-four hours. The prepara- tions are dried and mounted in Canada balsam. The spores are not stained by the ordinary methods. Tissue-sections containing bacilli are best stained b}- Gram's method, and after-stained with eosin or picro- carminate of ammonium. By double staining the rods are seen to consist of a hy.iline sheath with protoplasmic contents. (b'i Cultivation. — The bacillus of anthrax grows luxuriantly in dif- ANTHRAX BACILLI IN THE LIVING BODY AND THE SOIL. ,'u'S forent fluid and solid nutrient medio. Bouillon and aqueous humor of the eye furnish an excellent soil, but for inoculation purposes the cultures are now generallj^ grown upon solid nutrient media. Gelatin. — If a nutrient medium containing from 5 to 8 per cent, of gelatin is inoculated, a whitish line develops in the track of the needle- puncture, and from it fine filaments spread out on the sides. In a more solid nutrient gelatin the growth appears only as a thick, white thread. The culture liquelies the gelatin, and the growth subsides as a white, flocculent mass. Plate Cultures. — Cultures upon a sloping sur- face of solid nutrient agar-agar or gelatin form a viscous, snow-white plaque. "Without access of air the culture does not grow, the bacilli being aerobic. Potato. — Inoculation of sterilized potato yields a very characteristic growth. The deep chamber containing the potato is placed in the incubator, and in about thirty-six or forty-eight hours a creamy, very faintly yellowish layer forms over the inoculated surface, with, usuallv, a pecxiliar trans- lucent edge. On removing the cover of the damp chamber, a strong, penetrating odor of sour milk is emitted. MULTIPLICATION OF ANTHRAX BACILLI IN THE LIVING BODY AND THE SOIL. In the body of living animals the bacilli multipl}' exclusively b}' segmentation, and never produce spores. Spores are produced only in dead nutrient media, and under certain conditions only, PERATUREa6°Toi8°c.). ' •' ' Four Days Old. Natu- among which a proper temiierature is the most im- ^^^ f^A^^" , > portant factor. The limits of the temperature vary between 12 to 18° C. and 43° C. ; at a temperature of less than 12° C. growth of the rods and spore production no longer take i)lace. Pasteur's assertion that bacilli and spores in the cadavers of bui-ied animals are active Avhen l)rought to the surface by earth-worms is im- probable. The disease, according to Koch, is spread among animals by germinating spores which attach themselves to plants and grass in swamps and along river-banks, and which, when taken in with the food, become the cause of intestinal anthrax. Schrakamp and Friedrich are of the opinion that bacilli can multiply in the superficial layer of the soil, while Kitt maintains Fig. loa.— Stab Cul- ture OF Anthrax Bacilli in Gelatin, Grown at Room-Tem- 574 PRTNCIPLKS OF SURGERY. lli.'it fructitication of the l):iciUi takes place in tlio manure deposited in pastures. INOCULATION EXPERIMENTS. In order to cause death of animals b^ inoculation with the bacillus of anthrax, a pure culture or anthracic blood must be injected into the subcutaneous tissue or into the circulation, or the virus may be trans- mitted by inhalation or b}- feeding. Goats, hedgehogs, mice, sparrows, cows, horses, guinea-pigs, and sheep can l)e readily infected. Rats are less susceptible. Pigs, dogs, cats, white rats, and Algerian sheep are immune. Frogs and fish have been rendered susceptible to anthracic infection by raising the temperature of the water in which they ,^-,/?=»;))) fr^''~ Pf^M ^ ^ 'S-. B Fig. 104.— Anthrax Colony upon Gelatin. x80. (Fluegge.) A, after tnenty-four hours : B, after forty-eight hours. lived. Koch produced the disease artificially in rabl^its and mice by injecting a drop of anthracic blood, with the result of producing death usually within twenty-four hours. After death sections taken from dirterent organs, stained in methyl-violet with carbonate of potash, were examined under the microscope, and the Ijacillus was found in great uliundance in all of them. When magnified fifty diameters such prepara- tions present, at the first glance, an appearance as if a blue coloring material had been injected into the vessels. Each intestinal villus is permeated by an exceedingly delicate blue net-work; in the mucous membrane of the stomach all the capillaries surrounding the gastric glands are stained blue ; in the ciliary processes each projection is injected, and a spiral vessel stained of a dark-blue color leads from INOCULATION EXPERIMENTS. O ir> thence to the iris and breaks np into a fine, blue net-work, with loops directed toward the edge of the iris. The liver and lungs and the glandular structures, such as the pancreas and salivary glands, are com- pletelj' permeated by the same blue, vascular net-work. Indeed, there is no organ which is not more or less injected with the blue mass. It is, however, ver}' striking that this injection is only present in the capillar}' vessels. All the larger vessels, even the arteries and veins of an intes- tinal villus, are either not at all stained or have but a light-blue streak in their interior, and that only here and there. When magnified 250 times one can see that the blue capillary net-work is composed of numerous delicate rods, and when a power of 700 diameters is used it is found that K[^ 1 Fig. 105.— Intestinal Villus of Anthracic Rabbit. The Bacilli in Capillary Vessels Alone Stained. x250. (Koch.)* the apparent injection is nothing more or less than the bacillus anthracis, stained dark-blue, and present in incredible numbers in the whole capillary system. In the other vessels, especially in the larger ones, often only a single li:icillus may be met with at long intervals, or they ma}' be quite absent. The distribution of the bacillus in the capillaries is not, however, iiuite uniform. There are fewer in the brain, in the skin, in the capil- laries of the muscle, and in the tongue than elsewhere ; on the other hand, in the liver, lungs, kidney's, spleen, intestines, and stomach the}' are always present in enormous numbers. In the capillaries themselves » Copied from " Traumatic Infective Diseases," by permission of the New Sydenham Society, London. 576 rKix^'iPLEs OF si'HfjEin*. tlie bacilli accumulate in largest numbers at the i)oint most distant from the nearest afferent artery and the efferent vein, — that is, at points where the blood-current is sloM'est. Where the bacilli are present in greatest abundance it not unfrequently happens that the capillaries become torn, and blood with the contained bacilli is extra vasated. This occurs most frequently iu the glomeruli. Man}* of these burst, and the bacilli pass into the uriniferous tubules. In mice the spleen is more especially the seat of the bacilli ; then come the lungs, and, last of all, the kidneys. Frisch inoculated tiie cornea in animals and produced a keratitis, caused by the bacilli, which multiplied with great rapidit}^, local dissemination taking place through the corneal spaces. INFECTION IN MAN. An intact skin furnishes ample protection against infection with bacilli or spores, but the slightest abrasion ma}- become the necessary infection-atrium for either method of infection. Infection ma}' occur through a health}' mucous membrane, either with bacilli or spores. As the anthrax bacillus is a non-motile parasite, penetration of the epithelial lining can onl}^ occur b}' local growth of the bacillus. Spores are such minute structures that they can reach the circulation through a healthy mucous membrane in the same manner and b}' means of the same agencies as we have found necessary for the transportation of other minute foreign parasites from a mucous surface into the circulation. In man infection frequently takes place through a small wound or abrasion in persons handling the infected products of anthracic animals, such as wool, hair, and hides. In other instances, insects, such as mosquitoes and flies, that have fed on the blood of living anthracic animals or the dead tissues of animals that died of the disease, may become disease carriers. The sting of such an infected insect may communicate the disease with the same degree of certainty as an intentional inoculation with a drop of anthracic blood or a minute quantity of a pure culture. INTENSIFICATION OF VIRUS. While it is known that some chemical substances exert an attenuating influence on the virulence of the anthrax bacillus, it has also been found that an attenuated virus will again become more virulent by adding certain substances. It must, therefore, be taken for granted that the chemical composition in which the bacillus is suspended influences, in one wa}'^ or the other, its virulence. It has been found, for instance, that tlie addition of a minute quantit}' of lactic acid to a fluid containing the bacillus in an attenuated form greatl}' intensifies its virulence within a very short time. Thus, Arloing, Cornevin, and Thomas found that the ATTENUATION OF VIRUS AND PROPHYLACTIC INOCULATIONS. 577 pathogenic power of a fluid containing these bacilli, to which ^Jg part of lactic acid had been added, and the mixture allowed to stand for twenty -four hours, was increased twofold; if, then, a little w-ater, con- taining a very easily fermentescible sugar, is added to the mixture, and another twenty-four hours allowed to elapse, the virulence nttains its maximum, and frogs inoculated with this virus die in from twelve to fifteen hours; whereas, when inoculated with ordinary virus, the^' live from fort}^ to fift}' hours. Kitt has repeated and confirmed these experi- ments. ATTENUATION OF VIRUS AND PROPHYLACTIC INOCULATIONS. ^y cultivating the bacillus of anthrax in neutralized bouillon at 42° to 43° C. (107.6° to 109.4° F.), for about twenty days, the infecting power is weakened, and animals inoculated with it are protected against the disease. A still greater degree of immunity is obtained by inoculat- ing a second time with material that has been less weakened. Animals thus treated are then protected against the most virulent form of anthrax, but only for a time. A temperature of 55° C. (131° F.), or treatment with 1- to 5-per-cent. solution of carbolic acid, deprives the bacilli of their virulence. The virulence of the bacillus is also altered by passing- it through different species of animals. Woolbridge secured immunity against anthrax in animals by cultivating the bacillus in an alkaline solution at a temperature of 37° C. (98.6° F.) for two days. At this time the fluid was filtered, and a small quantity of the filtrate injected into the subcutaneous tissue of rabbits ; these rabbits remained well, and subsequently resisted injection of most virulent anthracic blood. Hankin, under the guidance of Koch, at the Hygienic Institute of Berlin, isolated an albuminose from anthrax cultures, which, when in- jected into rabbits and mice in small quantities, rendered these animals immune against the most virulent cultures. The albuminose was pre- pared from the cultures by precipitation with absolute alcohol ; the precipitate was well washed in this liquid to free it from ptomaines, — since it is known that all such substances are soluble in alcohol. After the addition of alcohol it w^as filtered off and dried, then re-dissolved, and filtered through Chamberland's filter. Four rabbits were inoculated with virulent anthrax spores, and 3 of them received an injection of albuminose into the ear-vein at the same time; the latter recovered, wdiile the remaining animal not thus protected died, in about fort3^-eight hours, of anthrax. In another experiment, 10 mice were each injected with the millionth part of their bod3'-w^eight of anthrax albuminose and with active vaccine at the same time. Of these 3 died after 108 to 116 hours ; the others recovered. Three others had only the two-millionth part of 578 PRINCIPLES OF SURGERY. their bod \' -weight of anthrax albiiminose and active culture. Two of them survived. Four control mice were inocuhited, and all died of anthrax. He has come to the conclusion that wlien a large dose of albuminose is injected into an animal the entrance of anthrax bacilli into tlie system is aided, and when a small dose is administered imnui- nitj' is acquired against its poisonous properties, protecting the animal against subsequent inoculations with active cultures. Prophylactic inoculations of sheep with mitigated virus is carried on upon an exten- sive scale in France by Pasteur and his pupils, and recent statistics bearing upon their value in protecting the animals against anthrax have shown them effective in preventing the spread of the disease in infected districts. CLINICAL VARIETIES OF ANTHRAX, PriuKuy bronchial and pulmonar}' anthrax, caused b}- the inhalation of dust containing bacilli or spores, and primary anthrax of the intes- tines, caused by eating anthracic meat or by drinking water infected with spores, are diseases that are occasionally^ met with in man ; but, as these affections belong to the physician and not to the surgeon, the student should consult any of the modern text-books on the practice of medicine to become familiar with their sj^mptomatology. Buchner has studied experimentall3^ the entrance of the anthrax bacillus through the intact mucous membrane of the bronchial tubes. The bacillus and spores were administered by inhalations, in the shape of dry powder, and suspended in steam. On examining the bronchial mucous membrane at different stages under the microscope, it was seen that the spoi'es were transformed in a very short time into bacilli, and that the latter, by their growth, pushed themselves between the cells and into the capillary vessels. It was observed that the greater the pulmo- nary irritation, the more the passage of the microbes was retarded. The entrance of the bacilli from the surface of the mucous membrane into the capillary vessels was seen to depend on an active process. Secondary anthracic bronchitis, pneumonia, and enteritis are met with in almost all cases of localized anthrax followed by secondary general infection. Primary intestinal anthrax in man was studied by Wahl, Recklinghausen, Buhl, Wagner, Bollinger, Leube, and Frankel, and all of these authors succeeded in demonstrating the presence of the essential microbic cause in the inflamed mucous membrane. When the microbe enters the body through the mucous membrane of the gastro- intestinal canal with the food or drink, it gives rise to a primar}' anthrax of the intestinal canal, that again may become general by metastatic dis- semination through the systemic circulalioii. Localization upon the mucous surface first takes place upon the most prominent part of the CLINICAL VARIETIES OF ANTHRAX. 579 valvulse conniventes on the mesenteric side of the bowel, and from here the infection spreads over the entire siirfnce. Vierhoft' lias collected 41 cases of anthrax intestinalis, the total number found rei)orted up to 1885. The author himself observed 2 cases of secondary intestinal anthrax in the hospital at Riga. Cases of secondarj' intestinal anthrax — that is. localization of the bacillus of anthrax in the mucous membrane of the intestinal canal after external infection — were known to the older authors while observations of primarj' localization in the digestive tract date onl^- from the middle of the last century. As soon as general infection has taken place, the diffusion throughout the capillary system is the same as has been described under the head of Inoculation Experiments. The forms of anthrax that concern the surgeon most are those whicli result from infection of the external surface by the introduction of the bacilli or spores through a small wound, abrasion, or the stins: of an infected insect. The favorite location for the development and growth of the anthrax bacillus in man and beast is in the connective tissue; it is, therefore, immaterial in what manner the microbe reaches this tissue, as localization here marks the beginning of the disease. The clinical forms vary according to the location of the disease, its extent, and the intensit}' of the infection. Most all authors follow Bollinger's classifica- tion, according to which all cases are brought under one of the follow- ing varieties : 1. Anthrax acutissimus, or apoplectiformis. 2. Aciitis. 3. Subacutis. The primary location of the disease is in accordance with the manner in which infection has taken place. W. Koch states that in animals and man the bacillus can enter the organism through one of the following routes : (a) through the skin ; (6) gastro-intestinal canal ; (c) respirator^' passages. Anthrax of the Externa! Surface.— Infection of the sub-epidermal connective tissue can onl^' occur through a defect in the epidermis ; hence, ever}- anthrax of the external surftice corresponds in its location with an infection-atrium, through which the essential microbic cause has entered the connective tissue. The bacillus of nnthrax, when brought in contact with living tissue susceptible to its pathogenic action, causes an acute inflammation characterized by grave alterations of the capillary wall and rapid exudation. The microbe first multiplies at the primary point of invasion, and, if it does not meet with suthcient tissue resist- ance, it enters the blood-vessels and causes general infection, whicli always proves fatal. Infection occurs most frequently in exposed parts of the bod}'; thus, of 63 cases of anthrax in man, collected b}' Slessarewskji, the disease showed itself 6 times on the face, 21 times on the neck, and 36 times in other places. Trousseau relates that in Paris 20 persons 580 PRINCIPLES OF SURGERY. were attacked with anthrax in ten years, and in all of them the source of infection could be traced to horse-hair imported from South America. The pathologico-anatomical conditions var^^ according to the primarj' seat of invasion, the structure of the organ, and seat of the disease. The first tissue changes are observed at the point of inoculation. From a prognostic and pathological point of view, external anthrax can be divided into two distinct varieties : 1. Anthrax pustule. 2. Anthrax cedema. 1. Anthrax Pustule. — This is the so-called malignant pustule. It is usually met with iu parts not covered b3' clothing, as the fingers, hands, and face. This form of the disease is determined b}^ the anatomical structure of the part affected, which must be dense and vascular. The pustule begins as a small, red point that resembles the ])ite of a flea, in the middle of which a small vesicle appears, which, at first, contains a transparent serum, and, later, becomes sanguineous. The patient com- plains of an itching, burning sensation. The skin around the centre of the pustule is at first slightly raised by the inflammatory infiltration underneath it. Within twenty-four or forty-eight hours the size of the infiltrated area is as large as a nickel, and the inflamed part presents all the evidences of a very acute circumscribed inflammation. The swelling is now painful, tender on pressure, and exceedingly firm to the touch. The centre, previously occupied by a vesicle, is of a brownish-red or blackish-gray color, and presents indications of approaching gangrene. The epidermis exfoliates, exposing a neci'osed area the size of a pea to a silver half-dollar. The dead tissue remains firmlj' connected with the surrounding indurated parts, until it becomes gradually detached in the course of the suppurative inflammation, which ensues sooner or later. After separation of the slough, spontaneous healing ma}' take place, alwaj'S leaving a depressed scar. In this form of anthrax general infec- tion seldom occurs, as the infection remains local, the early and abun- dant inflammatory exudation forming an impermeable wall around the infected zone, beyond which the bacilli cannot escape. General infection, however, in such cases occasionally takes place where a vein becomes implicated in the process, and general infection is not prevented by the formation of a plastic thrombus on the proximal side of the intra-venous culture. The acuteness of the inflammation, and probably, also, the direct necrotic eff'ect of the ptomaines of the bacilli, invariabl}' result in necrosis of the central portion of the pustule, which is the most characteristic pathological and clinical feature of this form of anthrax. 2. Anthrax (Edema. — This form of anthrax follows infection, if the tissues around the infection-atrium are freely supplied with loose con- nective tissue and the blood-supply to the part is scanty, — conditions PATHOLOGY AND MORBID ANATOMY. 581 which are present about the eyelids, neck, and forearm. Anthrax in these localities appears as a flat infiltration without well-defined borders, and with little or no discoloration of the skin. From the infiltrated tissues a rapidly-spreading oedema extends in all directions. This form of anthrax is attended by greater danger of general infection than an- thrax pustule, as the bacilli are less effectually walled in b}' the inflam- matory product. Vesication, exfoliation of cuticle, and gangrene may also take place, and in milder cases a spontaneous cure is possible. As long as the infection remains local general symptoms are absent, but as soon as general infection has occurred the sjanptoms point to progressive septicaemia. PATHOLOGY AND MORBID ANATOMY. If the tissues of a primary anthrax of the external surface are examined under the microscope, all the appearances of an acute non- suppurative inflammation are shown. The specific effect of the bacillus on the tissues results in serious alteration of the capillary vessels, which gives rise to an abundant inflammatory exudation. In malignant pus- tule, or anthrax pustule, the para-vascular and connective-tissue spaces become completely blocked with leucocytes in a remarkably short time, and necrosis of the central portion of the inflammatory product is a constant residt of the acute ischa;mia and the speedy coagulation necrosis thus produced. Anthracic inflammation never terminates in suppura- tion unless secondary infection with pus-microbes takes place. The local oedema in the oedematous variety, at the point of infection, is caused by vascular disturbances due to the presence of the bacilli witliin the blood- vessels and the interstitial inflammatory exudation caused bj' their pres- ence. In fatal cases the necrops}' reveals the same changes in different organs as Koch has described in his experiments on rabbits. The capil- lary vessels in every part of the body will be found completely or par- tially blocked with bacilli, but the number of microbes is always greatest in the most vascular organs, as the spleen, liver, and kidneys. Tlie bacilli, as in mice-septiccemia, will be found in the capillary ves- sels arranged in the direction of the blood-current, and most numerous where the flow of blood is most impeded, as at points of intersection. General infection always takes place through blood-vessels. The inter- nal organs are found enlarged and exceedingly vascular from engorge- ment caused by the capillar}' obstruction. Minute extravasations are found in different organs where the bacilli are most numerous, resulting in complete destruction of the capillary wall and rhexis. The secondary intestinal affection most frequently assumes the form of inflammatory hsemorrhagic infiltration, more seldom that of haemorrhagic catarrh; ulcerations the size of a split pea to 2 inches in diameter are frequently 582 FKINCIPLES OF SURGERY. present, the remaining portion of the mucous membrane showing well- marked evidences of acute inflammation, great vascularity, and infiltra- tion. Mesenteric glands are swollen and contain numerous bacilli. The bronchial and intestinal mucous membranes show all the appearances of recent inflammatory changes, great vascularity, slight thickening, and here and there minute extravasations. In some cases the meninges of the brain show well-marked lesions that account for the cerebral symptoms during life. Pathologists have often failed in locating the immediate mlmmi P pil 1^9, m^i m I \v> f»Mi iri^ vMBji' ^^^^ Fig. 106.— Anthrax. Section from Liver, x 700. {Fluegge.) cause of death in fatal cases of anthrax, and various theories have been advanced at different times to determine this point. In the most virulent form, the anthrax acutissimus, Bollinger be- lieves that the rapid growth of the bacillus in the blood brings about a sudden diminution of oxygen and a surplus of carbonic acid, and that death takes place b}' a slow process of asphyxia. Against this theory it can be maintained that, in the blood of animals that have died of the acutest form of the disease, comparatively few bacilli are found ; and, further, that in the experiments made by Nencki, on the blood of rabbits that had died of this form of anthrax, it was found as capable of oxy- genation as the blood of healthy animals. The theory that death results PATHOLOGY AND MORBID ANATOMY. 583 from purely mechanical causes, due to the presence of bacilli in great abundance in the blood-vessels, is likewise not tenable, because no such fatal degree of obstruction in the capilhuy circulation has been found at the post-mortem examinations. As a third hypothesis, Bollinger advanced that the bacillus may generate a cliemical poison that may cause death by intoxication. In refei'ence to the last-mentioned cause, Hotfa calls attention to the following three possibilities : — 1. The bacilli of anthrax are in themselves poisonous, and the in- crease in their number increases the quantity of the poison in the same ratio. Against this supposition the results of the experiments made b}'' Hofl'a himself furnish the most conclusive proof. Of a pure culture of anthrax bacilli he injected a large quantitj" directly into the jugular veins of rabbits. The animals thus infected showed no symptoms of acute intoxication, but died in the same manner as animals infected in the usual wa^'. 2. The bacilli of anthrax produce a poison capable of causing fer- mentation in the blood ; this poison is soluble in the blood. The fact that filtered blood of animals that had died of anthrax did not produce toxic symptoms when injected into health}' animals speaks against this argument. 3. The bacillus of anthrax separates toxic substances from complex combinations in the organism. This last explanation appears, from analogy of the views that are now entertained of bacteria and ptomaines, to be the most plausible, and he made an effort to produce such sub- stances outside of the animal body upon artificial culture media. For this purpose he cultivated the bacillus with the greatest precautions upon sterilized meat kept for several weeks in an incul)ator at 37^ C. (98.G° F.). The chemical product thus obtained he attenuated according to the methods advised by Stass-Otto, Brieger, and after the more recent method of Fischer. By the methods of Stass-Otto and Fischer he succeeded in pro- ducing a substance that possessed an alkaline reaction, and produced toxic effects in animals. A strictlv-pure article and an accurate chemical description of it could not be obtained, on account of the smallness of the quantity produced. The substance produced Iw Stass-Otto's method was used in experimenting on frogs, mice, guinea-pigs, and rabbits ; both of them p>roduced symptoms of intoxication. After a short period of intoxication, with increased action of the heart and accelerated respira- tion, the animals became somnolent ; respirations deep, slow, and irregu- lar, assisted b}' the action of all accessory muscles of respiration ; pupils dilated, temperature normal, diarrhoia, faeces bloody ; speedy death. At the necropsy the heart was found contracted, the blood was of a dark 58i PRINCIPLES OF SURGERY. color, iuid ecchymosis of the pericardium ami peritoneum existed. There were no micro-organisms in the blood. The pathological conditions described here are an accurate duplication of the post-mortem descrip- tion in fatal cases of anthrax. The same author succeeded subsequently in isolating, by a complicated process, a toxic substance from the bodies of anthracic rabbits with the formula CgH^Xg, which he called ardhracin, besides a small quantity of methylguanidin. To the former substance he attributes the toxic symptoms in cases of anthrax. Injected subcu- taneousl}' in rabbits, it produced first restlessness, rapid pulse, and accelerated respiration, followed hy somnolence, deeper and slower respi- ration, diarrhoea, asphyictic symptoms, convulsions, and death. This substance is closely allied to kreatin, and contains 23 per cent, of nitrogen. These experiments leaA'e but little doubt that the fatal termi- nation in cases of anthrax is caused b}' the action of toxic ptomaines formed in the bod}' in consequence of the action of the bacilli upon certain as 3'et unknown combinations in the organism. DIFFERENTIAL DIAGNOSIS. Anthrax must be distinguished from other forms of acute circum- scribed inflammation, notably from furuncle and carbuncle. A furuncle is conical from the beginning, and the summit is transformed into a small slough. A carbuncle is nothing more nor less than a multiple furuncle, and is produced by the same microbic cause. Antlirax develops from a single centre, and the infiltration proceeds from tliis point in all directions. Necrosis is preceded b}- vesication, and the black, necrosed tissue is fully exposed after exfoliation of the epidermis. The oedema- tous form of anthrax might be mistaken for erysipelas or acute phlegmo- nous inflammation. Anthrax oedema is usually not attended by much discoloration of the skin, and there is no such distinct and abrupt line of limitation as in erysipelas. Phlegmonous inflammation, when advanced to the extent where it ma}' resemble anthrax cedema, has gone on to the stage of suppuration. The differential diagnosis between malignant oedema and anthrax can only be made by searching for the primary cause by the use of the microscope. A positive differential diagnosis between suppurative lesions and anthrax can be made in the course of one or two days by inoculation experiments. If a rabbit or mouse is infected with a drop of antliracic blood or serum taken from the centre of the inflam- matory product, death from anthrax will follow within two days; while the same amount of fluid taken from a suppurative depot will produce no effect, or, at most, only a circumscribed abscess. As the anthrax bacillus can be readily stained and identified under tlie microscope, a positive differential diagnosis between these aflections can always be made by the use of the microscope. PROGNOSIS. 585 PROGNOSIS. The location of the disease, the character of the tissues primarily affected, and the general condition of the patient greatly influence the prognosis in cases of anthrax. The prognosis is most favorable in 3'oung, health^' individuals sutieriiig from authracic pustule, as in sucli instances the general strength of the patient and the active tissue proliferation at the seat of infection are well calculated to prevent general infection ; while, in persons debilitated from any cause affected with the oedematous variety, general infection is very liable to follow. An anthrax oedema of the hand or arm is a less serious condition than a similar affection of the lace or neck. Asa general rule, it may be stated that, the firmer and more circumscribed the local lesion, the more favorable the prognosis, and, vice vei'sd, the more extensive the area of infection and the more diffuse the oedema, the greater the danger to life from general infection. The occurrence of general infection may be recognized without difficult}' by the general symptoms which indicate the existence of progressive septic infection. The bacillus of anthrax multiplies with great rapidity after its entrance into the circulation, and the anthracin, which produces the septic symptoms, is elaborated in amounts proportionate to the number of bacilli in the body. Fever, cough, rapid respiration, feeble and rapid pulse, diarrhoea, and delirium are some of the symptoms indicating that the disease has become general. All hope of recovery must be abandoned as soon as general infection has occurred ; death from pro- gressive infection and intoxication will be certain to take place, in spite of the most heroic local and general treatment. TREATMENT. The surgical treatment of anthrax must be directed toward the elimination or neutralization of the primary microl)ic cause. As within the living bod}' the reproduction of the primary cause takes place ex- clusively by segmentation of the bacilli, any germicidal agents that inhibit or destroy the pathogenic property of the bacilli will be found useful in the local treatment of anthrax. It has been found experiment- all}' that a 5-per-cent. solution of carbolic acid will arrest the growth of anthrax cultures, and clinical experience has demonstrated that the same solution, when brought in contact with the infected tissues by parenchymatous injections, has a decided influence in arresting further extension of the infection. Lande reports 2 cases of malignant antlirax saved by parenchj^ma- tous injections of carbolic acid. In the first case, a man aged 27, the npi)C'V lip was the seat of the disease; in the second, a woman aged 65, the anthrax occupied the region below the scapula. Both patients were 586 PRINCIPLES (jy SUKGEKi'. very ill, low delirium and other symptoms of toxsemia being present. The injections were made into the subcutaneous tissue around the pustule. The strongest solution used consisted of 15 grammes of neutral glycerin and an equal part of distilled water, in which 3 grammes of pure carbolic acid were dissolved. The injections were made at five points around the pustule, and represented a total dose of 50 centi- grammes of the acid. The injections caused considerable pain, but rapid improvement followed. The solution used — 10 per cent. — was stronger than any previously employed for the same purpose by Bojckel, Raimbert, and others. A 5-per-cent. solution in ordinary cases is strong enough, but in grave cases the 10-per-cent. solution must be used until improvement takes place, which should occur within fort^'-eight hours. The object of the parench^'matous injections should be to saturate, as far as possible, all of the infected tissues with the antiseptic for the purpose of destroying the bacilli, and, at the same time, to permeate the surrounding healthy tissue for some distance, with a view of destroying the soil for the growth of the microbes in advance of the invasion. The surface over the entire infected area should be rendered thoroughly aseptic, in order to prevent secondar3' infection with pus-microbes through the needle-punctures. The punctures should be made a few lines from the border of infiltration, but always toward the centre of the infected district. The injection is made gradually as the needle is with- drawn, so as to saturate the tissues for some distance along the entire length of the track of the needle. At one sitting from four to twelve injections are made, according to the size of the anthrax and the urgenc}'' of the symptoms. A compress wrung out of a 1-to-lOOO solution of corrosive sublimate should be kept constantl}' applied. Application of an ice-bag over the antiseptic compress will assist the germicidal agents in retarding or arresting further multiplication of the bacilli in the tissues. The injections should be repeated every six hours until the disease is under control, or until it is deemed unsafe, from the quantity injected, to administer more carbolic acid for fear of causing intoxica- tion. Excision has been objected to on the ground that the wound might become a new source of infection, and thus leave the patient in a more precarious condition, so far as general infection is concerned, than l^efore the oi)eration ; but such is not the case if the ai'ea of infection is limited and the incisions can be made through healthy tissue. The following case affords a good illustration of the value of excision of anthrax in well-selected cases. Kaloff, of St. Petersburg, in making experiments with anthrax on animals, accidentally^ infected himself, either by a needle-puncture or by handling the organs of anthracic animals. The local infection appeai*ed TREATMENT. 587 on the outer side of the thumb of the left hand as a small vesicle, that soon disappeared, but gave place to circumscribed infiltration on the second daj-. This inflammation rapidly extended, and was surrounded with haemorrhagic vesicles. The indurated tissues were promptlj- removed by excision; nevertheless, on the next da}-, swelling of axillary glands on same side, fever, great prostration, also diarrhoea, set in. The skin in the axillary region and side of chest was much swollen, and at different points bright-red, at others bluish-red. One of the axiliary glands, the size of a hen's egg, and glands along the margins of the pectoralis major muscle were removed, and field of operation thoroughly disinfected with a 5-per-cent. solution of carbolic acid ; the same solu- tion was also thrown into the surrounding tissues with a hypodermic springe. Cessation of fever and rapid healing of wound, followed bj' recover}'. The diagnosis was confirmed by successful cultivations made with fragments of the excised tissue in bouillon and gelatin. Excision should always be resorted to in cases of anthrax pustule, as it fulfills the etiological indications more promptly and thoroughlj- than anj- other treatment. The incisions should be made outside of the indurated tissues, and, for the purpose of preventing traumatic dissemination of the disease, the surface, after thorough irrigation, should be brushed over with a 10-per-cent. solution of carbolic acid before the wound is sutured. This procedure will destro}^ any bacilli that may have become deposited upon the surfoce of the wound. In the case just cited it is possible that lymphatic infection — an unusual occurrence in anthrax — developed in consequence of the entrance of bacilli into the open lymphatic vessels on the surface of the wound. Excision under strict antiseptic precautions is also justifiable in anthrax (edema, even if all of the infected tissues cannot be removed, as sterili- zation of the remaining portion of the infected tissues can be secui'ed ^•ubsequently more efficiently by parenclnmatous injections than if the primary focus of infection is allowed to remain as a hot-bed for pro- gressive infection. In such cases it would be good practice to sear the whole surface of the wound with the actual cautery, for the purpose of preventing general and regional dissemination by the entrance of bacilli into the open luraiua of veins and lymphatics, and also to increase the resisting capacity- of the tissues to infection by exciting an active tissue proliferation. Tiie actual cautery would prove successful in recent cases, in cutting short an attack, if resorted to before any considerable infiltra- tion has occurred. It is said that shepherds, in districts where anthrax is endemic, destroy the vesicle with a red-hot needle as soon as it is detected, and it is seldom that the infection does not yield to this treat- ment. At this early stage the wdiole area of infection is limited, and 588 PRINCIPLES OF SUUGERY. coiilil be most effectutiUy destroyed with the sharp point of a Paquelin canter}'. The general symptoms in severe cases of local anthrax, and after general infection has occurred, resemble the clinical aspects of septicaemia produced by other causes, and patients suffering from general primary or secondary anthrax require the same stimulating, tonic, and supporting treatment that has been laid down in the treatment of septicaemia. CHAPTER XXIV. Glanders. Synonyms: Farcy; equinia; malleus humidus ; Morve ; Rotzkrank- heit. A contagious disease characterized by multiple foci of inflamma- tion and suppuration, and caused by infection with a specific microbe, — the bacillus mallei. The disease originates in the horse and occurs in men by contagion. Although glanders in man is a rare affection, it pre- sents, from a bacteriological stud}^, so many points of interest that it merits more than a passing notice. It is one of the infectious diseases whose microbic cause is now thoroughly understood. BACTERIOLOGICAL HISTORY OF THE DISEASE. That glanders in man occurred as an infection from the horse species of animals has been known for a long time. Its contagiousness among horses was asserted by Sollegsel in the seventeenth century. Rindfleisch believed that he saw vibriones in the granular contents of glanderous abscesses. Klebs detected, in cultures of pus taken from animals suffering from this disease, small rods and grannies, but further cultivations and inoculations in rabbits failed. The presence of minute organisms in cases of glanders was pointed out by Christatt and Kiener in 1868, and their observations were corroborated by Bouchard, Capitan, and Charrin, who found the organisms not only in parts exposed to the air, such as nasal ulcerations and pulmonar}'^ abscesses, but also in parts not so exposed, such as the spleen, liver, and lymphatic glands. Cliaveau demonstrated bj' his experiments that the virus of glanders was fixed to small, solid particles, as he found the sediment, which formed after di- lating pus with water, active. This discover}' marked an advance in the knowledge of the ph3'sical nature of the virus. Loffler and Schiitz are the discoverers of the bacillus of glanders in horses. In 1882 they made a preliminary report of their researches (Deutsche Med. Wochenschrift, 1882, No. 52). In 188fi Lotfler published his elaborate monograph on this subject ("Die ^tiologie der Rotzkrankheit," Arheiten aus devi Kaiserlichen Gesundheitsamte zii Berlin, Bd. i, pp. 141-199). About the same time, 0. Israel made cultures upon blood-serum from nodules of three glanderous horses, with which he produced the disease artificially in rabbits. The bacilli contained in these cultures correspond with the (589) 590 PRINCIPLES OF SURGERY. description of those isolated by Sehiitz and Loffler. Soon after Loffler's first paper appeared, Bouchard, Capitan, and Charrin published almost simultaneously the results of their researches and observations; but it appears from Loffler's second paper that none of them had been able to produce a pure culture. Kitt and Weichselbaum were the first who, by their own investigations, were able to corroborate the correctness of Loffler's discovery : the former by his observations and experiments on animals, the latter b}' a case of glanders in the human subject that came under his own observation. DESCRIPTION OF BACILLUS MALLEI. According to Loffler, the bacillus of glanders appears as a small rod, which is somewhat shorter and broader than the tubercle bacillus ; its length varies but little, and corresponds to about two-thirds of the di- ameter of a red blood-corpuscle ; the thickness varies between one-fifth and one-eighth of its length. These bacilli are either straight or slightly curved and rounded at '^V/\''\\i\K-^TTrt their ends. Usually, they are found in pairs in a ^//y^\^\(<^/,'y^{'\ parallel direction, held together by a delicate, unstained M^^^t^^/^ri^^h pellicle. Examined in a drop of fluid, they show active l^\//l^^\|l\\y^A)j molecular movements. Spontaneous movements could Fig. 107.— Bacilli ^'^t be observed by Loffler. The colorless and some- ^^v^T^^Si^'^'til^.^?.^ times even somewhat dilated portions of the stained A xOUNG x^OIAlU I ^Baumgarten )^ ^'''^' hacillus are not spores, but, as Loffler affirms, indica- tions of commencing death. Loffler found that bacilli kept in a dry state for three months could occasionally be made to grow, but in most instances, after a few weeks, tlie}^ could no longer be cultivated, which fact speaks against the existence of spores. On the other hand, in favor of the presence of endo-spores must be regarded the results obtained by Rosenthal, in Baumgai'ten's laboratory, with Neisser's method of staining spores, who showed that at least some of the bacilli contain spores, while in others the points which refuse staining material are undoubtedly, as Loffler claims, evidences of vacuolar degeneration. (a) Staining. — The method of staining the bacilli of glanders is characteristic ; when the bacilli are treated b}^ basic and aniline dyes no effect is produced. Method of Schutz. — The sections are placed for twenty-four hours in the following mixture: Potash solution (1 in 10,000), concentrated alcohol, methylene-blue solution, — equal parts. Wash the sections in a watch-glass with water acidulated with 4 drops of acetic acid. Transfer for five minutes to 50-per-cent. alcohol, clarify in clove-oil, and mount in Canada balsam. TENACITY OF BACILLUS MALLEI. 591 Lbffler's Method. — Sections are immersed for a few minutes in a solution of potasli (1 in 10,000), then for a few minutes in an alkaline solution of methyl-blue ; after which they are decolorized with a solution of tropseolin in acetic acid, or, what is still better, in a fluid composed of 10 centimetres of distilled water, 2 drops of sulphuric acid, and 1 drop of a 5-per-cent. solution of oxalic acid. (b) Cultivation. — When cultivated on solid sterilized blood-serum at a temperature of 38° C. (100.4° F.), the growth appears in the form of minute transparent drops on the surface, which consist exclusively of the characteristic bacilli. Cultures upon boiled potato, according to Loffler, Kitt, and Weichselbaum, form in three days a uniform amber-yellow layer, that about the sixth to the eighth day assumes a reddish hue, resem- bling the color of oxide of copper, which is not easih' mistaken for any other culture upon the same soil. Upon this nutrient medium the bacilli were cultivated through twelve generations, and the cultures retained their activit}' for a 3'ear ; whether the bacillus was capable of cultivation after this time is not mentioned. The temperature at which cultures could be made to grow varied from 30° to 40° C, (86° to 104° F.). The bacillus also grows in neutralized bouillon, with and without the addition of pep- tone. The culture first renders the fluid turliid, and, later, settles on the bottom of the vessel as a white, shining mass. Weichselbaum succeeded in growing the bacillus upon ordinary nutrient agar and gelatin. Ras- kina rendered these nutrient media more fertile for the growth of this microbe by the addition of chicken-natron albuminate. Kranzfeld suc- ceeded best with Nocard and Roux's mixture, — meat-peptone, glycerin, agar-agar. TENACITY OF BACILLUS MALLEI. Loffler ascertained that this bacillus shows the same degree of re- sistance to heat and germicidal substances as other bacilli without spores. The bacillus is destroyed b}- exposure for ten minutes to a temperature of 55° C. (131° F.). It is also destroyed by a 3- to 5-per-cent. solution of carbolic acid in five minutes, and in two minutes in a l-to-5000 solu- tion of corrosive sublimate. INOCULATION EXPERIMENTS. Kitt enumerates the following animals as being susceptible of inocu- lation with the A'irus of glanders : Tiger, lion, cat, sheep, goats, guinea- pigs, horse, ass, rabbits, and white rat. Pigs, dogs, the common rat, ducks, and chickens possess great immunity ; the inoculations at best produce only a slight local reaction. Loflfler made his first experiments on guinea-pigs and the field-mouse. In the guinea-pigs he observed, three to five days after subcutaneous injection of a pure culture, an ulcer 592 PRINCIPLES OF SUF^GERY. Jit the point of inoculation, and at the end of the first week swelling of the nearest lymphatic glands, attended by suppuration. At this stage of the disease the process often came to a stand-still and the animals recovered. In man}- animals the disease progressed quite rapidly to a fatal termination. Abscesses were frequently found in the testicle and the epididymis in the male, and in the breast and external genital organs of the female. The face, nasal cavity, and ankle-joint were also fre- quently the seat of ulcerative processes. In case the disease proved V3 ©. . Dc^-^^'^Q '"^''^'i "'"^.Vs '^''^''^O "^ " " >. ,, *- . Fig. 108.— Glanderous Nodule from the Liver of a Field-Mouse. Bismarck-Brown Staining. Bacilli Stained after Loffler's Method. Bacilli Magnified and Drawn Twice this Size. x250. {Baumgarten.) K, karyokinetic figures ia epithelioid cells. fatal, death usually occurred three or four weeks after inoculation. At the post-mortem, aside of the affections enumerated, nodules were found in the spleen, lungs, and frequently in the liver. The histological struc- ture of a recent nodule bears a great resemblance to tubercle. The bacilli are always found more numerous in the nodules if the disease is produced artificially'^ bj' inoculation. The inflammatory product is first composed almost exclusively of epithelioid cells, between which leuco- cytes from the periphery insinuate themselves. Giant cells are never INOCULATION EXPERIMENTS. 593 fuund ill glanderous nodules; the epithelioid cells are derivatives of con- nective tissue and endothelial cells ; while the leucocytes escape from the inflamed capillary vessels. Baumgarten constantly observed karyokinetic figures in the epithelioid cells. The leucocytes that enter the nodule soon show evidences of frag- mentation, and are converted into pus-corpuscles. The bacilli are dis- tributed among the cellular elements singly, in pairs, and in groups. Some of them may be seen also within tlie cellular elements, especiallj'^ the epithelioid cells. Field-mice proved a great deal more susceptible to the virus of glanders tlian guinea-pigs, as they usually died three or four da^'S after inoculation. The necropsy in these niiimals showed, at the point of inoculation, an infiltration from which swollen Ij'inphatic vessels led to the nearest lymphatic glands. In the spleen and liver, which were always found greatly enlarged, numerous small nodules could be seen, while the remaining internal organs presented a normal appearance. Glanders in guinea-pigs and field-mice presents a series of pathological changes that cannot be mistaken for any other aftection. The bacilli of glanders in the different organs can be detected most readily in recent specimens. In the blood bacilli were detected onl3' in very acute cases, — a circum- stance that explains wh}' so man}' inoculations with the blood of glan- derous horses proved unsuccessful. The bacilli of glanders are evidently strictly tissue- and not blood- parasites. Lundgren took a nodule from the lungs of a horse that had died of glanders, and implanted fragments of it under the skin of rabbits. The animals died about the nineteenth da}' after inoculation, and the necropsy revealed induration and small abscesses at the point of infection, and small, yellow nodules in the spleen, liver, lungs, testicles, and mucous membrane of the nose. Implantation of spleen-tissue into other rabbits fi^ed the period of incubation in this animal at from eleven to twelve days. Kranzfeld has recently published the results he obtained by inocula- tions with the virus of glanders in an animal hitherto not subjected to experimentation of this kind. He procured a pure culture from a nodule of a man who had died of glanders after a brief illness. Inoculations were made in a small rodent which is veiy numerous in the southern ])art of Russia, the Spermophilus guttatus. The course of the disease in this animal was almost the same as in the field-mice that were used by Loffler. Of 28 animals infected with different cultures, 16 died on the fourth day, 9 on the fifth, 2 on the seventh, and 1 on the tenth. The post-mortem appearances were always characteristic : a greenish-gray infiltration at the point of inoculation and a number of nodules in the 38 594 PRINCIPLES OF SURGERt. spleen ; in one animal also ver^' small, white nodnles in the liver. Culti- vations from these nodules yielded a pure growth of the bacillus of glanders. If animals are infected by direct injection of a pure culture into a vein, no serious symi)toms are produced ; but, if soon thereafter one or more muscles are injured subcutaneously, the microbes escape through the lacerated vessels, localize at the seat of injury, and produce a grave form of the disease. It has been determined by experiment that the farther from the trunk the inoculations are made, the less intense is the local reaction. When an animal is inoculated at a distance from the trunk, and shows no general symj^toms, a subcutaneous injury of any portion of the trunk will furnish the necessary conditions for the development of a local form of infection. It had been generally believed that the intact skin furnished an adequate protection against infection with the bacillus of glanders until shown very recently by the experiments of Babds and Nocard that infec- tion can take place through the healthy skin. Nocard rubbed a pure culture of the bacillus into the skin in two guinea-pigs, and found on the fifteenth daj' some of the hair-follicles the seat of glanderous inflamma- tion. Histological examination showed numerous bacilli in the follicles, the epithelial la^-er much thickened, and tlie surrounding connective tissue in a state of proliferation. The infection had extended from the follicles through the connective tissues into the lymphatic vessels underneath, as was evident from the presence of bacilli in the lymphatic glands, vessels, and connective-tissue spaces in the immediate vicinity of the primary lesion of the skin. GLANDERS IN THE HORSE. Glanders and furc}' in the horse are different manifestations of the same disease, and, as each of them is divided into an acute and chronic form, we find described four varieties of the disease in this animal, — acute and chronic glanders, acute and chronic fare}'. Acute Glanders. — This form of glanders is attended by a high tem- perature (106^ to 109° F.) and other symptoms of acute sepsis, and proves uniformly fatal in a few da3-s. The breathing is accelerated, the pulse feeble and rapid, and there is complete loss of appetite. The nasal mucous membrane, at first of a dark, copper}' color, with dark-red ecclij'- motic patches, becomes purple ; these ecch^-moses are rapidh' converted into ulcers, from which issues a copious sero-sanguinolent discharge. Lymphatic infection is a characteristic feature of acute glandei'S. The submaxillary and cervical glands enlarge and suppurate, discharging unhealthy-looking, ichoi'ous pus. Abscesses also form in the Ij-mphatics of the face. GLANDERS IN THE HORSE. 595 Chronic Glanders. — This is the form most commonly seen in the horse. The disease begins in the mucons membrane of the nose. Small, whitish nodnles, composed of small, round cells, are formed in the mucous membrane. These nodules soften and ulcerate. Similar nodules may be found in the larynx, trachea, and bronchi. The ulcerations may remain superficial, or they ma}' extend to the deep tissues, even attacking cartilage and bone. The internal organs, especially the lungs, may become the seat of metastatic foci. The left nostril appears to be affected more frequentl}^ than the right. The h'mphatic glands under- neath the lower jaw enlarge A'erj^ rapidly, often reaching considerable dimensions during a single night. The glandular swellings may continue for several days, afterward slowl}^ disappear, and then re-appear as rapidly as before. The discharge from the nostrils presents a starchy or glue-like appearance, adheres to the mucous membrane, where it dries and accumulates, causing narrowing of the nasal opening. Acute Farcy. — Acute farcy, together with chronic farc}^ is simply another manifestation of glanders, and is initiated in a verj' similar manner to acute glanders. There are the same lesions of the Ij-mphatics and nodules, and abscesses are found in the skin. A general swelling of the cutaneous tissues takes place, varj'ing in size for a time, but suddenh' a number of distinct swellings or nodules will appear, termed " farc\' buds." These specific nodules, so characteristic of farc}- in either its acute or chronic form, involve the skin, subcutaneous connective tissue, or they ma}^ extend to the deeper tissues. The}' var}- in size from a pea to a hazel-nut. These nodules suppurate, and, after evacuation of their contents, leave ragged ulcers that discharge a foul, graj^ish-white, cream}' liquid tinged with blood. When several ulcers are in close proximity tliey may become confluent and form an extensive ulcerating surface. With the appearance of the nodules the lymphatics become inflamed, swollen, and indurated. Not infrequently acute farcy terminates in tlie development of acute glanders, with all the pathological conditions that have been described as characteristic of that disease, thus showing their etiological identity. Chronic Farcy. — In this form of glanders the lymphatic glands are princii):illy involved. The disease is not attended by much febrile dis- turbance, and all of the other general symptoms are less marked than in the other varieties of glanders. The lymphatic glands become enlarged, and nodules are formed in the skin, lungs, and other viscera. Central softening and suppuration of the nodules is a regular occurrence. Long, fistulous tracts often result from extensive undermining of the skin. In all of these different forms of glanders in the horse the cause remains the same, and the pathological conditions are identical; only the clinical 596 PRINCIPLKS OF SURGERY. aspects vary from the location, intensity, and extent of the primary infection. GLANDERS IN MAN. In man the disease occurs in an acute and chronic form, but does not exactly resembe any of the varieties of the disease in the horse or the disease artificially produced in animals by inoculation. The discharge from the nostrils of a diseased horse, brought in contact with an abraded surface or a mucous membrane, will communicate the disease. Notwitli- standing the positive results that followed the cutaneous inoculations in guinea-pigs with a pure culture of the bacilli of glanders by Nocard, it is, for all practical purposes, safe to make the assertion that the virus of glanders can only find entrance into the organism through a wounded surface. Whether infection may not take place through the alimentar}- canal has, so far, not been definitel}^ ascertained. It is certain that the disease cannot be contracted bj' eating boiled or fried flesh of animals. Infection through the respiratory organs is possible, as cases have been reported in which the lungs were the primary and only seat of the dis- ease. The fact that man can be infected with a pure culture of the bacilli of glanders as successfully as the animals that have been successfully experimented on received a sad illustration last winter in Vienna. Dr. Hoffman, a young and promising ph3'sician, who was making some experimental investigations on animals with pure cultures, accident- ally inoculated himself with the needle used for making the inoculations, and died from acute glanders in a few days. Observations of veterinar}' surgeons and experimental researches have shown, conclusively, that the disease can be transmitted from the mother to the foetus m utero by passage of the bacilli through the placenta from the maternal into the foetal circulation. When man is the subject of glanders, bacilli are found more constantly in the blood than in glanderous animals. In the case described by Weichselbaum, numerous bacilli could be seen in the blood. In this case a thrombus was found in one of the large meningeal veins, containing numerous bacilli, and which, undoubtedly, was one of the sources of the bacilli in the circulation. In man the nasal mucous mem- brane is not so frequently' affected as in animals, although Bollinger has shown that in hoi-ses the nasal cavity is not always affected, and that it may present a normal condition, even when the larynx and lungs are seriously affected. Muscular abscesses, that may assimilate rheumatism, are a frequent occurrence, especially in the chronic form of the disease. SYMPTOMS AND DIAGNOSIS. The symptomatology of glanders is variable, as it is greatly modi- fied by the intensity of the infection, the primary location of the disease. SYMPTOMS AND DIAGNOSIS. 597 and the number and distribution of the metastatic foci. The disease may begin at a single point, and may then be mistaken for a carbuncle or a gangrenous erysipelas. Griefe reports a case which began as an acute exophthalmos, and the nature of the disease was not ascertained until after death. In this case there were nodules in the choroid of the eye. Acute glanders runs a rapid and malignant course. Infection usually takes place through a small wound-puncture or abrasion about the face or hands. At the point of inoculation a somewhat elongated, soft, inflammatory swelling or nodule forms in a few days. Central softening and suppuration soon transform the inflammatory product into an undermined ulcer, with irregular, ragged margins, surrounded by a wall of infiltration. In mild cases the disease may remain local, and the ulcer heals under proper treatment in a few weeks. In other cases regional infection takes place, and the l3rnphatic glands become swollen and suppurate, leaving the same kind of ulcers as at the primary seat of infection. In the fatal cases general infection takes place either through the veins or the lymphatic vessels, and the symptoms then resemble septi- caemia or pyaemia, or a combination of these two diseases, — septico- P3'semia. If infection take place directly through the veins, a thrombo- phlebitis develops in connection with one of the nodules and the bacilli in the thrombus, which multipl}' in this nutrient medium and gain entrance into the general circulation singly or through the medium of infected emboli. Under such circumstances, nodules are found in the lungs, kidneys, and other internal organs, as suppurating metastatic deposits in muscles, bone, joints, and testicle. In such cases the general symp- toms may simulate to perfection typhoid fever, pyaemia, suppurative osteomyelitis, and acute general miliary tuberculosis. In acute cases, where general infection occurs earl}^ and rapidly, death results in from one to three or four weeks, while in chronic cases the final fatal termi- nation is often postponed for months. In illustration of the clinical history of this disease I will quote briefly a few cases. A Russian medical journal of recent date states that a young- soldier, who had been a wagoner before his admission into the arm3',was received into the military hospital suffering from two foul ulcers on the hard palate, which had perforated the nasal fossa and destroyed the inferior turbinated bones. Three weeks later a swelling appeared over the eyebrow ; a fortnight afterward he complained of pain on the inner side of the left knee, around the internal tuberosity of the tibia. A purulent discharge occurred from the left ear, and, at the same time, an abscess developed on the back of the right hand which appeared as a deep-purple tubercle, with a hard circumference, and sunken toward the 598 PRINCIPLES OF SURGERY. centre ; a purulent discharge oozed from the surface. At first, for a sliort time after admission, the temperature varied, rising in the evening to 103° to 104° F. ; later on it fell to normal. The disease was mistaken for syphilis, and iodide of potassium was given without the least benefit. About ten weeks after admission he was in better health, and left the hospital, receiving his discharge from the army. Within a few weeks he returned, with extension of ulceration of the hard palate; the uvula was destroyed. The characteristic nodules, the " fare}' buds," appeared in the face ; the metastatic abscess on the back of the hand remained. The patient ultimatelj' died of exhaustion. Before death some of the nodules were extirpated ; the}' were found to contain micro-organisms reseml)ling to perfection the bacillus of Loffler and Schiitz. Kiittner reports a number of cases in which the skin was the seat of numerous points of suppuration in the form of pustules, or more diffuse abscesses followed by ulcera- tion. The disease has been mistaken more frequently for syphilis than any other affection. This mistake in diagnosis is very liable to be made in the chronic form, in which the nodules grow ver}' slowh', are hard, and may occur in groups or like a string of beads. The nodules usually soften, and form chronic ulcers, that closely resemble the FIG. 109.-ACUTE Glanders, involv- "leers resulting from the breaking ^^^ t^^rolf^llV'K^J'Tr^l ^lown of gummata. If the disease lo^s:''f^\^^h%l^sckM^^^^^ primarily attack the nasal cavity, the mucous membrane presents hard nodules, and a copious discharge from the nose is present. In acute glanders affecting the nose and face, extensive destruction of tissue by the rapid breaking down of the nodules is one of the prominent clinical features of the disease. Complete destruction of the nose, with formation of large ulcers of the face, may happen in the course of a week. Chronic glanders may also be easil}' mistaken for tuberculosis of the skin, mucous membranes, and hmphatic glands. Acute glanders may simulate furuncle, carbuncle, and other acute suppurative lesions, as well as l^'mphangitis and er3-sipelas. In making a differential diagnosis be- tween these different affections and glanders, it is important, if possible, to trace the infection to its proper source. If the clinical history point to the possibilit}^ of infection by contact with a glanderous horse, it PATHOLOGY AND MORBID ANATOMY. 599 should be remembered that the period of incubation in man varies from two daj'S to three weeks. A positive diagnosis must necessaril}^ rest on the detection of the specific microbe in the granulation tissue or in the discharges, and the results obtained by inoculation experiments. As soon as general infection has taken place, the symptoms resemble pyaemia or septicaemia ; so that a differential diagnosis between metastatic glanders and general infectiou with pus-microbes cannot be made without the aid of the microscope and inoculation experiments. PATHOLOGY AND MORBID ANATOMY. The bacillus of glanders resembles, in its immediate action on the tissues, both the bacillus of tuberculosis and the pus-microbes. The histological change first observed in the infected tissues is a transforma- tion of mature into embryonal tissue, the microscopical picture, with the exception of the absence of giant cells, resembling tubercle ; but this stage is of short duration, as the p3'ogenic effect of the bacillus of glanders soon produces purulent softening by the speedv conversion of the embry- onal cells and leucocytes into pus-corpuscles. The formation of abscesses is a constant occurrence, wherever localization has taken place, either b}' direct infection, secondar}' infection from regional diff'usion through the l^'mphatic vessels and connective-tissue spaces, or b}^ general infection b^' embolic diffusion through the general circulation. As soon as the disease has become general, the clinical picture and pathological conditions are the same as in pyaemia caused bj' a suppu- rative lesion. The differentiation between the two forms of metastasis can be made onl}' by demonstrating the priniar}- cause, by use of the microscope, or b}' the results obtained from inoculation experiments. The pus found in glanders is gi'ayish red in color, and quite tenacious in recent lesions, but after opening the abscesses it assumes the character of ordinary pus, as the abscess-cavities then become the seat of secondary infection with pus-microbes. Swelling and abscesses of the testicles have been frequently observed in cases where the disease has become general, the affection in these organs l)eing one of the clinical manifestations that embolic dissemination has occurred. Primar}' glanders of the lungs from inhalation of the microbes into the air-passages gives rise to symp- toms and pathological conditions that cannot be distinguished from pul- monary tuberculosis, unless the essential cause can be demonstrated in the sputa under the microscope, or glanders can be artificiallj- produced by the injection of sputum into the subcutaneous tissue or the peritoneal cavit}' of guinea-pigs. The pulmonar}'^ nodules soften and suppurate, and cavities form in the same manner as in pulmonarj- tuberculosis. 600 PRINCIPLES OF SURGERY. PROGNOSIS. The prognosis in glanders should alwa3^s be guarded, as a limited local lesion may be followed by a fatal form of general infection. The prognosis is comparatively favorable if the infection remain limited to a circumscribed area accessible to direct surgical treatment. It must be more guarded if regional infection through the lymphatic vessels has occurred, and it is absolutely fatal in cases of primary glanders of im- portant internal organs, and when general infection has followed in the course of a local lesion with or without regional dissemination. In the local form of the disease the ulcerations usually prove inveterate to treatment, and final recovery is often retarded for months by extensive undermining of the sliin. Acute glanders with general infection, as a rule, proves fatal within one to three weeks, and death occurs in conse- quence of septic infection. TREATMENT. The prophylactic treatment consists in preventing infection from glanderous horses and substances which have become contaminated with the specific virus from diseased animals, and requires earl}^ recognition of the disease and killing of the affected animals, as well as thorough disinfection of tlie premises occupied b}' the diseased beast. The ca- davers should be cremated or deeply buried. Abrasions or granulating surfaces that have been exposed to infection should be cauterized. In cases -of primar}^ pulmonar}'^ or intestinal glanders, and after general infection from a local form of the disease has occurred, the treatment must be necessarily symptomatic, as such cases are be3'0nd the reach of local or general treatment. The embarrassed respiration and feeble and rapid pulse indicate the use of alcoholic stimulants. A primary nodule should be removed by excision, taking all necessary pre- cautions to prevent infection of the wound in case the skin has been destroyed by ulceration. Limited regional infection should be treated in the same manner if ulceration has not taken place, and the conditions are such that all of the infected tissues can be removed with safety. After multiple abscesses have formed a radical operation is no longer indicated, the extent of the affection precluding the possibility of removing all of the infected tissues. In such cases the abscesses should be freel}- incised, fistulous tracts laid open, undermined skin cut away, and, as far as possible, the infected tissues removed with a sharp spoon; then the entire surface should be disinfected with a 12-per-cent. solution of chloride of zinc. No attempt should be made, under such circumstances, to obtain healing of the superficial wounds until it be- comes apparent tliat the specific microbic cause has been eliminated or TREATMENT. 601 destroyed, and several repetitions of the curetting and disinfection may become necessjuy until this object is realized. The scraped surfaces should be kept covered with a moist antiseptic compress gauze, wrung out of l-to-2000 solution of corrosive sublimate or a 2-per-cent. solution of carbolic acid. If the i)rolonged use of these antiseptics is objection- able, on account of danger from absorption of toxic doses of drugs, strong iodine-water can be used in the same wa}'. The internal use of iodine, creasote, and arsenic have been recommended as specifics in the treat- ment of glanders, but clinical experience has not supported this claim, and the surgeon must rely upon local measures in his efforts to pro- tect the patient against tlie dangers arising from regional and general infection ; while he must aim, at the same time, to maintain the resisting power of the tissues to the microbic invasion by a supporting tonic and stimulating treatment- INDEX. Abnormal and defective callus, 53 Abscess, 212 acute, 214 diagnosis, 215 treatment, 217 chronic, 219 diagnosis, 219 treatment, 220 of brain, 271 cerebral localization, 273-277 prognosis, 272 symptoms and diagnosis, 272 treatment, 273 of internal organs, 259 of lung, diagnosis, 287 exploration, 288 operation, 288 tubercular, 450 pathological anatomy, 450, 451 prognosis, 453 symptoms and diagnosis, 452 treatment, 453-457 Absolute asepsis, 23 Accurate suturing, 25 Achromatine, 8 Actinomycosis hominis, 549 clinical varieties, 555-562 description of fungus, 550-552 history, 549 of brain, 564 of bronchial tubes and lungs, 562 pathology and morbid anatomy, 553, 554 prognosis, 567 sources of infection, 553 symptoms and diagnosis, 565, 566 treatment, 568 Action of bacteria on tissues of body, 134 Acute suppuration, 209 tetanus, 397 Amputation in tuberculosis of joints, 524 Anthrax, 571 attenviation of virus, 577 clinical varieties, 578 description of bacillus, 572 diflferential diagnosis, 584 history, 571 in living body and in soil, 573 infection in man, 576 inoculation experiments, 574, 575 intensification of virus, 576 multiplication, 573 oedema, 580 of external surface, 579 pathology and morbid anatomy, 581 prognosis, 585 prophylactic inoculations, 577 pustule, 580 treatment, 585-588 Antiphlogistic treatment of inflamma- tion, 120 Arterial blood-supply, defective, 165 Arteries, ligation of, 165 Arthrectomy in tuberculosis of joints, 518, 519 Arthritis, suppurative, 259 Ascites, 482 Aspiration in tuberculosis of joints, 517 Attenuation of pathogenic bacteria, 136 Atypical resection, 520-522 Bacilli of putrefaction, 315-322 Bacillus of anthrax, description of, 572 multiplication of, 573 mallei, 589 description of, 590 tenacity of, 591 pyocyaneus, 204 pyogenes fcetidus, 204 saprogenes, 315 316 (603) 604 INDEX. Bacillus tetani, 384 ptomaines of, 390, 391 tuberculosis, 423 cultivation, 426 description, 423 manner of infection and dissemi- nation, 4G9, 470 stainins, 424, 425 Bacteria, 127 action of, on tissues of body, 134 attenuation, 136 classification, 127 cultivation, 131-133 elimination, 149, 150 fission, 129 growth, 134 inoculation experiments, 135 localization, 141-146 multiplication, 129 outside of the body, 138 presence of, in healthy body, 139 140 putrefactive, 163 secondary or mixed infection, 146- 149 specific, 160-162 spores, 130 therapeutic inoculation, 137 transmission of, from parents to foetus, 151-155 Bacteridia, 571 Bacteriological causes of suppuration, 191 researches, 232, 233, 259, 260, 280, 281, 291-298, 303-311, 334-337, 383-391, 461, 462, 491, 492 Bladder, tuberculosis of, 544 prognosis and treatment, 545 symptoms and diagnosis, 545 Blood-corpuscles, red, 71 white, 70 Blood-plates, 72 Blood-vessels, 42 Bone, 49 tuberculosis of, 489 artificial, 490 clinical and bacteriological re- searches, 491, 492 means of differential diagnosis, 500, 501 Bone, tuberculosis of, pathology and morbid anatomy, 493-496 prognosis, 502 symptoms and diagnosis, 497-500 treatment, 503-507 Brain-abscess, 271-280 Brain, actinomycosis of, 564 exploration of, 278-280 Bronchial tubes and lungs, actinomy- cosis of, 562 Callus, 53 Capillary vessels, 68, 69 Cancer aquations, 180 Carbuncle, 229 diagnosis, 230 treatment, 230 Cartilage, 34, 107 Catarrhal inflammation, 101 Caustics producing necrosis, 167 Cauterization of wounds, 418 Cavum Retzii, 215 Cell division, 13 Central nervous system, 57 Chemical pyogenic substances, 194 Chromatin, 8 Chronic circumscribed suppurative os- teomyelitis, 256 pathological anatomy, 257 symptoms, 257 treatment, 257, 258 inflammation, 111-114 suppuration, 210 tetanus, 398 Cicatrization, 19 Classification of bacteria, 127 Clinical forms of septicaemia, 312-331 surgical tuberculosis, 447 Coagulation necrosis, 175, 176 Cold producing necrosis, 167 Color in gangrene, 171 Condition of tissues in necrosis, 171 Connective tissue, 41 Cornea, 31, 103-107 Corpuscle, third, 72 Croupous inflammation, 102, 103 Cultivation of bacteria, 131, 133 Decubitus, 164, 180 Defective arterial blood-supply, 166 INDEX. 605 Diabetic gangrene, 179 Diapedesis, 87 Direct causes of suppuration, 194-205 transmission of bacteria, 151 Disturbance of function, 91 Division of cells, 13 Dry gangrene, 178 Elimination of gangrenous part, 173 pathogenic bacteria, 149, 150 Embolism, 343-348 Emigration of leucocytes, 83-87 Emphysema, 171 Empyema, 280 after-treatment, 285 multiple resection, 286 thoracoplastic operation, 286 bacteriological studies, 280, 281 diagnosis, 282 prognosis, 282 treatment, 283 drainage, 285 evacuation of pus and removal of membranes, 284 incisions, 283 irrigation, 285 resection of rib, 284 Encapsulation of necrosed tissue, 173 Endocranial suppuration, 263-271 Epidermization, 22 Epididymis and testicle, tuberculosis of, 541 symptoms and diagnosis, 542 treatment, 543 Epiphyseolysis, 239 Epithelia, 36 Epithelioid cells, 439 Ergot the cause of gangrene, 167 Ergotine, 184 Erysipelas, 359 bullosum, 373 clinical forms, 373-376 cultivation, 361 description of streptococcus erysipe- latosus, 361 erythematosum, 373 facialis, 376 gangrsenosum, 374 history of microbic origin, 359, 860 inoculation experiments, 362 Erysipelas, inoculation experiments, for therapeutic purposes, 362 manner of infection, 364-366 metastaticum, 375 migrans, 375 prognosis, 377 relation of, to puerperal fever, 3G7 to phlegmonous inflammation and suppuration, 368, 369 symptoms and diagnosis, 370-372 traumatic, 376 treatment, 377-379 Erysipeloid, 380, 381 Essential condition for growth of bac- teria, 134 Excision of wounds, 413 Experiments, inoculation, of bacteria, 135 Exploration of brain, 378-280 of lung, 288 External parts, gangrene of, 168 Exudation, inflammatory, 83 Fallopian tubes, tuberculosis of, 538 symptoms and diagnosis, 539 treatment, 540 Farcy, acute, 595 chronic, 595 Fascia tuberculosis, 530 Fermentation fever, 313 symptoms and diagnosis, 314 Fibrous tubercle, 443 Fission of bacteria, 129 Five phases of chromatin substance, 9 Fixed tissue-cells, 73 Foot, perforating ulcer of, 183 Fragmentation of nucleus, 12 Function, disturbance of, 91 Furuncle, 227 Gangrene, caused by ergot, 167 color in, 171 diabetic, 179 dry, 178 hospital, 181, 182 line of demarcation, 172 moist, 178 of external parts, 168 prognosis, 184 progressive, 177, 178 606 INDEX. Gangrene, senile, 179 SAvelling, 171 treatment, 185-189 Genito-urinary organs, tuberculosis of, 537 Giant cells, 437-439 Glanders, 589 acute, 594 bacteriological history of, 589 chronic, 595 in the horse, 594 in man, 596 inoculation experiments, 591-594 pathology and morbid anatomy, 599 prognosis, 600 symptoms and diagnosis, 596-598 treatment, 600, 601 Glands, 56 Glans penis and urethra, tuberculosis of, 541 Granulating surfaces, skin-grafting in, 38 Granulation tissue, 13 vascularization of, 16 Granulomata, 112 Growth of bacteria, 134 HEMORRHAGIC INFLAMMATION, 95 Haemostasis, 24 Head tetanus, 398 Healing of wounds, 3 Heat producing necrosis, 166 Histogenesis of suppuration, 191 of tubercle, 435, 436 Histological structure of tubercle, 437- 442 Histology of tubercle, 433, 434 Histozym, 313 Hospital gangrene, 181, 182 Hyaline tubercle, 444 Hydrophobia, 403 a microbic disease, 405, 406 causes, 407 in the dog, 404 pathology and morbid anatomy, 411, 412 prognosis, 410 sj^mptoms and diagnosis, 407-409 treatment, 413 Hydrophobia, treatment, cauterization of wound, 413 excision of wound, 413 palliative, 416, 417 prophylactic, 413, 414 Icterus, hfematogenous, 349 Immediate or direct union of wounds, 3 Incubation period of tetanus, 392 Indirect causes of suppuration, 193 Infection-atrium of bacillus tetani, 393, 394 Inflammation, 67, 158, 159 chronic. 111, 114 hfemorrhagic, 95 histological elements in, 68 interstitial, 95 modification of, 93 of mucous membranes, 101, 102 of non -vascular tissue, 103 of serous membranes, 96-100 parenchjmiatous, 93 prognosis, 116 suppurative, 96 symptoms, 74-91 symptoms and diagnosis, 114-116 treatment, 117 anodynes, 125 antiphlogistic, 120 antipyretics, 123 antiseptic fomentations, 122 application of cold, 122 counter-irritation, 126 diet, 124 elevation of part, 121 ignipuncture, 126 massage, 125 parenchymatous injections, 118, 119 physiological rest, 121 stimulants, 124 tonics and alteratives, 125 Inflammatory exudation, 83 transudation, 90 Inoculation experiments of bacteria, 135 of tuberculosis, 426-428 Inoculation-tuberculosis in man, 429- 433 Inoculations, prophylactic. 414-416 Internal ear, tuberculosis of 457 INDEX. 60' Internal ear, necrosis, 168 organs, abscess of, 259 Iris, tuberculosis of, 458 Joints, tuberculosis of, 507 etiology, 507 pathology and morbid anatomy, 508 prognosis, 514 symptoms and diagnosis, 511-514 treatment, 515 amputation, 524 arthrectomy, 518, 519 aspiration, 517 atypical resection, 520-522 rest, 516 subcutaneous evacuation, 517 typical resection, 523 varieties of, 509-511 Karyokinesis, 8 Karyolysis, 168 Karyomitosis, 8 Karyorbexis, 168, 17'; Large cavities, suppuration in, 259 Leptomeningitis, suppurative, 267, 268 Leucocyte, 70, 437 emigration of, 83-87 Ligation of arteries in tbeir continuity, 165 Liquefaction of necrosed tissue, 173 Localization of bacteria, 141-146 Loss of function in osteomyelitis, 239 Lung-abscess, 287-289 Lupus, tubercular nature of, 459-462 Lymphatic glands, tuberculosis of, 469 pathological histology and morbid anatomy, 471 prognosis, 475 symptoms and diagnosis, 472-474 treatment, 476-480 Lyssa nervosa falsa, 410 Macrocytes, 438 Malignant oedema, 309-311 Mammary gland, tuberculosis of, 536 Metastatic suppuratiqn, 349-351 Microbe enchapelet, 334 Microbic cause of tetanus, 392 origin of erysipelas, 359, 360 Microbic origin of suppuration, 191, 192 of tuberculosis, 419-422 Micrococcus pyogenes tenuis, 202 Modification of inflammation, 93 Moist gangrene, 178 Mouth and tongue, tuberculosis of, 533 pathology, 532 symptoms and diagnosis, 533 treatment, 534 Mucous membrane, inflammation of 101, 103 of intestines, tuberculosis of, 535 suppurative inflammation of, 212 transplantation of, 41 Mummification, 172 Muscles, 46 non-striated muscular fibre, 46 striated muscular fibre, 46 suture of, 49 Myeloplaques, 438 Necrobiosis, 177 Necrosed tissue, liquefaction of, 173 Necrosis, 157 coagulation, 175, 176 etiology, 158-167 general symptoms, 174 internal, 168 pathological and clinical varieties, 175-189 prognosis, 184 symptoms, 168-174 treatment, 185-189 Nerve suture, 62 primary, 63 secondary, 63 Nerves, peripheral, 58 Nervous system, central, 57 Noma, 180 Non-vascular tissue, 31 cartilage, 34 cornea, 31 infiammation of, 103 Nucleus, fragmentation of, 13 Obstructed venous circulation, 166 Odor of necrosed tissue, 172 (Edema, malignant, 309-311 Opening of the skull, 278 Operation, thoracopiastic, 288 608 INDEX. Origin of suppuration, 191, 193 Osseous tuberculosis, cause of, 489 Osteomyelitis, suppurative, 231 early operations, 248 intermediate operations, 249, 250 late operations, 251-256 Pachymeningitis, suppurative, 263 Pain a symptom of necrosis, 169 of osteomyelitis, 237 Parenchymatous inflammation, 93 Paronychia, 226 Pathogenic bacteria, 127 attenuation, 136 classification, 127 cultivation, 131-133 elimination, 149, 150 inoculation, 137 localization, 141-146 multiplication, 129 presence of, in healthy body, 139, 140 secondary or mixed infection, 146- 149 transmission of, from parents to foetus, 151-155 Perforating ulcer of foot, 183 of stomach and duodenum, 188 Pericarditis, suppurative, 289 Pericardium, incision and drainage, 290 puncture and aspiration, 290 Peripheral nerves, 58 Peritoneum, tuberculosis of, 480 bacteriological remarks, 480 clinical studies, 481 pathology and morbid anatomy, 482 symptoms and diagnosis, 483 treatment, 484-487 Peritonitis, adhesive, 483 fibrino-plastic, 483 plastic and suppurative, 295 suppurative, 291-302 Phagocytosis, 108-111 Phlegmonous inflammation, relation of erysipelas to, 368 with suppuration, 220 Physiological rest, 26 Plasma rhexis, 177 Progressive gangrene, 177 with emphysema, 178 Prophylactic inoculations, 414-416 Proteus mirabilis, 317 vulgaris, 316 Zenkeri, 317 Ptomaines, 134, 198-200, 317-322 of bacillus tetani, 390, 391 of pus-microbes as a cause of sup- puration, 198-200 Puerperal fever, relation of erysipelas to, 367 Pulse, after ligation of artery, 170 Purulent infiltration, progressive, 223 Pus, 205 corpuscles, 206-208 microbes, 195-198 description and specific action of, 200-205 ptomaines of, 198-200 serum, 206 Putrefactive bacteria, 163 Pyaemia, 333 bacteriological and experimental researches, 334^337 etiology, 338-347 in rabbits, 335 pathological anatomy, 353, 353 prognosis, 352 symptoms and diagnosis, 348-351 treatment, 354-356 Pyogenic microbes as a cause of sepsis, 311 substances, chemical, 194 Redness a symptom of osteomyelitis, 238 Regeneration, 1 of different tissues, 31 Reticulum, tubercle, 440 Rib, resection of, 284 Ribs, multiple resection of, 286 Sapr^mia, 315 prognosis, 323 symptoms and diagnosis, 322 treatment, 333, 324 Senile gangrene, 179 Sepsis, pyogenic microbes as a cause of, 311 Septicaemia, 303 bacteriological researches, 303-311 INDEX. 609 Septicaemia, clinical forms of, 312-331 in mice, 304, 305 in rabbits, 306^300 progressive, 325 causes, 325, 326 pathology and morbid anatomy, 330 prognosis, 329 symptoms and diagnosis, 327, 328 treatment, 330, 331 Septicopysemia, 356-358 kryptogenetic, 357 spontaneous, 357 Serous membranes, inflammation of, 96-100 Skin-grafting, 38, 39 Skin, tuberculosis of, 459 pathology and morbid anatomy, 462 prognosis, 466 symptoms and diagnosis, 463-465 treatment, 466-468 Skull, opening of, 278 Specific bacteria, 160-162 Spores of bacteria, 130 Staphylococcus cereus albus, 202 cereus flavus, 202 flavescens, 202 pyogenes albus, 201 pyogenes aureus, 201 pyogenes citreus, 201 Stomach and duodenum, perforating ulcer of, 183 Streptococcus erysipelatosus, 361 pyogenes, 203 Subacute suppuration, 210 Suppuration, 191 acute, 207 bacterial causes and histogenesis of, 191 chronic, 210 clinical forms, 209 direct causes, 194-205 endocranial, 263-271 history of microbic origin, 191, 192 in large cavities, 259 in wounds, 211 indirect causes, 193 pus, 205-208 relation of erysipelas to, 368, 369 subacute, 210 Suppurative arthritis, 259 bacteriological researches, 259, 260 symptoms and diagnosis, 261 treatment, 261-263 inflammation, 96, 101 of mucous membrane, 213-230 leptomeningitis, 267, 268 symptoms and diagnosis, 269 treatment, 270 osteomyelitis, 231 bacteriological and experimental investigations, 232, 233 causes, 234, 235 chronic circumscribed, 256-258 diagnosis, 239, 240 history, 231 pathological anatom}% 242, 243 prognosis, 241 symptoms, 236-238 treatment, 244-255 pachj'uieningitis, 263 symptoms and diagnosis, 264 treatment, 265-267 pericarditis, 289 peritonitis, 291 bacteriological and experimental researches, 291-298 causes, 295-297 clinical and bacteriological stud- ies, 294 symptoms and diagnosis, 298, 299 treatment, 300-302 tendo-vaginitis, 224 Surgical tuberculosis, 419-446 clinical forms, 447-468 Suture of muscles, 49 of nei'ves, 62-66 Suturing, 25 of granulating wounds, 29 Symptoms of inflammation, 74-91, 114- 116 Synovitis, 238 Swelling a symptom of osteomyelitis, 237 in moist gangrene, 170 Temperature in gangrene, 170 Tenderness a symptom of osteomyelitis, 237 in diagnosis of necrosis, 169 39 (ilO INDEX. Tetanus, 383 acute, 397 bacteriological studies. i38-]-891 clinical forms, 397, 398 cultivation, 384 etiology, 392-394 liydrophobicus. 398 infection-atrium, 393, 394 inoculation experiments. 385-390 neonatorum, 398 pathology and morbid anatomy, 399^ period of incubation. 392 prognosis, 398 specific microbic cause, 392 symptoms and diagnosis, 395-397 treatment, 399-401 Therapeutic inoculation of bacteria, 137 Third corpuscle, 72 Thoracoplastic operation, 286 Thrombosis, 340-342 Tissue-cells, 73 Tissue, condition of, 171 connective, 41 non-vascular, 31 vascular, 35 Tissues, action of bacteria on, 134 Transmission of bacteria, 151-155 Transplantation of mucous membrane, 41 of skin, 38 Transudation, inflammatory, 90 Trauma, 163 Traumatic erysipelas, 376 Treatment of acute abscess, 217, 218 anthrax, 585-588 brain-abscess, 273 carbuncle, 230 chronic abscess, 220 empyema, 283-287 erysipelas, 377-379 furuncle, 228 gangrene, 185-189 glanders, 600, 601 hydrophobia, 413-417 inflammation, 117-126 necrosis, 185-189 paronychia, 226 phlegmonous inflammation, 221,222 purulent inflammation. 223 Treatment of pytemia, 354-3.")6 saprsmia, 323. 324 septicaemia, 330, 331 suppurating wounds, 28 suppurative arthritis, 261-263 leptomeningitis, 270 osteomyelitis, 244-255 pachymeningitis. 265-267 peritonitis, 300-302 tendo-vaginitis, 225 tetanus, 399-401 tubercular abscess, 453-457 tendo-vagiuitis, 528-530 tuberculosis of actinomycosis hom- inis, 568 bladder, 545-548 bone, 503-507 epididymis and testicle, 543 Fallopian tubes, 540 joints, 515-524 lymphatic glands, 476-480 mammary gland, 536 mouth and tongue, 584 peritoneum, 484-487 skin, 466-468 vulva, vagina, and uterus, 537 wounds, 23 skin-grafting in. 39 Trismus, 398 Tubercle, fibrous, 443 hyaline, 444 nodule, arrangement of cells in, 440, 441 growth of, 443 reticulated, 443 Tubercular abscess, 450 ascites, 482 tendo-vaginitis, 525 pathology, 525 prognosis, 527 symptoms and diagnosis, 527 treatment, 528-530 Tuberculosis, surgical, 419 calcification, 446 caseation, 444, 445 description of bacillus, 423 growth of tubercle-nodules. 442 hereditary and acquired disposi- tion, 448, 449 histogenesis of tubercle. 435. 436 INDEX. 611 Tubercnlosip, surgical, histological structure of tubercle, 487-441 histology of tubercle, 433, 434 history of microbic origin, 419-422 inoculation experiments, 426-428 tuberculosis in man, 429-432 pathological varieties, 443 Tuberculosis of bladder, 544 bones, 489-507 epididymis and testicle, 541 Fallopian tubes, 538 fascia, 530 genito-urinary organs, 537 glans penis and urethra, 541 internal ear, 457 joints, 507-524 lymphatic glands, 409-480 mammary gland, 536 mouth and tongue, 532 mucous membrane of intestines. 535 peritoneum, 480-487 the iris, 458 the skin, 459-468 vesiculse seminalis, 543 vulva, vagina, and uterus, 537 treatment, 538 Ulcer of foot, 183 of stomach and duodenum, 183 Union of wouuds by primary inten- tion, 6 by secondary intention, 27 Vacuolak degeneration, 177 Varieties of necrosis, 175-189 of tuberculosis of joints, 509-511 Vascular tissue, 35 surface epithelia, 36 Vascularization of granulation tissue, 16 Venous circulation, obstructed, 166 VesiculfE seminalis, tuberculosis of, 543 Vessels, capillary, 68, 69 Vulva, vagina, and uterus, tuberculosis of, 537 Wounds, cauterization of, 413 excision of, 413 healing of, 2 immediate or direct union, 3 of blood-vessels, 42 skin-grafting in, 39 suppuration in. 211 suturing of granulating, 29 treatment of, 23 absolute asepsis in, 23, 28 of suppurating, 28 union by primary intention. 6 by secondarv intention, 27 MARCH, 1890. 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Arrangements are being made for volumes upon the "Eye," "Nose and Throat," " Gyasecology," "Medical Microscopy," "Physiology," etc., to follow the above, at intervals, in the " Physicians' and Students' Ready-Reference Series." The Physicians' and Students' Ready- Reference Series Includes publications of great value to students during their attendance at college, and to the busy physician in his daily practice. While they in no way attempt to supplant the various Text-Books, it cannot be doubted that they are necessary to the often overworked student when examination time is approaching, previous to which, for weeks, but little time can be gained from the lectures in which to make careful and thorough pre|>aration for the examination-room. Complete synopses of the several important branches, and valuable monographs on various important subjects, are furnished in the publications of this series in such form and arrangement by confpetent writers as to render them of special ])ractical value to the busy student and also to the physician in active practice. The volumes are neat and con- venient in size and shape, and appropriately illustrated with many fine wood-engravings. See Pages 3, 20, 21, and 27 for those now published, and the upper part of this page for those in preparation. (F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) JUST PUBLISHED— A NEW AND VALUABLE WORK ON Practical Electricity IN MEDICINE AND SURGERY. G. A. L.IEBIG, Jr., Ph.D., Assisiaot in Electricity, Johns Hopkins University ; Lecturer on Medical Electricity, College of Phy- sicians and Surgeons, Baltimore; Member of the American Institute of Electrical Engineers, etc., -AND- GEORGE H. 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Professor Rohe. who writes on Electro-Thera[ieutics, discu.sses at length the recent developments of Electricity in the treatment of stricture, enlarged prostate, uterine fibroids, pelvic cellulitis, and other diseases of the male and female genito-urinary organs. The ai)plications of Electricity in dermatology, as well as in the diseases ot the nervous system, are also fully considered. THE SECOND VOLUME IN THE PHYSICIANS' AND STUDENTS' READY REFERENCE SERIES. H:A]sri3_BOOPC OF Materia MsdicaJhapmaGji, and Tiierapeutics By OUTHBERT BOWEN, M.D., B.A., Editor of " Notes on Practice." EXTRACT FROM THE PREFACK.—" While this isessentially a Stuuents Manual, alarge amount of matter has been incorporated which, it is hoped, will render it a useful reference-book to the young GRADUATE wlio is just entering on his professional career, and more particularly the individual whose sphere of work demands a more practical acquaintance with pharmaceutical processes than is required of the ordi- nary city practitioner. Cireat care has been taken throughout the book to familiarize the student with the \>e^^\ methods of administering the various drugs he will be called upon to use, and with this object a large number of standard prescriptions have been selected from the works of the most eminent authorities, which he can either adopt, with modifications to suit particular cases, or use as models on which to construct his own formula;." This excellent manual comprises in its 366 small ooiavo pages about as much sound and valuable in- forniatiori on the subjects indicated in its title as could well be crowded into the compass. The book is exhaustively and correctly indexed, and of a con- venient form. The paper, press-work, and binding are excellent, and the typography (long primer and brevier) is highly to be commended, as opposed to the nonpareil and agate usually used incompendsof this sort, and which are destructive to vision and temper alike. — St. Louis Med. and Surg. your. In going through it, we have been favorably im- pres.sed by the plain and practical suggestions in regard to prescription writing, and the metric sys- tem, and the other things which must be known in order to write good and accurate prescriptions. — Medical and Surgical Reporter. .Many works claim more in their title-pages than •■an be verified further on, but the only adverse criticism we can make on this volume is that it does not claim enough. — Southern California Prac- titioner. The book is one of the very best of its class. — Columbus Medical Journal . This is a very condensed and valuable resume of the drugs recognized by the United States Phar- macopoeia, and all the officinal and important preparations. — Southern Medical Record. Dr. Bowen's work is a very valuable one indeed, and will be found " to fill a want " beyond a doubt. —Cincinnati Medical News. It is short and concise in its treatment of the subjects, yet it gives sufficient to gain a very correct knowledge of everything that comes under this head- ing. This is a ready work for the country physician, who must of necessity have a more practical acquain- tance with pharmaceutical processes. — Medical Brief. Une I'itno volanie of 370 pages. Handsomely Bound in Dark-Blae Clotb. Price, poet-paid, in the United States and Canada, $1.40, net; in Great Britain, 6s. 6d.; in France, 9 fr. 35. (F. A. DAVIS. Medical Publisher, Philadelphia. Pa.. U.S.A.) Bashore's Improved Clinical Chart. For the SEPARATE PLOTTINa of TEMPERATURE, PULSE, and RESPIRATION. ? Convenient, Accurate, and Permanent Daily Recor Hospital and Private Practice. By HARYHY B. BASHORK, m.D. Designed for the Convenient, Accurate, and Permanent Daily Recording of Cases in Hospital and Private Practice. CO?TEIGHTED, 1888, BY F. A. DAVIS. SO Olxarts, ian TaTolet I^orm.. Size, S2cl2 incites. Price, in the United States and Canada, Post-paid, 50 Cents, Net; Great Britain, 2s. 6d. ; France. 3 fr. 60. The above diagram is a little more than one-fifth (1-5) the actual size of the chart and shows the method of plotting, the upper curve being the Temperature, the middle the Pulse, and the lower the Respiration. By this method a full record of each can easily be kept with but one color ink It is so arranged that all practitioners will find it an invaluable aid in the treatment of their patients. On the back of e.ich chart will be found ample space conveniently arranged for recording "Clinical History and Symptoms" and "Treatment." By its use the physician will secure such a complete record of his cases as will enable him to review them at any time. Thus he will always have at hand a source of individual improveuient and benefit in the practice of his profession, the value of which can hardly be overestimated. (F. A. DAVIS. Medical Publisher, Philadelphia. Pa., U.S.A.) -4HB OO^^H^ ON The Physician Himself AND THINGS THAT CONCERN HIS REPUTATION AND SUCCESS. D. W. CATHELL, M.D., BALTIMORE, MD. Being the NINTH EDITION (Enlarged and Thoroughly Revised) of the "PHYSICIAN HIMSELF. AND WHAT HE SHOULD ADD TO HIS SCIENTIFIC ACQUIREMENTS IN ORDER TO SECURE SUCCESS.' In One Handsome Octavo Volume of 298 Pages, Bound in Estra ClotL Priee, Pc»t-paid, in United States and Canada, $2.00, Net; Great Britain, 8s. 6d. ; France, 12 fr. 40. This remarkable book has passed through eight (8) editions in less ihun Hve years, has met with the unanimous and hearty approval of the Profession, and is practicall}^ indispensable to every young graduate who aims at success in his chosen profession. It has just undergone a t horougli revision by the author, who has added much new matter cover- ing many points and elucidating many excellent ideas not included in former editions. This unique book, the onl}^ complete one of the kind ever written, will prove of inestimable pleasure and value to the practi- tioner of many years' standing, as well as to the young physician who needs just such a work to point the way to success. We give below a few of ^le many unsolicited letters received by the author, and exti'acts from reviews in the Medical Jciurnals of tlie fonniM' editions : " ' The Physician Himself is an opportune and most useful book, which cannot fail to exert a good influence on the morale and the business success of the Mctlical profession." — From ProJ". Roberts iitirt/io/oiv, Philadelphia, Pa. 'I have read 'The Physician Himself with pleasure — delight. It is brimful of medical and social philosophy ; cverj- doctor in the land can Mudy it with pleasure and profit. I wi.sh 1 could Iiave read such a work thirty years ago." — From Pro/. John S. Lynch, Baltimore. Md. "'The Physician Himself interested me so much that 1 actually read it through at one sitting. It is brimful of the very best advice possible for iiicxlical men. I, for one, shall try to prolit by it." — From Pro/. William Goodell, Philadelphia. •' I .would be glad if, in the true interest of the profession in 'Old England,' some able practitioner here would prepare a work for us on the same line as ■The Physician Himself.'" — From Dr. Jukes de Styrap, Shreiusbury, England. " 1 am most favorably impressed with the wisdom and force of the points made in ' The Phy- sician Himself,' and believe the work in the hands of a young graduate will greatly enhance his chances for profe.ssional success." — From Pro/. D. Hayes Agne'tu, Philadelphia, Pa. " This book is evidently the production of an unspoiled mind and the fruit of a ripe career. 1 aiimire its pure tone and feel the value of its practi- cal points. How 1 wish I could have read such a guide at the outset of my career!" — Frotn Pro/. James Nezdns Hyde, Chicago, III. " It contains a great deal of good sense, well expressed.'' — Froi>i Pro/. Oliver Wendell Holmes, Har'i'ard University. " 'The Physician Himself is useful alike to the tyro and the sage — the neophyte and the veteran. It is a headlight in the splendor of whose beams a multitude of our profession shall find their way to success." — Froi>! Pro/. J. Jif. Bodine, Dean Uni- versity o/ Louisz'ille. " It is replete with good sense and sound phi- losophy. No man can read it without realizing that its author is a Christian, a gentleman, and a shrewd observer." — From Pro/. Edivard Warj-en (Bey), Chevalier o/ the Legion o/ Honor, etc.. Paris, France. "I have read 'The Physician Himself,' care- fully. I find it an admirable work, and shall advise our Janitor to keep a stock on hand in the book de- partment of Bellevue." — From Pro/. U'illiam T. Lusk, New York. " It must impress all its readers with the belief that it was written by an able and honest member of the profession and for the good of the profession." — From Pro/ W. H. By/ord, Chicago, III. "It is marked with good common sense, and replete with e.Kcellent maxims and suggestions for the guidanceof medical men." — From The British Medical Journal, London. " We strongly advise every actual and intend- ing practitioner of medicine or surgery to have ' The Physician Himself,' and the more it influences his future conduct the better he will be." — From The Canada Medical and Surgical Journal, Montreal. "We would advise every doctor to well w^h the p.dvise given in this book, and govern his con- duct accordingly." — From The Virginia Medical Monthly. (F A. DAVIS, Medical Publisher, Philadelphia. Pa.. USA.) AN IMPORTANT PUBLICATION OF GREAT VALUE TO THE MEDICAL AND LEGAL PROFESSIONS. Spinal Concussion: Surgically Considered as a Cause of Spinal Injury, and Neurologi- cally Restricted to a Certain Symptom Group, for which is Suggested the Designation ERICHSEN'S DISEASE, AS ONE FORM OF THE TRAUMATIC NEUROSES. S. V. CLEVENOER, 1S/I.I3., CONSULTING PHYSICIAN REESE AND ALBXIAN HOSPITALS; LATE PATHOLOGIST COUNTY INSANE ASYLUM, CHICAGO; MEMBER OF NUMEROUS AMERICAN SCIENTIFIC AND MEDICAL SOCIETIES; COLLABORATOR AMERICAN NATURALIST, ALIENIST AND NEUROLOGIST, JOURNAL OF NEUROLOGY AND PSYCHIATRY, JOURNAL OF NERVOIS AND MENTAL DISEASES; AUTHOR OF "COM- PARA TIVE PHYSIOLOGY AND PSYCHOLOGY," "ARTISTIC ANATOMY," ETC. For more thuu twenty years this sul)ject has occasioned Idttoi' con- tention in law courts, between physicians as well as attorneys, and in that time no work has appeared that reviewed the entire field jndicially until Dr. Clevenger's book Was written. It is the outcome of five years' special study and experience in legal circles, clinics, hospital and private practice, in addition to twenty years' labor as a scientific student, writ^n-, and teacher. The literature of Spinal Concussion has been increasing of late years to Jin unwieldy shape for the general student, and Dr. Clevenger has in this work arranged and reviewed all that has been done by obsei'vers sinci- the days of Erichsen and those who preceded him. The dificrent and sometimes antagonistic views of many authors are fully given from tiic writings of Erichsen, Page, Oppenheim, Erb, Westphal, Abercrouibit-. Sir Astley Cooper, Boyer, Charcot, Leyden, Rigler, Spitzkn. Putnam, Knapp, Dana, and many otlier European and American students of the subject. The small, but important, work of Oppenheim, of tiie Berlin University, is fully translated, and constitutes a chapter of Dr. Cleven- ger's book, and reference is made wherever discussions occurred in American medico-legal societies. There are abundant illustrations, particularly for Electro-diagnosis, and to enable a clear comprehension of the anatomical and pathological relations. The Chapters are : 1. Historical Introduction ; II. Erichsen on Spinal Concussion ; III. Page on Injuries of the Spine and Spinal Cord; lY. Recent Discussions of Spinal Concussion : V. Oppenheim on Ti-au- matic Neuroses; Ti. Illustrative Cases from Original and all other Sources; VII. Traumatic Insanity; YIII. The Spinal Column; IX. Symptoms; X. Diagnosis; XI. Pathology; XII. Treatment; XIII. Medico-legal Considerations. Other special features consist in a description of modern methods of diagnosis b}^ Electricity, a discussion of the controversy concerning hysteria, and the author's original pathological view that the lesion is one involving the spinal sympathetic nervous system. In this latter respect entireh' new ground is taken, and the diversity of opinion con- cerning the functional and organic nature of the disease is afforded a basis for reconciliation. Ereri/ Phi/i^iciav and Lawyer should own this work-. In one handsome Royal Octavo Volume of nearly 400 pages, with Thirty Wood-Engravings. Net price, in United States and Canada, $2.50, post-paid ; in Great Britain, lis. 3d. ; in France, 15 fr. CF. A. DAVIS. Medical Publisher. Philadelphia, Pa.. U.S.A.) JUST READY-A NEW AND IMPORTANT WORK. -^^^^^^^^ K S S AY MEDICAL PNEDMAT0L06YIAER0THERAPY: A PRACTICAL INVESTIGATION OF THE CLINICAL AND THERAPEUTIC VALUE OF THE GASES IN MEDICAL AND SURGICAL PRACTICE, WITH ESPECIAL REFERENCE TO THE VALUE AND AVAILABILITY OF OXYGEN, NITROGEN, HYDROGEN, AND NITROGEN MONOXIDE. By d. M. DEMARQUAY, Surgeon to the Municipal Hospital, Paris, and of the Council of State ; Member of the Imperial Society of Surgery; Correspondent of the Academies of Belgium, Turin, Munich, etc. ; Officer of the Legion of Honor ; Chevalier of the Orders of Isabella-the- Catholic and of the Conception, of Portugal, etc. TRANSLATED. WITH NOTES, ADDITIONS, AND OMISSIONS, By SAMUEL 8. WALLIAN, A.M., M.D., Member of the American Medical Association ; Ex-President of the Medical Association of Northern New York ; Member of the New York Coimty Medical Society, etc. In one Handsome Octavo Volume of 316 Pages, Printed on Fine Paper, iu tbe Best Style of the Printer's Art, and Illustrated with 21 Wood-Cuts. Unit«d State.?. Canada (duty paiiU. Great Britain. France. NET PRICE, CLOTH, Post-paid, $2.00 S3. 20 8s. 6d. 12 fr. 40 ^-RUSSIA, " 3.00 3.30' 13s. 18 fr. 60 For some years past there has been a growing demand for something more satisfac- tory and more practical in the way of literature on the subject of what has, by common consent, come to be termed '" Oxygen Therapeutics." On all sides professional men of standing and ability are turning their attention to the use of the gaseous elements about us as remedies in disease, as well as sustainers in health. In prosecuting their inquiries, •the first hindrance has been the want of any reliable, or iu any degree satisfactory, literature on the subject. Purged of the much quackery heretofore associated with it, Aerotherapj- is now recognized as a legitimate department of medical practice. Although little noise is made about it, the use of Oxygen Gas as a remedy has increased in this country within a few- years to such an extent that in New York City alone the consumption for medical ]'ur- poses now amounts to more than 300,000 gallons per annum. This work, translated in the main from the French of Professor Demarquay, contains also a very full account of recent English, German, and American experiences, prepared by Dr. Samuel S. Wallian, of New York, whose experience in this field antedates that of any other American writer on the subject. Plain Talks on Avoided Subjects. — BY — < HENRY N. GUERNSEY, M.D., Formerly Professor of Materia Medica and Institutes in the Hahnemann Medical College of Philadelphia; Author of Guernsey's " Obstetrics," including the Disorders Peculiar to Women and Young Children ; Lectures on Materia Medica, etc. IN ONK NEAT 16mo VOLUME. BOUND IN EXTRA CLOTH. Price, Post-paid, is United States and Canada, $1.00; Great Britain, 48. 6d.; France, 6 fr. 20. This is a little volume designed to convey information upon one of the most important subjects con- nected with our physical and spiritual well-being, and is adapted to both sexes and all ages and conditions of society ; in fact, so broad is its scope thai no human being can well afford to be without it, and so com- prehensive in its teachings that, no matter how well informed one may be, something can yet be learned from this, and yet it is so plain that any one who can read at all can fully understand its meaning. The Author, Dr. H. N. Guernsey, has had an unusually long and extensive practice, and his teachiags in this volume are the results of his observation and actual experience with all conditions wf human life. His work is warmly indorsed by many leading men in all branches of professional life, as well as by many whose business connections have caused them to be close observers. The following Table of Contents shows the scope of the book: — CONTENTS. Chapter L— Introditctory. H.— The Lnfant. IIL — Childhood. IV.— Adolbs- CENCB OF THE MaLE. V. — ADOLESCENCE OF THE FeMALE. VL — MARRIAGE : ThE HUSBAND. VIL — "^'he Wife. VIIL— Husband and Wife. IX. — To the Unfortunate. X.— Origin o* the Sex. CF. A. DAVIS, Medical Publisher, Philadelphia. Pa.. U.S.A.) 7 •NB^W BOIXIOB{= Lessons in Gynecology. By WILLIAM GOODELL, A.M., M.D., Etc., Phofkssor op Clinical Gynecology in thb University of Pennsylvania. With 112 Illaatrations. Third Edition, Thorong:hly Revised and Greatly Knlarged. ONK VOLUMK, LAKGE OCTAVO, 578 PAGES. This exceedingly valuable work, from one of the most eminent specialists and teachers in gynecology in the United States, is now offered to the profession in a much more complete condition than either of the previous editions. It embraces all the more important diseases and the principal operationsjn the field of gynecology, and brings to bear upon them all the extensive pr.ictic.il experience and wide reading of the ;uithor. It is an indispensable guide to every practitioner who has to do with the diseases peculiar to women. Fig. 44. Natural Position of the Womb When the Bladder is Full. After Briesky. These lessons are so well known that it is en- tirely unnecessary to do more than to call attention to the fact of the appearance of the third edition. It is too good a book to have been allowed to remain out of print, and it has unquestionably been missed. The author has revised the work with special care, adding to each lesson such fresh matter as the prog- ress in the art rendered necessary, and he has en- larged it by the insertion of six new lessons. This edition will, without question, be as eagerly sought for as were its predecessors. — American Journal of Obstetrics. The former editions of this treatise were well received by the profession, and there is no doubt that the new matter added to the present issue makes it more useful than its predecessors. — Nezv York Medical Record. His literary style is peculiarly charming. There is a directness and simplicity about it which is easier to admire than to copy. His chain of plain words and almost blunt expressions, his familiar compari- son and homely illustrations, make his writings, like his lectures, unusually entertaining. The substance of his teachings we regard as equally excellent. — Phila. Medical and Su rgical Reporter. Extended mention of the contents of the book is unnecessary; suffice it to say that every important disease found in the female se.x is taken up and dis- cus.sed in a common-sense kind of a way We wisli every physician in America could read and carrj' out the suggestions of the chapter on " the sexual re- lations as causes of uterine disorders — conjugal onanism and kindred sins." The department treat- ing of nervous counterfeits of uterine diseases is a most valuable one. — Kansas City Medical Index. Price, in United States and Canada, Cloth, $5.00; Full Sheep, $6.00. Biscount, 20 per cent., making it, net. Cloth, $100; Sheep, $180. Postage, 27 Cents estra. Great Britain, Cloth, 18s. ; Sheep, £1.2s., post-paid, net. France, 30 fr. 80. (F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A. AMERICAN RESORTS, WITH NOTES UPON THEIR CLIMATE. :By :b"U"SZ3:i?.03z> "w. trjft.KEES, jiOi..i>am a large ori/ice. This is plamly and admirably set forth in his book. To bleed requires a cutting instrument, — not necessarily a lancet, — for Dr. M. states how in one case a pocket-knife was used and the desired effect produced. Let the young physician gather courage from this little book, and let the more experienced give testi- mony to confirm its teaching. We liave always thought tliat tliis treatment was inilor.sed, approved, and i)racticed by physicians generally ; and to such as doiiht tlie efficacy of blood-letting we woulU commend this little volume. — Southern Clinic. The authors are seriously striving to restore the "lost art" of blood-letting, and we must commend the modesty of their endeavor. — North darolina Mid. .Imir. The cases were ably analyzed, and this plea for vene- section should receive the most attentive consideration froih obstetricians. — Medical and Sarijirnl Reporter. TTJST I5,E-A_nD"2r.- A MANUAL OF INSTRUCTION FOR GIVING '""""^""""tii tease Treatment. F*ROK. HARTVia NiSSEN, Director of the Svi^edish Health Institute, Washington, D.C. ; I.ate Instructor in Physical Culture ani Gymnastics at the Johns Hopkins University, Baltimore, Md. ; Author of " Health by Exercise without Apparatus." ILLUSTRATED WITH 29 ORIGINAL WOOD-ENGRAVINGS. In One 12mo Volume of 128 Pages. Neatly Bound in Cloth. Price, post-paid, in United States and Canada, Net, $1.00; in Great Britain, 4s. 3d.; in France, 6 fr. 20. This is the only publication in the English language treating this very important subject in a practical manner. Full instructions are given regarding the mode of applying The Swedish Movemeiit and Massage Treatment in various diseases and conditions of the human system with the greatest degree of effectiveness. Professor Nissen is the best authority in the United States upon this prac- tical phase of this subject, and his book is indispensable to every physician who wishes t*- know how to use these valuable handmaids of medicine. This manual is valuable to the practitioner, as it contains a terse description of a subject but too little under- stood in this country The book is got up very creditably.— if. Y. Med. Jour. The present volume is a modest account of the appli- cation of the Swedish Movement and Massage Treatment, in which the technique of the various procedures are clearly stated as well as ilhistrated in a very excellent manner. — North American Practitioner. This Jittio manual seems to be written by an expert, and to those who desire to know the details connected with the Swedish Movement and Massage we commend th» book. — Practice. This attractive little book presents the subject in a very practical shape, and makes it possible forevery physician t* understand at least how it is applied, if it does not give hii» dexterity in the art of its application. lie can certainly acquire dexterity by following the directions so plainly ad- viied in this book. — Chicago Med. Times. It is so practical and clear in its demonstrations that if you wish a work of this nature you cannot do better thaa. peruse this one. — Medical Brief. (F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) JUST READY— THE LATEST AND BEST PHYSICIAN'S ACCOUNT- BOOK EVER PUBLISHED. THE PHYSICIAN'S ALL-REQai51TE TlNE- AH^ Labor- 5avinq Account-Book: BEING A LEDGER AND ACCOUNT-BOOK FOR PHYSICIANS' USE, MEETING ALL THE REQUIREMENTS OF THE LAW AND COURTS. DESIGNED BY 0£ Elaston, ^=SL. PROBABLY no class of people lose more money through carelesslj' kept aceonnts and overlooked or neglected bills than ph^^sicians. Often detained at the bedside of the sick until late at night, or deprived of even a modicum of rest, it is with great difficulty that he spares the time or puts himself in condition to give the same care to his own financial interests that a merchant, a lawj^er, or CA'en a farmer -devotes. It is then plainly apparent that a sj^stem of bookkeeping and accounts that, without sacrificing accuracy, but, on the other hand, ensuring it, at the same time relieves the keeping of a physician's book of half their complexity and two-thirds the labor, is a convenience which will be eagerly welcomed by thousands of overworked physicians. Such a sys- tem has at last been devised, and we take pleasure in offering it to the profession in the form of The Physician's All-Requisite Time- and Labor- Saving Account-Book. There is no exaggeration in stating that this Account-Book and Ledger reduces the labor of keeping your accounts more than one-half, and at the same time secures the greatest degree of accuracy. We may mention a few of the superior advantages of The Physician's All- Requisite Time- and Labor- Saying Account-Book, as follow: — First — Will meet all the requirements of the law and courts. Second — Self-explanatory ; no cipher code. Third — Its completeness without sacrificing anything. Fourth — No posting ; one entry only. Fifth — Universal ; can be comnienced at any time of year, and can be continued in- definitely until every account is filled. Sixth — Absolutely no waste of space. Seventh — One person must needs be sick ever)' day of the year to fill his account, or might be ten years about it and re- quire no more than the space for one account in this ledger. Eighth — Double the number and many times more than the number of accounts in any similar book ; the 300-page book contains space for 900 accounts, and the 600-page book contains space for 180d • accounts. Ninth — There are no smaller spaces. Tenth — Compact without sacrificmg com- pjleteness ; every account complete on same page — a decided advantage and recommendation. Eleventh — Uniform size of leaves. Twelfth — The statement of the most com- plicated account is at once before j'ou at any time of month or year — in other words, the account itself as it stands is its simplest statement. Thirteenth — No transferring of accounts, balances, etc. To all physicians desiring a quick, accurate, and comprehensive method of keeping their accounts, we can safel}^ say that no book as suitable as this one has ever been devised. NET PRICES, SHIPPING EXPENSES PREPAID. No. 1. 300 Pages, for 900 Accounts per Year, Size 10xl2, Bound in i; Russia, Baised '" U. S. Back-Bands, Cloth Sides, . . . S5.00 No. 2. 600 Pages, for 1800 Accounts \>er Year, .Size 10x12, Bound in % Russia, Raised Back-Bands, Cloth Sides, . . . 8.00 Canada (duty paid). Great Britain. France. $5.50 £0.18s. 30 fr. 3© 8.80 1.13s. 49 fr. 40 (F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 17 PHYSICIANS' INTERPRETER IN FOUR I.ANGUAGES. (ENGLISH, FRENCH, GERMAN, AND ITALIAN.) Specially Arranged for Diagnosis by M. von \, The object of this little work is to meet a need often keenly felt hj the busy physician, namely, the need of some quick and reliable method of communicating intelligibly with patients of those nationalities and languages mi familiar to the practitioner. The plan of the book is a sys- tematic arrangement of questions upon the various branches of Practical Medicine, and each question is so worded that the only answer required of the patient is merely Yes or No. The questions are all numbered, and a complete Index renders them always available for quick reference. The book is written by one who is well versed in English, French, Ger- man, and Italian, being an excellent teacher in all those languages, and who has also had considei'able hospital experience. Bound in Full Russia Leather, for Carrying in the Pocket. (Size, 5x2f Inches.) 206 Pag-es. Price, post-paid, in United States and Canada, $1.00, net; Great Britain, 4s. 6d. ; France, 6 fr. 20. , To convej' some idea of the scope of the questions contained in the Physicians' Interpreter, we append the Index : — General health i. Special diet 31. Age of patient 52 Necessity of patients undergoing an opera- tion 63 Office hours 7i Days of the week 78- 84 Patient's history: hereditary affections in his family; his occupation; diseases from his childhood up 85-130 Months of the year. 106-117 Seasons of the year 118-121 Symptoms of typhoid fever ..131-158 Symptoms of Bright's disease 159-168 Symptoms of lung diseases 169-194 and 311-312 Vertigo 195-201 The eyes 201-232 Paralysis and rheumatism 236-260 Stomach complaints and chills 26 1-269 Falls and fainting spells 271-277 How patient's illness began, and when pa- tient was first taken sick 278-279 Names for various parts of the body 283-295 The liver 300-301 The memory 304-305 Bites, stings, pricks 314-316 Eruptions 317-318 Previous treatment 319 Symptoms of lead-poisoning 320-324 Hemorrhages 325-328 Burns and sprains 33°-33i The throat.. 33Z-335 The ears 336-339 General directions concerning medicines, baths, bandaging, gargling, painting swelling, etc 34'*-373 Numbers pages 202-204 The work is well done, and calcnlated to be of great service to those who wish to acquire familiarity with the phr.ises used in questioning patients. More than this, we telieve it would be a great help in acquiring a vocabulary to be used in reading medical books, and that it would fur- nish an excellent basis for beginning a study of any one of the languages which it includes. — ^Medical and Surgical Reporter. Many other books of the same sort, with more ex- tensive vocabularies, have been publislied. but, from their size, and from their being usually devoted to equivalents in English and one other language only, they have not had the advantage which is pre-eminent in this — convenience. It is handsomely printed, and bound in flexible red leather in the form of a diary. It would scarcely make itself felt in one's hip-pocket, and would insure its bearer against any «rdin.ary conversational difficulty in dealing with foreign- speaking people, who are constantly coming into our city hospitals. — Neio York 3ledical Journal. In our larger cities, and in the whole Northwest, the physician is constantly meeting with immigrant patients, t» whom it is difficult for him to make himself understood, •r to know what they Bay in return. This difficulty will Phy. be greatly obviated by use of this little work.- sician find Surgeon. The phrases are well selected, and one might practice long without requiring more of these languages than this little book furnishes.— PAJta. Mediral T'mux. How often the physician is called to attend those with whom the English language is unfamiliar, and manv pliy- sicians are thus deprived of the means, save through an interpreter, of arriving at a correct knowledge on which t« base a diagnosis. An interpreter is not alwa3's at hand, but with this pocket interpreter in vour hand you are able to ask all the questions necessarv, and receive the answer in such manner that you will be' able to fully comprehend. — The .Vediniil Brief. This little volume is one of the most ingenious aids' to the physician which we have seen. We heartil.v com- mend the book to any one who, being without a knowledge of the foreign languages, is obliged to treat those who do not know our own language. — St. Louis Courier of Medi- cine. It will rapidly supersede, for the practical use of the doctor who cannot take the time to learn another language, all other suggestive works. — Chicago Medical Times. 18 (F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) An Important Aid to Students in the Study of Anatomy. Three Chart5 or The Nervo-Vascular System. l^ART I.— THE JSEBVBS, PABT II.— THE ABTEBIES. I'ABT III.— THE VEINS. Arranged by W. HENRY PRICE, A.M., M.D., AND S. POTTS EAGLETON. ENDORSED BY LEADING ANATOMISTS. PRICE, IN THE UNITED STATES AND CANADA, 50 CENTS, NET, COMPLETE; GREAT BRITAIN, 2s. 6d. FRANCE, 3 fr. 60. TEE NERVO-VASCULAR SYSTEM OF CHARTS " far Escels Every Other System in their Completeness, Compactness, and Accuracy. I*(l7't I. The JVerves. — Gives in a clear form not only the Cranial and Spinal Nerves, showing the formation of the different Plexuses and their branches, but also the complete distribution of the fe^MP ATRETIC Nerves, thereby rhaking it the most complete and concise chart of the Nervous System yet published. Part II. The Arteries. — Gives a unique grouping of the Arterial System, showing tlie divisions and subdivisions of all the A^essels, beginning from the heart and tracing their continuous distribution to the periphery, and showing at a glance the terminal branches of each artery. Part III. The Veins. — Shows how the blood from the periphery of the bod}- is gradvially collected by the larger veins, and these coalescing forming still larger vessels, until the}' finall}' trace themselves into the Right Auricle of the heart. It is therefore readily seen that " The Nervo-Yascular System of Charts " offers the following superior advantages : — 1. It is the only arrangement which combines the Three Systems, and yet each is perfect and distinct in itself. 2. It is the onlj' instance of the Cranial, Spinal, and Sympathetic Nervous Systems being represented on one chart. 3. From its neat size and clear t^rpe, and being printed' only upon one side, it may be tacked up in any convenient place, and is always ready for freshening up the memory and reviewing for examination. 4. The nominal price for w-hich these charts are sold places them within the reach of all. For the student of anatomy there can possibly be no ; veins of the human body, giving names, origins, distribu- more concise way of acquiring a knowledge of the'nerves, ; tions, and functions, very convenient as memorixers and veins, and arteries of the human system. It presents at a reminders. A similar series, jnepared by the late J. H. glance their trunks and branches in the great divisions of Armsby, of Albany, N.Y., and framed, long found a place the body. It will save a world of tedio\is reading, and wili in the study of the writer, and on more than one occasion impress itself on the mind as no ordinary i(/ to the standard, and nothing will be left undone to make the work first-class in every particular, CF. A. DAI/IS, Medical Publisher, Philadelphia, Pa., U.S A.) 23 iJUST PUBLISHED.: THE PHYSIOLOGY OF THE Domestic Animals. A TEXT-BOOK FOR VETERINARY AND MEDICAL STUDENTS AND PRACTITIONERS. — BY — ROBERT MEADE SMITH, A.M., M.D., Professor of Comparative Physiology in University of Pennsylvania ; Fellow of the C'ollege of Physicians and Academy of the Natural Sciences, Philadelphia ; of the American X'hysiological Society ; of the American Society of Naturalists ; Associe Etranger de la Societe Frangaise D' Hygiene, etc. liG. 117. — Parotid and Submaxillary Fistula in the Horse, after Colin. (Thanhoffer and Tor may .) K. K', rubber bulbs for collecting saliva; cs, cannula in the parotid duct. In One Handsome Royal Octavo Volume of over 950 Pages, Pro- fusely Illustrated -with more than 400 Fine "Wood- Engravings and many Colored Plates. United States. Canada (duty paid). Great Britain. France. NET PRICES, CLOTH, $5.00 $5.50 £1. 30 fr. 30 SHEEP, 6.00 6.60 1.6. 36 fr. 20. 'THIS new and important work, the most thoroughly complete in the English language on this subject, has just been issued. In it the physiology of the domestic animals is treated in a most comprehensive manner, especial prominence being given to the sub- ject of foods and fodders, and the character of the diet for the herbivora under different conditions, with a full consideration of their digestive peculiarities. Without being over- burdened with details, it forms a complete text-book of physiology, adapted to the use of students and practitioners of both veterinary and human medicine. This work has already heen adopted as the Text-Book on Physiology in the Veterinary Colleges of the United States, Great Britain, and Canada. 24 (F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) Ab5TRACT5 FROn KeV!EW5*^5m1TH'5 PhY5I0L0QY. ^^ -Ecr The work throughout is well balanced. Broad, though not encyclopasdic, concise without sacrificing clearness, it combines the essentials of a successful text-book. It is eminently modern, and, although first in the field, is of such grade of excellence that successors must reach a high standard be- fore they become competitors. — Annals of Surgery. Dr. Smith has conferred a great benefit upon the veterinary profession by his con- tribution to their use of a work of immense value, and has provided the American vet- erinary student with the only means by which he can become properly familiar with the physiology of our domestic animals. Veterinary practitioners and graduates will read it with pleasure. Veterinary students will readily acquire needed knowledge from it.« pages, and veterinary schools which would oe well equipped for the work they aim to perform cannot ignore it as their text-booK in physiology. — American Veteri- nary Review. Dr. Smith's presentment of his subject IS as brief as the status of the science per- mit.-*, and to this much-desired conciseness he has added an equally welcome clearness of statement. The illustrations in the work are exceedingly good, and must prove a valuable aid to the full understanding of the text. — Journal of Comparative Medicine and Surgery. We have examined the work in a great many particulars, and find the views so correct, where we have had the means of comparison of statements with those of some recognized authority, that we will be com- pelled hereafter to look to this work as the text-book on physiology of animals. The book will prove of incalculable benefit to veterinarians wherever they may be found; and to the country physician, who is often called upon to attend to sick animals as well as human beings, we would say, lose no- time in getting this work and let him familiarize himself with the facts it con- tains. — Virginia Medical Monthly. Altogether, Professor Smith's " Physi- ology of the Domestic Animals" is a happy production, and will be hailed with delight in both the human medical and veterinary medical worlds. It should find its place besides in all agricultural libraries. — Paul Paqufn, M.D., Vs., in the Weekly Melical Beview. It may be said that it supplies to the veterinary student the place in physiology that Chauveau's incomparable work — " The Comparative Anatomy of the Domesticated Animals" — occupies in anatomy. Higher praise than this it is not possible to bestow. And since it is true that the same laws of physiology which are applicable to the vital prof-ess of the domestic animals are also ap- plicable to man, a perusal of this carefully wi itn-n book will rejiuy the medical student or luartiliniir-i- — (^a.nadian Practitioner. The work before us fills the hiatus of which complaint has so often been made, and gives in the compass of less than a thousand pages a very full and complete account of the functions of the body in both carnivora and herbivora. The author has judiciously made the nutritive functions the strong point of the work, and has devoted special attention to the subject of foods and digestion. In looking through the other sections of the work, it appears to us that a just proportion of space is assigned to each, in view of their' relative importance to the practitioner. Thus, while the subject of re- production is dismissed in a few pages, a chapter of considerable length is devot«d to locomotion, and especially to the gaits of the horse. — London Lancet. This is almost the only work of the kind in the English language, and it so fully covers every detail of general and special physiology that there is no room for any rival. The excellence of typographical work, and the wealth, beauty, and clear- ness of the illustrations, correspond with the thoroughness and clearness of the treatise. — Albany Medical Annals. It is not often that the medical profes- sion has the opportunity of reading a new book upon a new subject, and doubtless English-speaking physicians will feel grate- ful to Professor Smith for his admirable and ])ioneer work in a branch of medical science ujion which a great ainou'At of ignor- ance prevails. . . . The last portion of the work is devoted to the reproductive functions, and contains much valuable in- formation upon a portion of animal physi- ology concerning which many are ignorant. The book is a valuable one in every way, and will be consulted largely by veterinary and medical students and practitioners. — Buffalo Medical and Surgical Journal. 1 The appearance of this work is most op- portune. It will be much appreciated, as I tending to secure the thorough comprehen- I sion of function in the domesticated ani- mals, and, in consequence, their general well-being — a matter of world-wide impor- 1 tance. With a thorough sense of gratifica- I tion we have perused its pages: throughout ! we find clear expression, clear reasoning, I and that patient accumulation of facts so valuable in a text -book for students. — ' British Medical JournaL \ For notice this time, I take up the vol- ume on the " Physiology of the Domestic 1 Animals," by Dr. R. Meade Smith, a vohnne of 988 pages, closely printed, and dealing j with its subject in a manner sufficiently ex- ! haustive to insure its place as a text-book for fifteen years at tlie very least. Its learning is only equaled by its industry, and its industry by the consistency and skill with wtiichits varied parts are brouuht together into harmonious, lucid, and in- tellectual unity.— Dr. BEN.i.'iMrN Ward Richardson, in the /..ondon Asclepiod. ^^- rS^ (F. A. DAVIS. Medical Publisher, Philadelphia. Pa.. U.S.A.) THE; — — International Pocket Medical Fopmulapj), ARRANGED THERAPEUTICALLY. By G. SUMNER WlTHERSTlNE, M.S., M.D., Associate Editor of the "Aiimuil of tlic Universal Mcdital Sciences ;" Visiting I'hysician of the Home for the Aged, (jermantuun, Philadelphia; I. ate House-Siirgeon Charily Hospital, New York. More than 1800 Formulae from Several Hundred Well-Known Authorities. With an Appendix containing a Posological Table, the newer remedies included ; Important Incompati- bles ; Tables on Dentition and the Pulse : Table of Drops in a Fluidrachni and Doses of Laudanum graduated lor age ; Formula; and Doses of Hypodermic Medication, including the newer remedies; Uses of the Hypo- dermic Syringe ; Formula; and Doses for Inhalations, Nasal Douches, (largles, and Eye-washes ; Formula; for Suppositories; Use of the Thermometer in Disease; Poisons, Antidotes, and 'I'reatment ; Directions for Post-Mortem and Medico-I.egal Examinations ; Treatment of Asphyxia, Sun-stroke, etc. ; Anti-emetic Remedies and Disinfectants; Obstetrical Table; Directions for Ligation of Arteries ; Urinary Analysis; Tabic of Eruptive Fevers ; Motor Points for Electrical Treatment, etc., etc. ■J'his work, the best and most complete of its kind, contains about 875 prmtearticularly the sections on tiie Viscera, Special Senses, and Surgical Anatomy. The work includes a complete account of Osteology, Articulations and Ligaments, Muscles, Fascias, Vascular and Nervous Sj'stems, Alimentary. Vocal, and Kespiratory and Genito-Urinarv Apparatuses, the Organs of Special Sense, and Surgical Anatomy. In addition to a most carefully and accurately prepared •text, wherever possible, the value of the work has bee.n enhanced by tables to facilitate and minimize the labor of students in acquiring a thorough knowledge of this impor- tant subject. The section on the teeth has also been es|iecially prepared to meet the requirements of students of Dentistry. In its preparation, Gray's Anatomy [last edition], edited by Keen, being the anatomical work most used, has been taken as the standard. Anatomy is a theme that allows such concen- tration better than most medical subjects, and, as the accuracy of this little book is beyond question, its value is assured. As a companion to the dis- secting-table, and a convenient reference for the practitioner, it has a definite field of usefulness. — Pittsburgh Medical Re-uieiu. This is a very carefully prepared compend of .matomy, and will be useful to students for college or hospital examination. There are some excellent tables in the work, particularly the one showing the origin, course, distribution, and functions of the cranial nerves. — Medical Record. Dr. Young has compiled a very useful book. We .are not inclined to .approve of compends as a gener.al rule, but it certainly serves a good purpose to have the subject of anatomy presented in a com- pact, reliable way, and in a book easily carried to the dissecting-room. This the author has done, i'he book is well printed, and the illustrations well selected if a student can indulge in more than one work on .anatomy, — for, of course, he must have a general treatise on the subject, — he can hardly do better than to purcha-se this compend It will save the larger work, and can always be with him during the hours of dissection. — Buffalo Medical and Surgical yourttal. Excellent tables have been arranged, which tersely and clearly present important anatomical facts, and the book will be found very convenient for ready reference— Coluvibus Medical Journal. The book Is much more satisfactory than the "remembrances" in vogue, and yet is not too cum- bersome to be carried around and read at odd moments — a propeny which the student will readily appreciate. — H'eekly Medical RevieT.v. If a synopsis of human anatomy may serve a purpose, and we believe it does, it is very imponant that the synopsis should be a good one. In this respect the above work may be recommended as a reliable guide. Dr. Young has shown excellent judgment In his selection of illustrations, in the numerous tables, and in the classification of the various subjects.— 7y/cr-(i/f«//<: Gazette. Every unnece.ssary word has been excluded, out of regard to the very limited time at the medical student's disposal. It is also good as a reference book, as it presents the facts about which he wishes to refresh his memory in the briefest manner consistent with clearness. — New York Medical "jfournal It is certainly concise and accurate, and should be in the hands of everv student and practitioner. — The Medical Brief. (F. A. DAVIS. Medical Publisher. Philadelphia. Pa.. U.S.A.) ANNUAL - OF IHH Universal ]Vl*^'dical S'^it^^^^'*^-"^- A YEARLY REPORT OF THE PROGRESS OF THE GENERAL SANITARY SCIENCES THROUGHOUT THE WORLD. Edited by CHARLES E. SAJOUS, M. D., LBi Tl'NKK ON I.AKYNGOLOGY AND RHINOLOGY IN JKFFHKSublications of all nations, and obtain for him special reports from countries in which such publications do not exist, and Lastly, to enable any physician to ])0ssess, at a moderate cost, a complete CONTEMPORARY HISTORY OP UNIVERSAL MEDICINE, edited by many of America's ablest teachers, and superior in every detail, of print, paper, binding, etc., etc., a befitting continuation of such great works as " Pepper s System of Medicine," "Ashhurst's International Encyclopasdia of Surgery," " Buck's Reference Harid-Book of the Medical Sciences," etc., etc. EDITORIAL STAFF of the ANNUAL of the UNIVERSAL MEDICAL SCIENCES. ISSUE OP 1888. Chief Kditor, DK. CHARLES E. SAJOUS, Philadelphia Volunae I. — Obstetrics, Oynatcology, Pediatrics, Anatomii, Physiology, Pa.thelogy. Histology , and Em bryology. Prof. Wm. L. Richardson, Boston. Prof. William Goodell and Dr. W. C. i Prof. H. Newell Martin and Dr. W. H. Prof. TheophiluB Parvin, Philada. Goodell. Philadelphia. Howell, Baltimore. Prof. l,;»ifi<'e'»tl.v Illustrated with Chi-oiiio-L.ithog;rai>hs, Kiigi'aviiiy;!i, J\Ia]>s, Charts, and Diagrams. THE SUBSCRIPTION PRICE (including the ••Satellite" for one yearj. I'nit«(l Stiites. C:iuada((liitviiaiil i. (Jivut Britain. France. Cloth, 5 Vols., Royal Octavo, - - $15.00 $16.50 £3.6s. 93 fr. 95 Half-Russia, 5 Vols., Royal Octavo, - 20.00 22.00 16s. 124 fr. 35 This work is bound in above styles only, and sold by subscription. Published in Connection with the Annual and for Subscribers Only. XHE SAXEI.I.IXE — OF llll-. — AI^JBilTAI, OK THE UNIVERSAI^ 9I£»ICAL SCIETVCES. \ .\lonihly Review of the mo.st important articles upon the practical branches of medicine appearing in the medical press at large, edited by the Chief Editor ot the Annual and an able staff. Editorial Staff of the Annual of the Universal Medical Sciences, issue of 1889. Chief Editor, Dr. CHAS. E. SAJOUS, Philadelphia. jPLSSOOIjfiLTE: STjfiLli'ir'. Volume I. — Diseas&s of the Lungs, Diseases of the Heart, Diseases of the Gastro- Hepatic System, Diseases of the Intestines, Intestinal Entozoa, Diseases of ihe Kidneys and Bladder, Fevers, Fevers in Children, Diphtheria, Rheu- matism and Gout, Diabetes, Volume Index. Piof. Jas. T. Whittaker, Cincinnati. I Dr. Jas. C. Wilson, Philadelphia. Prof. A. L. I^omis, New York City. I Prof Louis Starr, Philadelphia. Prof. E. T. Bruen, Philadelphia. Prof. J. Lewis Smith, New York. Prof. W. W. Johnston, Washington. i Prof. N. S. Davis, Chicago. Dr. I,. Emmeit Holt, New York. Prof. Jas. Tyson, Philadelphia. Prof. Jos. Leidy, Philadelphia. "Volume II.— Diseases of the Brain and Cord, Peripheral Nervous System, Mental Diseases, Inebriety, Diseases of the Uterus, Diseases of the Ovaries, Diseases of the External Genitals in Women, Diseases of Pregnancy, Obstetrics, Dis- eases of the Newborn, Dietetics of Infancy, Growth, Volume Index. Prof. E. C. Seguin, New York City. Prof. Henry Hun, Albany. Dr. E. N. Brush, Philadelphia. Dr. W. R. Birdsall, New York. Prof. Paul F. Munde, New York City. Prof. Wm. Goodell. Philadelphia. Prof W. H. Parish. Philadelphia. Prof. Theophilus Parvln, Philadelphia. Prof Wm. L. Richardson, Boston. Dr. A. F. Currier, New York. Prof. Louis Starr, Philadelphia. Dr. Chas. S. Minot, Boston. Dr. W. C. Goodell, Philadelphia. Volume III. — Surgery of Bram, Surgery of Abdomen, Genito-Urinary Surgery, Dis- eases of Rectum and Anus, Amputation and Resection and Plastic Surgery, Surgical Diseases of Circulation, Fracture and Dislocation, Military Surgery, Tumors. Orthopaedic Surgery, Oral Surgery, Surgical Tuberculosis, etc., Sur gical Diseases, Results of Railway Injuries, Anaesthetics, Surgical Dressings, Volume Index. Prof. N. Senn, Milwaukee. Prof. E. L. Keye-s, New York City. Prof. J. Ewing Mears, Philadelphia. Dr. Chas. B. Kel-sey, New York City. Prof. P. S. Conner, Cincinnati. Dr. John H. Packard, Philadelphia Prof Lewis A. Stimson, New York City. Dr. J. M. Barton, Philadelphia. Prof. D. Hayes Agnew,lPhiIadelphia. Dr. Morris Ixjngstreth, Philadelphia. Dr. Thos. G. Morton, Philadelphia. Prof. J. E. Garretson, Philadelphia. Prof. J. W. White, Philadelphia. Prof. C. Johnston, Baltimore. Prof. E. C. Seguin, New York City. Volume IV. — Skin Diseases, Ophthalmology, Otology, Rhinology, Diseasas of Pharynx, etc., Intubation, Diseases of Larynx and CEsophagus, Diseases of Thyroid Gland, Legal Medicine, Examination for Insurance, Diseases of the Blood, Urinalysis, Volume Index. Prof. A. Van Harlingen, Philadelphia. I Dr. Chas. E. Sajous, Philadelphia. Dr. Chas. A. Oliver and Dr. Geo. M. ! Prof. D. Bryson Delavan, New York. Govdd, Philadelphia. Prof. R. Fletcher Ingals, Chicago. Dr. Charles S. Turnbull, Philadelphia. Prof. F. W. Draper, Boston. Prof J. Solis Cohen, Philadelphia. Prof. Jas. Tyson, Philadelphia. Prof. John Guiteras, Charleston, S. C. ! Volume V. — General Therapeutics, Experimental Therapeutics, Poisons, Electric Therapeutics, Climatology, Dermography, Technology, Bacteriology, Embry- ology, Physiology, Anatomy, General Index. Dr. C. Sumner Witherstine, Philadelphia. T>r. J. P. Crozer Griffith, Philadelphia. Dr. Hobart A. Hare, Philadelphia. Prof Geo. H. Rohe. Baltimore. Prof John B. Hamilton, Washington. Dr. Harold C. Ernst, Boston. Prof H. Newell Martin, Baltimore. Dr. R. J. Dunglison, Philadelphia. Prof. J. W. Holland, Philadelphia. Prof. A L. Rannev, New York. Dr. Albert H. Gihon. C. S. N. Dr. W. P. Manlon, Detroit. Dr. W. X. Sudduth, Philadelphia. Prof Wm. T. Forbes, Philadelphia. m (F. A. DAVIS, Medical Publisher. Philadelphia, Pa.. U.S.A.) THE LATEST BOOK OF EEFEBENCE ON NERVOUS DISEASES. Lectures on Nervous Diseases, FROM THE STAND-POINT OF CEREBRAL AND SPINAL LOCALIZATION. AND THE LATER METHODS EMPLOYED IN THE DIAGNOSIS AND TREATMENT OF THESE AFFECTIONS. By /^^MBROSE L. RANNEY, A.M., M.D., Prj.ct.sor of the Anatomy and Physiology of the Nervous System in the New York Post-Graduate Medical School and Hospital ; Professor of Nervous and Mental Diseases in the Medical Department of the University of Vermont, etc ; Author of "The Applied Anatomy of the Nervous System," ■' Practical Medical Anatomy," etc., etc. r'I2,O^TrSEIj-S- IXjX.-CrSTXa.A.TE3D With Original Diagrams and Sketches in Color by the Author, carefully selected Wood- Kng:ravings, and Reproduced Photographs of Typical Cases. ONE HANDSOME ROYAL OCTAVO VOLUME OF 780 PAGES. United States. Cannda (duty paid). fireat Britain. France. CLOTH, - - - «5.50 «6.05 «1.3s. 34 fr. 70 SHEEP, . . - 6.50 7.15 1.6s. 40 fr. 45 HALF-KUSSIA, - - 7.00 7.70 1.9s. 43 fr. 30 SOLD 02